Welcome! We thank you for your interest in the 2018/2019 Capo Kids Afterschool Program. Our program is a great way for your child to release extra energy in a safe, fun, healthy, and constructive way. Children have fun learning the unique martial art of Capoeira while developing self-confidence and self-control all within a nurturing environment. We offer an exciting alternative to standard after-school care and we pride ourselves in providing a top quality program where your child will become more fit, focused, disciplined and self-confident. Your children will get all the benefits of: O Homework time and supervision O Reading time O Martial arts kicks, self-defense & self-control O Learn to play the different instruments & songs in Portuguese O Learn basic Portuguese from a native Brazilian O Acrobatic movements and tumbling O History and culture of Capoeira O Importance of living a healthy lifestyle O Other important life skills to help make each child the best he/she can be O Access to ISTATION. Get reports of your child s progress (prices to be determined by the first day of school) Your child will be picked up from school and brought to our academy for an afternoon starting with a healthy snack, homework time (until it is all finished), reading time, games, and capoeira class and music. Afterschool Program Fee Our program tuition is based on a full school year. You have the choice to pay equal monthly installments due the 1 st of each month or weekly installments: Weekly Payments: $93 per week. Payment is due on the Friday or last operating day prior to the week of attendance. Winter break (2 weeks) and spring break (1 week) are excluded. All other weeks must be paid in full. Monthly Payments: See payment schedule below (equates to $87.69 per week). August 15 (first day of school) - $228 9 equal payments of $360.50 due on the 1 st of the month thereafter* Last payment is May 1, 2019. *Payments are calculated to exclude winter break (2 weeks) and spring break (1 week) We follow Broward county school board schedule. If there is no school, there is no afterschool program. On the days there is no school, if Capo Capoeira is open, you can bring your child to classes for their age group/level. Late Pickup: We offer late pick up until 7:00 pm for $25/ weekly.** **Later pick up available but on a first come first serve basis, please inquire with Ceci or Laura for pricing.
Child s Name: First Name Last Name Date of Birth: Age: Sex: Date: Email: Address: Street City State Zip Mother s Name: Cell Phone: Father s Name: Cell Phone: How did you hear about us: Child Lives With: [ ] Both Parents Authorized to pick up Child: [ ] Both Parents [ ] Mother [ ] Mother Only, Not Father [ ] Father [ ] Father Only, Not Mother [ ] Guardian [ ] Guardian Name Relationship Name Name of anyone else authorized to pick up your child: Medical History: Allergies: Reactions: Does your child take any medications? History of Illnesses: History of Injuries: I agree to give Capo Capoeira permission to administer Children s Tylenol/Ibuprofen to my child INITIAL in the event he/she is running a fever in an emergency situation and a parent is not available. I give permission for my child to participate in all activities at Capo Capoeira including field trips. INITIAL Child s Physician: Phone: Insurance Company: ID: Special instructions regarding eating habits, fears, possible areas of concern, that will better help us understand your child s individual needs: Student Name Date of Birth
Parent/Guardian Name Phone Number As legal parent/guardian(s), I/We hereby give the above student permission to participate in Capo Capoeira s afterschool program including classes, workshops and all indoor and outdoor sports, field trips and related activities. In consideration of our child s right to participate in Capo Capoeira s activities, I/We hereby waive, release and discharge any and all rights or claims which I/We may have against Capo Capoeira. (herein called CAPO), their respective subsidiaries, affiliates, directors, officers, employees, members, staff and independent contractors as a result of our child s participation in CAPO s program. Further, I/We agree to defend, indemnify and hold CAPO harmless against any and all claims, actions or suits which may be brought as a result of damages or losses sustained as a result of participation in CAPO s program. I/We understand and acknowledge that our child can and will be asked to withdraw from this program at the discretion of the program staff should the child become a disciplinary problem and/or disrupts the operation of the program. Initial Date Transportation I give permission for my child to participate in off-site field trips for classes, after school program, and/or summer/spring break camp activities. I understand that, by signing this WAIVER, I am giving my express consent and permission for employees or persons designated by Capo Capoeira to transport my child to and from Capo Capoeira events and trips in Capo Capoeira-owned vehicles, leased vehicles or private vehicles. I understand that Capo Capoeira will provide transportation to and from these events and I release CAPO of all liability during such times. I understand that transportation is being made available as a courtesy in order to ensure that my child has the opportunity to participate in the event, however, I am aware that my child is not required to accept the transportation being offered. I further understand and agree, for my child, and myself that neither Capo Capoeira nor any of their directors, trustees, officers, employees, agent or volunteers shall have any liability for any injury or damage to my child s person or belongings, whether the result of negligence or any other cause, arising out of or relating to transportation of my child to or from events related to or sponsored by Capo Capoeira. Initial Date In the event of a serious accident or illness, I request that CAPO contact me. If I cannot be reached, CAPO may make whatever arrangements are necessary to provide emergency care and treatment for my child. This may include conveyance to treatment at a hospital or other medical facility. I will assume responsibility for payment for services rendered. In case of an accident or illness where immediate treatment of my child is not necessary, but where he/she is unable to remain at CAPO, I request that CAPO attempt to contact me first at the numbers that I have provided to arrange transportation for my child. In the event that I cannot be reached, please contact the emergency contact I have listed. Parent/Guardian Signature Date: Primary Doctor: Phone Number: Health Insurance Carrier: Policy Number:
Emergency Contact 1: Phone Number: Emergency Contact 2: Phone Number: Afterschool Program Acknowledgments AFTERSCHOOL PROGRAM DAYS: Our afterschool program follows the Broward County School Board Calendar. We pick up on all early release days. There is NO afterschool program on teacher planning days/ holidays/ or any day that school is not in session. (Initial) PICK UP: Afterschool program runs until 6:00 pm. After 6:00 pm, we no longer have organized activities in our afterschool program room, although there are always two staff members in the school beyond this time. If you are running late, please call the academy at (954) 755-9424 to let us know. We allow a window of 15 minutes if you are late picking up your child. If you are later than 6:15, there will be a $10 late fee per each day you are late. We offer a late pick-up until 7:00 PM for a fee of $25 per week (Initial) If you need a later pick up, please speak to the front staff. CLASS TIMES: If your child s capoeira class ends AFTER 6:00, there is no late charge; however, you must pick them up promptly after their class ends. Please check the Capo Kids Training schedule as the times and days are subject to change. If your child is picked up later on a day they do not have a scheduled class, a $10 fee will be charged. (Initial) ABSENCE: I understand that if my child will not be attending the afterschool program due to an absence from public school, it is my responsibility to inform Capo Capoeira before pick up. If I fail to notify Capo Capoeira, I understand a $10 fee will be charged to my account. If you fail to notify the academy more than once, this fee will increase to $20. (Initial) HOMEWORK: I understand that my child will have time to complete homework daily. During this time, a staff member will be available if my child has a question regarding directions of his or her homework. I also understand it is my child s responsibility to know if they have homework and to use this homework time if needed. (Initial) READING: We know the local schools require students to have a certain amount of reading time each night. If you would like your child to use any extra time available to get this reading done, please initial. (Initial) UNIFORM: All afterschool program students are REQUIRED to bring their capoeira uniform every day. Students not wearing their full uniform/shirt may not be able to participate in class or other activities. (Initial) SNACK: One healthy snack will be provided to your child every day. Please pack additional snacks (2) to send with your child each day. The children get very hungry with all the activities we do. A water tank is available in the back for your child to drink water. Please make sure your child brings a water bottle to fill. (Initial)
ADDITIONAL SNACKS: In the event I do not pack an extra snack and my child is hungry, I authorize Capo Capoeira to give my child additional snacks at a cost of $1.00 $3.00/snack. (Initial) Please no snacks after SICK POLICY: No child is to be brought to CAPO with the following symptoms: fever, diarrhea, vomiting, and/or abnormal behavior. If your child exhibits any of these symptoms during afterschool program hours, you will be called to pick up your child as soon as possible. Please alert the front if your child develops a communicable disease so that we can notify the other families. (Initial) PHOTO/VIDEO: The parent/student understands and gives CAPO permission to be photographed / video recorded and published or used in any lawful purpose. Capo Capoeira retains all rights of ownership to any video and photographs taken during classes, events, demonstrations, or any other activity in connection with Capo Capoeira. (Initial) PERSONAL BELONGINGS: CAPO employees & volunteers shall not be responsible for damaged, lost or stolen articles, inside or outside the facility. Phones/tablets will not be allowed during afterschool program (Initial) MOVIES: Students occasionally watch movies pertaining to the group books we are reading in class, or on rainy days of early release. Students will only view movies that have a rating of G or PG. I give permissions for my child to watch these movies. (Initial) Name: Signature: Date: Afterschool Program Tuition Agreement Please read and initial in the space provided: It is intended to fully inform you as to our standard of operating procedures in regard to registration, weekly payments, late charges, vacation credits, and summer policies. REGISTRATION: New Students: A $95 registration fee for the afterschool program is due at the time of registration/per child. This fee includes 1(one) white uniform shirt and capoeira pants. If you have more than 2 children, a family registration of $190 is due. Returning-Students: A $50 registration fee for Afterschool program is due at the time of registration/per child. If you have more than 2 children, a family registration of $100 is due (Initial) UNIFORM: Capoeira is a martial art. A uniform is required every day and must be purchased by the end of your first week of afterschool program. Shirts can be purchased at the front desk for $15-$20. The cost of pants is $45.00. (Initial)
PAYMENTS: Monthly payments are due on the 1 st of the month. Weekly tuition payments are due on the Friday or last operating day prior to the week of attendance. If payment is not received by 7:00 pm on the date is due, your account will accrue a $5 per day late/ per child, e.g., If your weekly tuition is late: Monday tuition will be $98, Tuesday tuition will be $103, and so on (Initial). FAMILY DISCOUNT: A 5% discount will be given to any additional children in your family if they attend the afterschool program. We encourage families to do capoeira together. If your child is attending the afterschool program, and a family member would like to train, you will get $10 off your monthly membership. (Initial) CANCELLATION POLICY: Prior to your child s last two weeks of attendance, Capo Capoeira must receive two weeks notice in writing. Lack of notification will result in a charge of one week s tuition. As a result, no refunds will be given. (Initial) SICK POLICY: There will be NO credit applied for illness or school scheduled holidays. This policy is strictly enforced due to the fact that your child s place is being reserved and all associated expenses still exist. (Initial) VACATION: A total of two weeks vacation time may be taken any time during the school year with no payment due. Two weeks notice must be given for all vacation requests. Vacations must be taken in weekly increments Monday- Friday. Payment is still required for any additional absences beyond the allotted two weeks. You must inform the office if your child is expected to be out of school for more than two weeks. If he/she does not attend the afterschool program for a period of time exceeding two weeks, your child will be disenrolled. Upon return, a $50 re registration fee will apply, assuming the afterschool program s capacity has not been exceeded. This policy is strictly enforced due to the fact that your child s place is being reserved and all associated expenses still apply. (Initial) RETURNED OR DECLINED PAYMENT: In the event of a returned check or declined payment, a $10 fee will be charged. We reserve the right to require cash payments on the account thereafter. (Initial) DISMISSAL: Capo Capoeira reserves the right to terminate enrollment for parental disregard of school policies or disruption of the school community. (Initial) Student Name: Parent Name: Signature: Date:
Credit Card Autopay Here s How Recurring Payments Work: You authorize regularly scheduled charges to your Visa, MasterCard or Bank Account. You will be charged each billing period the amount indicated below. A receipt will be emailed to the email address we have on file. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 5 days prior to the payment being collected.* Please complete the information below: I authorize Capo Capoeira to charge my credit card (please check one) $93.00/ week on the Friday before each week that my child attends the afterschool program. Payments will continue until the end of the school year/ or the end of the student s enrollment in the afterschool program after I have given two week s written notice. For students with late pick up, $25 will be added to total amount weekly. One payment of $228 on August 10 (or the prorated rate if we start after August 15), and 9 additional monthly payments of $360.50 due on the 1 st of each month. *Snacks: All additional snacks will be charged with the following week s or month s autopay payment. Billing Address Phone# City, State, Zip Email: Account Type: Visa MasterCard Cardholder Name Account Number Expiration Date CVV2 (3 digit number on back) I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. I understand that this authorization will remain in effect until the end of the school year unless two weeks notice is given. The registration fee and down payment are non-refundable. If you voluntarily withdraw from Afterschool program, and you sign this form, your money will be refunded in the following manner: Two weeks notification given prior to ending/vacation date: Autopay will be ceased. One week notice or less: Half tuition will be charged. No refunds will be granted the week has started. I will notify the business of any changes in my account information at least 5 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; provided the transactions correspond to the terms indicated in this authorization form Full Name: Signature: Date: