This enrollment agreement is between the above-named school and:

Student Full Name:

Telephone #:

Date of Birth:

Age:

Address:

City:

State:

Zipcode:

Parent/Guardian Email Address:

Expected Start Date:

Expected Completion Date:

Which plan best fits your needs?:

Number of children:

The school agrees to provide the following training:

(Course or program title) Total hours are listed for each program. (Check all that apply)

Courses	* Registration Fee	Assessment Test	Tuition	Supplies (+tax)
Math	$60	$40	$50/hr	$150
Science	$60	$40	$50/hr	$150
Handwriting	$60	$40	$50/hr	$150
English/ Language Arts	$60	$40	$50/hr	$150
Abacus	$60	$40	$50/hr	$150

Courses	* Registration Fee	Assessment Test	Tuition	Supplies (+tax)
Math	$60	$40	$350/m	$150
Science	$60	$40	$350/m	$150
Handwriting	$60	$40	$350/m	$150
English/ Language Arts	$60	$40	$350/m	$150
Abacus	$60	$40	$350/m	$150

* This is a one time fee. If the student registers for multiple classes then the registration fee may be waived for any additional classes the student takes.

Date:

Parent/Guardian Signature:

Parent/Guardian Name:

METHOD OF PAYMENT:

I agree that the payment of program costs will be satisfied by (check all that apply):
Paypal Credit / Debit Card

PAYMENT	AMOUNT DUE	PAYMENT TYPE	PAYMENT DATE	AMOUNT PAID
Registration Fee
Assessment Test
Tuition
Book
Discount ( 10% )
TOTAL PAYMENTS

Terms and Conditions: To hold a place in a class, the student must pay the registration fee

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Application

Directions: Check one in each category.

Education:

1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade

7th grade
8th grade
9th grade
10th grade
11th grade
12th grade

Race:
White/Caucasian
Black/African American
American Indian or Alaskan Indian
Asian
Hawaiian Native o Pacific Islander
Multi-Racial
Other
Unknown or wish not to answer

Disability:
Yes
No
Blank/Unknown/Wish not to answer.

If yes, kindly provide details:

In Case of Emergency:

Parent Name:

Phone:

Email ID:

Parent Name:

Phone:

Email ID:

How were you referred to our institution?:

Other Emergency Contact Details:

Name:

Relationship:

Phone:

Email ID:

TUITION PAYMENTS:

Tuition is due on the first day of each month. Tuition is based on the cost per child for the total number of days of the year. It may be paid in one of the following ways:

Choose to pay in cash or by check with a credit or debit card on the first day of each month.
Make one payment for one level (3 months) and receive a 5% discount off the total fees.

Please make all tuition checks payable to “GENIUS KIDS ACADEMY”

Tuition Discounts:

Genius Kids Academy offers a 10% discount to families with more than one child in the school. The first child’s tuition is the full amount; each additional child receives a 10% discount from the same party.

Late Tuition:

Tuition is due by the first day of each month. If monthly tuition payments are more than one week late, a student’s parent will be sent a delinquent notice and they will be charged $50 late fees. If payment is two months overdue, it will result in the removal of the student from the school.

Tardy Fees:

Students should be picked up promptly when their session ends for the day. Students who remain at school longer than 15 minute after dismissal will be charged a $10 fee for every 15 min. or portion thereof that they remain at school.

UNFORESEEN FINANCIAL CIRCUMSTANCES:

If unforeseen financial circumstances occur which prevent timely payment of tuition, parents may contact the office at 253-220-8008, before the tuition due date. Parents needing tuition assistance must speak personally to the director, to determine if an emergency scholarship may be available.

Extended Period of Absence:

Should a child be away from the academy for an extended period, due to travel or other circumstances, and the parent wishes to keep the child enrolled, payment must be made for the time the child is not in attendance, otherwise the position may be filled by another student on our waiting list and reapplication will need to be made.

The registration fee is $60 per child. This fee is payable upon enrollment and is non- refundable.
I /We have read the tuition policy above and agree to abide by its items.

Student Full Name:

Parent Name:

Signature of Parent:

Parent Name:

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AGREEMENT NOTICE:

This agreement will be binding only when it has been fully completed, signed, and dated by the parent and an authorized representative of the school before the time instruction begins.

Changes to the Agreement Notice:

Any changes in the agreement will not be binding on either the student or the school unless such changes are acknowledged in writing by an authorized representative of the school and by the student’s parent or guardian.

Refund Policy:

1. The school must refund all costs paid if the applicant is not accepted. This includes instances where starting a class is canceled by the school.

2. The school must refund all the tuition costs paid if the applicant cancels the class within five business days of signing the contract but before the class starts (excluding Saturday, Sundays, and holidays).

3. The school has a policy where, if an applicant cancels their enrollment beyond the fifth business day after signing the contract or making an initial payment, the school may retain an amount equal to ten percent of the total tuition cost or one hundred dollars, whichever is lower. A registration fee is any fee charged by a school to process student applications and establish a student record system.

4. The school will only refund the full tuition payment, not the fees and costs paid for registration, entrance exam, costs for books, and other materials purchased for the class. The fees are only refundable within 14 days before the start of the program.

When calculating refunds, the official date of a student’s termination is the last day of recorded attendance: When the school receives notice of the student’s intention to discontinue the training program; or,

When the student is terminated for a violation of a published school policy which provides reason for termination.
When a student, without notice, fails to attend classes for thirty calendar days. All refunds must be paid within thirty calendar days of the student’s official termination date.

5. If training is terminated after the student enters classes, the school may retain the registration fee established under (3) of this subsection, plus a percentage of the total tuition as described in the following table

If the student completes this amount of training:	School may keep this percentage of tuition:
One week or up to 10% whichever is less	10%
More than one week (or 10%), whichever is less, but less than 25%	25%
25% to 50%	50%
More than 50%	100%

Acknowledgement By Enrollee/Guardian and the School:

ACKNOWLEDGEMENT BY ENROLLEE:

I understand and accept that any contract entered with the above-mentioned contains legally binding obligations

I understand and accept that repayment obligations will be placed on me by any loans or other financial arrangements I enter to pay for my training.

I understand that any enrollment contract I enter will not be binding or take effect for at least (5) five business days, excluding Saturdays, Sundays, and legal holidays, following the last date such a contract is signed by the school and myself, provided I have not entered classes sooner

ACKNOWLEDGEMENT BY SCHOOL:

Prior to being enrolled in this school, the training applicant whose name and signature appear below have been made aware of the legal responsibilities and obligations he/she takes on by entering a contract for training. Those discussions included cautions by the school about acquiring an excessive debt burden that might become difficult to repay

PARENT SIGNATURE:

Name:

Signed:

Date:

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AUTHORIZATION FOR RELEASE OF CHILD FROM SCHOOL:

Student Full Name:

Parent/Guardian Name:

I_________give my full authorization to release my (Parent/Guardian Full Name):

child to the following adult:

Relationship To Student:

1. Name:

Phone:

2. Name:

Phone:

3. Name:

Phone:

Authorized personnel must provide picture identification to Genius Kids Academy before the child is released.

Parent/Guardian Signature:

Parent/Guardian Name:

Date:

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CHILD CARE EMERGENCY FORM:

Child's Name:

Birthdate:

Home Address:

Parent/ Guardian 1:

Telephone Numbers: Home

Work:

Cell Phone:

E-mail Address:

Home Address:

Place of Employment:

Department:

Contact person at work (who usually knows your whereabouts):

Phone Number:

Emergency Contacts (when attempts to reach parents are not successful, who may pick up your child)

Name:

Telephone:

Home:

Work:

We must have written permission for anyone other than parent/guardian to pick up the child from the center.

Child’s Health Information:

Insurance Name and Plan:

Certificate Number (Or ID) #:

Group#:

Policy Holder’s Name:

Special conditions, Disabilities, Allergies, or medical information for emergency:

Guardian Consent and Agreement for Emergencies: As parent/legal Guardian, I give consent to have my child receive first aid by facility staff, and if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I agree to review and update this information.

Parent / Guardian #1 Signature:

Parent / Guardian #1 Name:

Date:

Parent / Guardian #2 Signature:

Parent / Guardian #2 Name:

Date:

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This enrollment agreement is between the above-named school and:

METHOD OF PAYMENT:

Application

In Case of Emergency:

TUITION PAYMENTS:

Tuition Discounts:

Late Tuition:

Tardy Fees:

UNFORESEEN FINANCIAL CIRCUMSTANCES:

Extended Period of Absence:

AGREEMENT NOTICE:

Changes to the Agreement Notice:

Refund Policy:

Acknowledgement By Enrollee/Guardian and the School:

ACKNOWLEDGEMENT BY ENROLLEE:

ACKNOWLEDGEMENT BY SCHOOL:

PARENT SIGNATURE:

AUTHORIZATION FOR RELEASE OF CHILD FROM SCHOOL:

CHILD CARE EMERGENCY FORM:

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