Capitol Educational Support Inc.

Presents
Afterschool at
Bancroft Elementary School
REGISTRATION FORM

Student Name:
Siblings Attending:
Address:
City:
Parents/Legal Guardian Name:
Parent/Legal Guardian Email Address:
Phone:

(h)

Student Age:

(w)

(c)

Student Grade:

Student DOB:

Current School Attending:

Emergency Contact Person:
Emergency Contact Phone:

(c)

Sessions:
After Care (3:30pm 6:00pm)

One-time Registration Fee:

Monthly Rate:
Drop-in Rate:
Late Fee:

$20/ per student

$225/month
$13/per day
$5 1-15 minutes after close, $1/min each minute thereafter

*Families with more than one child will receive a 10% discount on monthly tuition. We also accept students through
our TANF grant for free. Please check here if you will be applying as TANF RECIPIENT ___________

Payment Information
TIMING AND METHODS OF PAYMENT: Monthly fees paid after the 5th of the month will be subject to a
$25.00 late fee. If you enroll your child in the Program after the first day of a month, you will pay on or
before the first day your child attends the Program. A portion of the monthly fee will be pro-rated on a
daily basis for the period remaining in the month. Payment may be made by credit card check or money
order. If any check is returned unpaid, you will owe a service charge of $25.00 in additional to other
amounts due. All payments for that month and the three (3) months thereafter must be made by money
order. Payment may be made via credit card online or by calling CES office at 202-957-1331;
checks/money orders can be dropped in the CES lockbox in the school main office. Any charges due to
the Program (e.g., returned check fees) that remain unpaid will be due at the time of enrollment
termination.

Credit Card:

Money Order:

Credit Card Number:

Expiration Date:
Card Holder Signature:
Registration may also be faxed to (888) 395-0772, or sent via email to ces.dc20002@gmail.com.

Health/Medical Info
Does Your child have Health Insurance:

Yes:

No:

Health Insurance Company:

Health Insurance Company Phone #:
Policy Holder:

Policy #

Does the student have any Food Allergies or Medical/Health conditions?

Yes:

No:

If Yes, Please list or describe here:

Health Waiver
I/we, the undersigned, hereby certify that I/we are the parent or legal guardian of the Student. I/we further certify
that the Student is physically capable of participating in all activities. I/we agree to provide the Student with the
appropriate documentation on or before the first day of services, restricting the Student from participating in
specified activities. (Must be a signed letter from parent or a signed doctors certificate) I/we hereby give permission
for the staff of Capitol Educational Support Inc. to seek appropriate medical treatment for the Student during the
period of the Before and After Care and for the camper to receive medical attention in the event of an accident,
injury, disease or illness. I/we will be responsible for all costs of medical attention provided.
Print Student Name:
Print Parent/Legal Guardian Name:
Signature Parent/Legal Guardian Name:
Date:

Before and Aftercare REGISTRATION FORM (Continued)

PROGRAM SCHEDULE: CES operates from the opening day of first day of school for District of
Columbia Public Schools (DCPS) and follows the cancellation and/or closing policy of DCPS. When
schools are closed due to inclement weather, the Program does not operate. When schools are opened late
due to inclement weather, the Before School program will be canceled. In the event that DCPS requires
the school building to be closed early for any reason, parents or guardians will be contacted and advised
to arrange prompt pick-up. The Program will be closed on the following Holidays and DCPS closings:
Columbus Day
Martin Luther King, Jr. Day
Veterans Day
Presidents Day
Thanksgiving Day
Spring Break **
Friday after Thanksgiving
Memorial Day
Winter Break **
** Dates for Winter Break and Spring Break are designated by DCPS.
LATE POLICY: Three (3) consecutive late pick-ups will result in a one-day suspension from the Program
and a probationary period of one month during which no late pick-ups can occur. Three (3) late pick-ups
in one month will result in a one-day suspension the next day.

TERMINATION BY THE PROGRAM: The Program may terminate your childs enrollment immediately for
any of the following reasons:
a. In the judgment of CES Bancroft Site Director and staff, the childs behavior threatens the
physical or mental well-being of other children in the Program.
______ Initials

b. Tuition fees are not paid by the end of the month that they are due.
_______ Initials

c. The family has more than two suspensions for tardiness.

_______ Initials

d. A child is ill when brought to the Program more than three (3) times in any 30-day period, or the
Parent or Guardian fails to pick-up promptly a sick child more than three (3) times within any 30day period.
_______ Initials

CHILD RELEASE AUTHORIZATION FORM

Childs Name: _______________________________________________ DOB: ________________

The CES Afterschool Program is authorized to release my child to the individuals listed below. I
understand that each authorized person must be at least 16 years old and that my child will not be
permitted to leave the Program with anyone not listed below.
Signature:
_______________________________________________________________ Date: _______________
AUTHORIZED PERSONS FOR PICKUP (INCLUDING YOURSELF)
Name: _______________________________________ Relationship to Child: ___________________
Address: ____________________________________ City/State/Zip: ___________________________
Home No.: __________________ Work No.: _________________ Cell No: ___________________
Name: _______________________________________ Relationship to Child: ___________________
Address: ____________________________________ City/State/Zip: ___________________________
Home No.: __________________ Work No.: _________________ Cell No: ___________________
Name: _______________________________________ Relationship to Child: ___________________
Address: ____________________________________ City/State/Zip: ___________________________
Home No.: __________________ Work No.: _________________ Cell No: ___________________
Name: _______________________________________ Relationship to Child: ___________________
Address: ____________________________________ City/State/Zip: ___________________________
Home No.: __________________ Work No.: _________________ Cell No: ___________________

If you have questions, please contact:

Mia Stewart
Dir: 202-957-1331

Capitol Educational Support, Inc.

820 H St., NE
Washington, DC 20002

Bancroft Elementary School

1755 Newton St NW
Washington, DC 20010