School Age Schedule Request Form

Schedule Request Form - School Age Program
Please submit one form per child. Fields marked with a red asterisk (*)are Required.

For other program requests, please use general schedule request form.

Child's Name:

Child's Birth Date:

Gender:

Male Female

Tuition Payment Method:

Personal Funds DSHS

First Time Smooth Sailor?:

Yes No

Grade Next Fall:

School Attending:

Programs:

Before & After School Program: Please check the days of the week and the session that you want to enroll your child in Hillcrest Kid's Before & After School program. All requests must be confirmed by the Hillcrest Kid's office before registration is final. Thank you.
	Days of Week
	Monday	Tuesday	Wednesday	Thursday	Friday

	Daily Sessions
	Before After Before & After

Smooth Sailor Summer Session Schedule Please check all days that you want to enroll your child in Hillcrest Kid's Smooth Sailing program. All requests must be confirmed by the Hillcrest Kid's office before registration is final. Thank you. Smooth Sailors serves children who will be entering 1st - 5th grade in the Fall.
	Summer Break 2010
Week of...	Monday	Tuesday	Wednesday	Thursday	Friday
6/21-25
6/28 - 7/2				7/1
7/5 - 7/9
7/12-16
7/19-23
7/26-30
8/2-6
8/9-13
8/16-20
8/23-27
8/30 - 9/3			9/1

Contact Information

Parent's First Name:

Parent's Last Name:

Address:

City:

State

ZIP Code:

Home Phone:

Email Address:

Work Phone:

A Schedule Request is the first step in determining whether or not we have an opening for your child to attend Hillcrest Kids. We will contact you either by email or phone to let you know about availability. If and when you accept an opening in our program, you are responsible to pay the annual registration fee by a date set up by yourself and the scheduling manager. In addition, once the registration fee has been paid, you are responsible to give a two week notice in the event you decide to withdraw from our program. For families receiving state assistance, the annual registration fee is also required when an opening is accepted. Once the state authorizes payment towards the fee, a credit will be applied to your account, which will go towards the amount of your monthly copay.

To accept the terms of this agreement and send your schedule request, please click on "Submit."