K 6 th Express Billing Contract

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1 K 6 th Express Billing Contract Child Information: First Middle Initial Last Parent/Guardian Information: First Middle Initial Last Address Phone Requested Start Will you be receiving state/other agency assistance for your child care? Yes No If Yes, who? Requested Site School Child Attends PLEASE check programs and days that you need child care. Minimum enrollment is two (2) sessions per week per program for six (6) consecutive weeks Before and After School Programs M T W Th F Morning Program 6:30am Start of School Day Afternoon Program End of School Day 6:00pm (INCLUDES CONFERENCE EARLY RELEASE DAYS) EXPRESS BILLING AGREEMENT Contract Terms and Conditions Express fees/co-payments are due by the first (1st) and must be received in full by the Express Billing office by the fifth (5th) of that same month. Payments received after the fifth (5th), will be assessed a late payment fee of 10% of the unpaid balance not to exceed $50 per month, charged to the family account. Childcare services will be interrupted on accounts where payment or payment arrangements are not made by the fifth (5th) of the current month. Payment for child care is due in full for the current month at time of registration if enrolling on or after the fifth (5th) of the month. Note: Five (5) consecutive absences from any program without proper parent communication may result in removal from program. Registration Fee and Paper Statement Fee There is a $50 non-refundable fee per family due at time of pre-registration for the upcoming school year, to reserve your enrollment. This $50 family fee applies toward the $50 per child registration fee payable with the first month s tuition. The $50 per child registration fee is paid each school year and is nonrefundable, non-transferable. For agency assisted families, this fee will apply to any co-payments due. If child is withdrawn and re-enrolled to start more than sixty (60) days later, another registration fee will be charged. A one time $5.00 non-refundable paper statement fee will be assessed for paper invoices and duplicate statements State/Other Agency Assistance Families receiving child care assistance, whose registration paper-work is submitted prior to agency approval, must pay a $50 fee per family at time of registration in order to reserve your enrollment. Once we receive notification from the authorizing agency that you are approved, your account will be credited and the $50 fee will be applied toward your monthly co-payments or refunded. Any sessions used over what the agency will cover, will be billed as extra usage and are the responsibility of the parent/guardian. DSHS will be informed if co-payments are delinquent; this may result in a termination of subsidies. Childcare will not be provided without agency authorization or the completion of a parent payment contract. Please refer to Contract Terms and Conditions for specific payment information.

2 Sibling and Other Discounts The discount rate for siblings is 15% calculated on the sibling whose contract is of equal or lesser value. A 25% discount will be applied for December and April. A 50% discount will be applied for June. Special Needs Child(ren) If your child(ren) has special needs, extra time will be required prior to your desired start date for an assessment of your child(ren) s needs in a child care setting. A meeting with the program supervisors may be necessary; if additional staffing is required, the time frame may be longer; this is to ensure a safe, quality experience for your child(ren) in Express. Schedule and Program Change Requests Must be received by the billing office in writing (letter/ /fax), by Wednesday of the current week to take effect as quickly as the following week. Schedule and Program changes will be accommodated based on space availability. There is a minimum requirement of two (2) sessions per week and six (6) consecutive weeks of enrollment. Extra Usage Parents/Guardians will be charged an additional fee for sessions used outside of their current billing contract. Extra usage will be determined based on space availability (contact Billing Office) and requires prior approval from the site director. Fees will be charged on a per session basis. There is no sibling discount for extra usage charges. Switching days or programs will be charged as extra usage. Absence Credit There is no vacation credit, illness credit, or after school activity credit. Late Pick Up/Early Drop off An additional fee of $5 for each five (5) minutes or portion thereof will be charged per child for child(ren) picked up after the end of each program or dropped off prior to the start of each program Withdrawal Written notification (letter/ /fax) of withdrawal is required in the Express Billing office ten (10) business days (2 weeks) prior to the child(ren) s last day of attendance. The bill will continue to accrue charges until written notification is received in the Express Billing office. Final payment on accounts is due ten (10) days after the final statement date. Dishonored Checks Parents/Guardians will be notified if a check or electronic check has been dishonored by our bank. There is a $25 fee for a dishonored check. Child care will be denied if the dishonored check is not redeemed. Dishonored checks are redeemable only for cash, money order, cashier s check, or online payment using debit or credit card. Past Due Accounts Accounts are considered past due if the account is not paid by the fifth (5th) of each month. Past due accounts will not be allowed to reenroll until the account has been paid in full. Re-enrollment is conditional upon Express management approval. If payment arrangements have not been made with the Billing Supervisor, the collection process will be followed as per District Policy. Collection Accounts Accounts that have been referred to a collection agency per district policy will be allowed to re-enroll provided the debt has been satisfied with the collection agency and written notice is received from the collection agency. Re-enrollment is conditional upon Express management approval and will require future payments be made on the 1st of each month. Bankrupt Accounts Past due accounts that have filed bankruptcy will not be allowed to re-enroll in Express. Express strives to offer equal access to all families; however, we reserve the right to refuse services when deemed necessary. By signing this contract, I am stating that I have read and understand the terms of the contract and accept full responsibility for all items above, including payment in full. I further agree that I understand the role of the Express program, and that I will abide by all rules, regulations, policies, and procedures of the program. Parent/Guardian (Print) Social Security Number Parent/Guardian Signature

3 Express Enrollment Form OFFICE USE ONLY Start : Processed By: Power School ID: Child Information: First MI Last Birth Grade Gender Express Site 1 Parent/Guardian Information: First MI Last School Child Attends Address City State Zip Employer Work Schedule (Days/Hours) Send Monthly Statements (please circle preference): U.S. Mail 2 Parent/Guardian Information: First MI Last Address City State Zip Employer Send Duplicate statements: No Yes (If yes, send by) U.S. Mail Work Schedule (Days/Hours) Persons (OTHER THAN PARENT/GUARDIAN) authorized to pick up child: (Please indicate N/A or none if no one else authorized.) Persons NOT authorized to pick up child In an emergency and Parent/Guardian cannot be contacted, notify or provide a written emergency plan: Other adults in the home s of siblings

4 Express Emergency/Medical Information If emergency medical care is needed, call: Doctor Phone LAST PHYSICAL EXAM (REQUIRED) Dentist Phone LAST DENTAL EXAM (REQUIRED) Check here if your student has any special needs or allergies or will be taking any medications. Describe below any special needs, allergies or medications. If specialized staffing is required, a waiting period may occur prior to the student being enrolled. Failure to disclose pertinent medical or health data may lead to inadequate staffing and forfeiture of child care from the Express program. SPECIAL NEEDS (Health concerns, emotional/physical needs, etc. if does not apply, please indicate N/A or none): ALLERGIES (if does not apply, please indicate N/A or none): MEDICATIONS (if does not apply, please indicate N/A or none): OTHER (if does not apply, please indicate N/A or none): SPECIAL DIET REQUIREMENTS (if does not apply, please indicate N/A or none): Field trips are planned as part of the Express program. I understand I will be notified at least one (1) week prior to any field trip. I am aware that I cannot drop off my child at a field trip location. Prior arrangements may be made for pick up from a field trip location. If I choose to not have my child attend any of the field trips, I need to make other arrangements for the day. Parent/Guardian Signature: : In case of injury or sudden illness, I hereby give authority to any hospital or doctor to render immediate emergency aid/or any medical, surgical or hospital care, treatment and procedures as might be required at the time for my child s health and safety. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I understand that any expense for this service is my responsibility. Parent/Guardian Signature: :

5 Certificate of Immunization Status (CIS) For Kindergarten-12 th Grade / Child Care Entry Office Use Only: Reviewed by: : Signed Cert. of Exemption on file? Yes No Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System. Child s Last : First : Middle Initial: Birthdate (): Sex: I give permission to my child s school to share immunization information with the Immunization Information System to help the school maintain my child s school record. Parent/Guardian Signature Required I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Required for School and Child Care/Preschool Required Only for Child Care/Preschool DTaP, DT (Diphtheria, Tetanus, Pertussis) Tdap (Tetanus, Diphtheria, Pertussis) Required Vaccines for School or Child Care Entry Documentation of Disease Immunity Healthcare provider use only If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider Td (Tetanus, Diphtheria) I certify that the child named on this CIS has: Hepatitis B 2-dose schedule used between ages a verified history of Varicella (Chickenpox). Hib ( Haemophilus influenzae type b) IPV / OPV (Polio) laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. MMR (Measles, Mumps, Rubella) PCV / PPSV (Pneumococcal) Varicella (Chickenpox) History of disease verified by IIS Recommended Vaccines (Not Required for School or Child Care Entry) Diphtheria Mumps Other: Hepatitis A Polio Hepatitis B Rubella Hib Measles Tetanus Varicella Flu (Influenza) Hepatitis A HPV (Human Papillomavirus) MCV, MPSV (Meningococcal) MenB (Meningococcal) Rotavirus Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed

6 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand. To print with immunization information filled in: Ask if your healthcare provider s office enters immunizations into the WA Immunization Information System (Washington s statewide database). If they do, ask them to print the CIS from the IIS and your child s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at If your provider doesn t use the IIS, or call the Department of Health to get a copy of your child s CIS: or To fill out the form by hand: #1 Print your child s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as ). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. #4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS. Reference guide for vaccine abbreviations in alphabetical order DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 DTaP DTP Flu (IIV) HBIG Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, Pertussis Influenza Hepatitis B Immune Globulin Reference guide for vaccine trade tames in alphabetical order For updated list, visit Trade Vaccine Trade Vaccine Trade Vaccine Trade Vaccine Trade Vaccine ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1) Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix For updated list, visit Meningococcal Conjugate Vaccine Hep B Hepatitis B MenB Meningococcal B Hib HPV (2vHPV / 4vHPV / 9vHPV) IPV Haemophilus influenzae type b Human Papillomavirus Inactivated Poliovirus Vaccine MPSV / MPSV4 DTaP + Hep B + IPV RotaTeq Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib + IPV Trumenba MenB Rotavirus (RV5) Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B MMR MMRV Meningococcal Polysaccharide Vaccine Measles, Mumps, Rubella Measles, Mumps, Rubella with Varicella If you have a disability and need this document in another format, please call (TDD/TTY call 711). DOH December 2016 OPV PCV / PCV7 / PCV13 PPSV / PPV23 Oral Poliovirus Vaccine Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine Rota (RV1 / RV5) Rotavirus Td Tetanus, Diphtheria Tdap VAR / VZV Tetanus, Diphtheria, acellular Pertussis Varicella

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