Kyrene Kids Club SCHOOL YEAR

Program Change Request Form

CHILD’S NAME:    PARENT NAME:

PROGRAM SITE:    EMAIL ADDRESS:

 

TODAY’S DATE:      

Other siblings in Kids Club?        YES        NO

 

MY CHILD IS CURRENTLY ENROLLED IN (Please check all that apply and circle days):

 

BEFORE SCHOOL	AFTER SCHOOL	EARLY LEARNING CENTER	ONE HOUR
	1 Day3 Day5 Day1 Hour MTWTHF	MTWTHF HALF FULL Days

I want to:

CANCEL MY CHILD’S PROGRAM (five business days notice required)    

            LAST DATE OF ATTENDANCE:       

CHANGE MY CHILD’S PROGRAM (two business days notice required)

            EFFECTIVE DATE of Change: 

REINSTATE MY CHILD’S PROGRAM if previously registered during the current school year

            DATE of REINSTATEMENT: 

CHANGE MY PAYMENT PLAN - account balance must be $0 in order to change

CANCEL MY CHILD’S SCHOOL CLOSURE CAMP on the following days:       

I want to change or reinstate my child’s program to:   BEFORE SCHOOL        AFTER SCHOOL        EARLY LEARNING CENTER        ONE HOUR   1 Day3 Day5 Day1 Hour MTWTHF   MTWTHF HALF FULL Days   My family account balance is $0 and I want to change my payment plan to: Regular Plan (tuition due on 1st)       Alternate Plan (1/2 tuition due on 1st; 1/2 tuition due on 15th)

IF CANCELLATION box is checked, please tell us why!

 

Relocation                         New childcare               Unemployment          Tuition

Not needed at this time      Work schedule change   Staff/Administration   Other   

 

On the scale, please rate with a circle your overall satisfaction with the Kids Club program:

 

Extremely satisfied

Satisfied

Unsatisfied

Extremely unsatisfied

 Any request for changes must be received at least two business days prior to the effective date and cancellations must be received at least five business days prior to the effective date. If a request is received with less than the two business days or five business days, the two days/five days tuition must still be paid. I understand this form is only a request form. All changes are subject to availability, and submission of a Program Change Request Form does not indicate a change in program. It is the responsibility of the parent/guardian to provide current enrollment information in order to be billed accurately.      

Parent/Guardian Signature: