Parent/Guardian #1 Information
* First Name 
* Last Name 
* Email 
* Address 
* City 
* State 
* Zip 
* Cell Phone 
  Home Phone 
  Work Phone 
* Employer 


Additional Information
* Which is the best phone number to reach you at? 


Parent/Guardian #2 Information
  First Name   Last Name 
  Email 
  Address 
  City   State 
  Zip   Cell Phone 
  Home Phone 
  Work Phone 
  Employer 


Person(s) Responsible for Payments of Fees
* Indicate 
  Other 


Payment Policy
     
REFUNDS POLICY
A non-refundable registration fee per child is due at registration. No refunds are provided on monthly fees for absences, vacations, or withdrawals from any of the FAU-Pine Jog Programs.
  
*   
     
NFS POLICY
If a check is returned because of insufficient funds, you will be contacted by FAU/Cashier’s office and a service fee will be applied. All future payments must be made in the form of either cash or money order.
  
*   
   
FEES POLICY AND FEES SCHEDULE
Continued enrollment in our program is dependent upon timely payment of fees. If we have not received your payment by the 10th of the month (Including the $15.00 late fee), your child won’t be able to attend the program. Each child in our program has a reserved placed whether or not the child is present. No payment adjustments or refunds will be made for participation in clubs, sports, tutoring, absences, vacations, or withdrawals from the Afterschool Program. **There will be a $15 late fee assessed to late payments. A payment is considered late if received after the due date**.
Full-Time Fee Schedule
Part-Time Fee Schedule
Pine Jog Elementary School Teachers Fee Schedule
Morning Care Fee Schedule
Summer Day Camp Fee Schedule
Spring Camp Fee Schedule
  
*  


Parent Permissions and Terms of Agreement
     
IN CASE OF EMERGENCY
I give permission to have my child treated at Wellington Regional Hospital or Palms West Hospital in case of a serious illness or injury. (Every effort will be made to contact the parent immediately.)
  
*  
     
Please select desired hospital below.
  
*  
     
EMERGENCY TOPICAL APPLICATION NOTICE
Listed below are topical creams or sprays that FAU/Pine Jog Staff can apply due to sun exposure, bug bite and cuts. Please indicate whether you would like the following items applied by a staffer in case of an emergency.
  
* Sunblock 
* Bug Spray 
* After Bite (for bug bites) 
* Neosporin (cuts and scrapes) 
     
PARENTAL CONSENT FOR RELEASE OF STUDENT'S PHOTOGRAPH INFORMATION
I hereby give permission for FAU/Pine Jog Afterschool Program to use my child’s photograph, video image, voice recording, name, grade level and school name in publications or in School District-approved news media interviews, articles and photographs. If you do not want your child’s photograph used, you must check I disagree.
  
*  
   
PARENT ACKNOWLEDGEMENT
Click to review the appropriate Parent Handbook:
Afterschool Parent Handbook
Spring Camp Parent Handbook
Summer Camp Parent Handbook

I understand that the FAU/Pine Jog Afterschool Program policies and procedures have been developed to ensure the safety of all children and the fiscal stability of the program. I have received and read the Parent Handbook and understand the program policies. I have discussed the rules of the program with my child(ren).
  
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CODE OF CONDUCT (Click here to review in detail.)
I understand and certify that my child’s participation in the FAU Pine Jog Program and its activities is completely voluntary. I have familiarized myself with the Program and the activities in which my child will be participating. I recognize and have instructed my child in the importance of knowing and abiding by the students’ CODE OF CONDUCT for safety of all students participants.
  
*   
     
FIELD TRIP RELEASE NOTIFICATION
Parent/Guardian may not drop off students at field trips sites and students will not be released at field trip locations without prior approval.
  
*   
     
SPORTS/ACTIVITY PERMISSION
I hereby give permission for my child/children to participate in sports and activities offered through FAU Pine Jog Afterschool Program. I release the program and staff from any responsibility due to injury.
  
*   
     
MOVIES
During the course of our programs, we will show a variety of movies to our students. Some selections may be PG Rated.
  
*   
     
VERIFICATION OF STUDENT REGISTRATION INFORMATION
I verify that the information given on this student registration is true and accurate to the best of my knowledge. Registration is not valid without a verification signature and date. My signature indicates agreement to accept policies and procedures established by the FAU-Pine Jog Program.
  
*   


By entering my name and date below, I confirm having read these permissions and terms.
* Name 
* Date 


Health Insurance Information
* Company 
* Policy Number 


Password for Pick-Up
* Password 
                                                             


Authorized Pickups Other Than Parents (must be 18 years or older)
     
PICKUP #1  
  First Name   Last Name 
  Relationship    Phone #1 
  Phone #2 
     
PICKUP #2  
  First Name   Last Name 
  Relationship    Phone #1 
  Phone #2 
     
PICKUP #3  
  First Name   Last Name 
  Relationship    Phone #1 
  Phone #2 
     
PICKUP #4  
  First Name   Last Name 
  Relationship    Phone #1 
  Phone #2 


Registered Student(s)
  
To register your student(s), please click the Add a Student button.
 



Privacy Policy
We keep your personal information private and secure.

Contact Us
FAU Pine Jog Afterschool Program •• 6301 Summer Blvd., West Palm Beach, FL 33415-0991 •• 561.656.5430 •• pinejogassp@fau.edu

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