The Mother Connection
3115 Albany Post Road * Office B * Buchanan, NY 10511
BEFORE AND AFTER SCHOOL PROGRAMS
REGISTRATION
AND
ENROLLMENT FORMS
School Year 2017-2018
Main Office:
3115 Albany Post Rd. Office B
Buchanan, NY 10511
914-737-8976
Buchanan-Verplanck Center (BV):
914-257-5405
Frank G. Lindsey Center (FGL):
914-257-5505
Furnace Woods Center (FWS):
914-257-5605
REGISTRATION AND ENROLLMENT POLICIES
Registration Applications or “Contracts” are effective on a yearly basis from September through June (or remainder
of the year for late registrants). Due to space restrictions, enrollment in the Program is limited.
Applicants are enrolled in the order in which forms and fees are received by the Center, dependent upon the
availability of space and staffing. A Waiting List is kept for all Centers. Once an opening at a Center becomes
available, those families on the Waiting List are contacted in the order in which they were placed.
Registration Packets must be returned completed with:
 Non-refundable Registration Fee of $50 for the first child and $35 for each additional child
 First month tuition. Sept tuition refundable only until Aug.15, 2017.
DUE DATES/FEES
To be considered for enrollment, the following Due Dates must be adhered to:
CURRENT ENROLLEE’S ONLY: Due date Friday, April 28, 2017
Registration and enrollment forms and fees should be delivered directly to the Director at the center. Any issues with Reg. Fee and Payments
due by the above date please call the office. Space will NOT be held after this date without a registration pkt.
NEW ENROLLEE’S: Registration begins Monday, May 1, 2017
Families on the waiting list will be contacted first.
TUITION FEES
Tuition fees are based on a 182-day school year divided into ten (10) equal monthly installments. Families are
responsible for their Tuition commitment, for which they have contracted on their Registration Form.
Once accepted, contracts can only be rewritten for fewer days or a reduced time slot due to extenuating
circumstances. If modification of scheduling is requested, and can be accommodated, a $25 administrative fee will
be incurred. Tuition is due on the first of every month (with the exception of first month which will be paid at time
of Registration), you will be receiving an invoice monthly in the mail
Before School Centers: (7:00am – 8:15/8:30am)
1 Day
2 Days
3 Days
4 Days
5 Days
Drop In Fee
1st Child
$50
$81
$114
$152
$193
$28 per day
Additional Child
$37
$55
$83
$108
$137
$20 per day
3 Days
4 Days
5 Days
After School Centers:
A.
Early Pick Up (2:15/3:15pm - 4:45pm)
1 Day
2 Days
1st Child
$97
$184
$232
$286
$325
$31 per day
Additional Child
$67
$129
$160
$196
$229
$22 per day
3 Days
4 Days
5 Days
B.
Drop In Fee
Late Pick Up (2:15/3:15pm - 6:00pm)
1 Day
2 Days
1 Child
$127
$231
$292
$374
$435
$43 per day
Additional Child
$88
$160
$210
$263
$306
$31 per day
st
Drop In Fee
*The Centers will accommodate the hours of the school in which that Center is located*
**All refunds for cancellations are pro-rated according to yearly tuition.**
REGISTRATION FORM
(PLEASE PRINT CLEARLY)
Date:
School:BV 
___________________
Child Identification
Name _________________________________________
Address ___________________________________
Home Phone________________________________
Grade (Sept. 2017): ___________________
FGL 
FWS 
Date of Birth ______________________________
City/Zip_______________________________
Sex: Male  Female 
Current Enrollee  New Registrant 
Sibling (Please list the name of any sibling also being registered for September 2017)
Name___________________________________________ Date of Birth: ____________________________
Grade (Sept. 2017): _______________
Sex: Male  Female 
Current Enrollee  New Registrant 
Parent/Guardian Identification
* Please indicate next to number the order you would like contact to be made*
Mother/Guardian Name___________________________________________________________________
Address __________________________________________City/State/Zip ____________________________
Email ___________________________________________Home Phone________________________ (___)
Employer/Occupation _______________________________ Work Phone_________________________(___)
Work Hours________________________________________Cell Phone __________________________(___)
Father/Guardian Name ___________________________________________________________________
Address _________________________________________ City/State/Zip ____________________________
Email __________________________________________ Home Phone ________________________(___)
Employer/Occupation _______________________________ Work Phone________________________ (___)
Work Hours_______________________________________ Cell Phone __________________________(___)
Child resides with: ___________________________________________________________
Explain arrangements (if applicable): _____________________________________________
Parents’ Marital Status: Married  Divorced  Separated  Widowed  Single 
If there is a separation or divorce custody problem of which the Program staff should be aware, please explain:
__________________________________________________________________________________
Person responsible for payment of fees: ________________________________________________________
Enrollment Request
Before School Center Days:
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
After School Center
Days:
Monday 
Tuesday 
Wednesday 
Thursday 
Friday 
Time:
Early Pick Up (4:45pm) 
Late Pick Up (6:00pm) 
FOR THE MOTHER CONNECTION USE ONLY
Date Application Received: ___________________Number of Children attending the Center: _____
Registration Fee:
Amount: _________ Check #: ________ Date: _________
st
1 Month Tuition Received: Amount: _________ Check #: ________ Date: _________
First day of Attendance: ____________________
Emergency Persons/Contacts
Please list three local persons (other than the parent/guardian) who may be notified in case of emergency or
illness and you give permission for the child to be released to, when the parent/guardians listed are not available.
WE ARE REQUIRED TO HAVE 3 EMERGENCY CONTACTS.
Registration forms will not be accepted without 3 LOCAL contacts!
1. Name ______________________________ Relationship to Child _______________________________
Address ______________________________ Phone Number ___________________________________
2. Name ______________________________ Relationship to Child _______________________________
Address ______________________________ Phone Number ___________________________________
3. Name ______________________________ Relationship to Child _______________________________
Address ______________________________ Phone Number ___________________________________
MEDICAL ENROLLMENT FORM
1st Child Name____________________________________________________
Medical/Emergency Information
Please list all allergies and medical conditions influencing the care of your child:
Please list any special educational or social needs your child may have (e.g. dyslexia, etc.):
Please list all medications that your child is currently taking:
2nd Child Name_____________________________________________________
Medical/Emergency Information
Please list all allergies and medical conditions influencing the care of your child:
Please list any special educational or social needs your child may have (e.g. dyslexia, etc.):
Please list all medications that your child is currently taking:
Medical Consent/Release
In the event that my child/ren may require medical care, and I cannot be reached, I hereby give my consent to
medical treatment at the hospital selected by the ambulance or emergency vehicle. I agree to pay the entire costs
and fees contingent on any emergency care and/or treatment for my child as secured or authorized under this
consent.
Please note that the Before and After School Program states that every effort will be made to notify
parents/guardians immediately in case of emergency.
Signatures:
_____________________________________/_____________________________________
Parent/Guardian
Date
Parent/Guardian
Date
PARENT ENROLLMENT CONTRACT
1. I understand that enrollment in the Program constitutes an agreement that I will abide by the policies and
procedures set forth in the Parent Handbook.
2. I have read, understand and agree to the Emergency and Snow procedures in the Parent Handbook.
3. I understand that a non-refundable Registration Fee and the first month tuition must accompany my executed
Registration and Enrollment forms. September tuition is only refundable until August 15, 2016. Refunds WILL
NOT be given after August 15, 2016.
4. I understand that all monthly Tuition payments are to be mailed to: The Mother Connection, 3115 Albany Post
Rd. Office B Buchanan, NY 10511 or brought to the office and left in the mail slot in the door. Such
payments are due by the 1st day of the month and a $25 late charge will be incurred for payments postdated
after the 7th day of the month. Payments will not be accepted at the centers.
5. I understand that once my child starts the Program, any accommodated schedule change will incur a $25
administrative fee.
6. I understand that I must pick my child up on time, and that a late pick-up fee will be incurred if I do not pick up
my child by the contracted time. Continued lateness may result in removal from program.
7. I understand that I am responsible for contacting the Center directly, should my child not be attending the
Center on a scheduled day.
8. Photo Release (Initial choice)
_______I allow my child’s photo to be used on the website.
_______I do not allow my child’s photo to be used on the website.
I understand names will not be used and it will be only on our website, not shared with anyone else or for
any other purposes.
9. I understand that The Mother Connection follows the Hendrick Hudson District 3 school calendar. After School
Programs are closed when the schools are closed, on delay and/or on early dismissal. If after-school activities
are cancelled by the school district, after-school programs are cancelled.
10. I give permission to the The Mother Connection Center staff to discuss the progress and development of my
child(ren) attending the Center with the professional staff of the Hendrick Hudson School District when deemed
appropriate by the Director of The Mother Connection.
11. I understand the information contained on my child’s Registration and Enrollment Forms will be current,
especially in regards to address, home phone, employment change, and emergency person/contact information.
12. I understand that if a medical emergency arises, the Teacher/Director or Head Teacher of the Center will make
every attempt to contact me. If the emergency is such that immediate hospital attention is necessary, an
ambulance or emergency vehicle may take my child to the hospital and medical personnel may treat my child, as
needed.
ACKNOWLEDGEMENT/SIGNATURES:
_____________________________________/_____________________________________
Parent/Guardian
Date
Parent/Guardian
Date
_____________________________________/_____________________________________
Printed Names
___________________________________________________________________________
Child Name(s)