Capitol Educational Support Inc.

Presents
Afterschool at
JO Wilson Elementary School
REGISTRATION FORM

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

(h)

Student Age:

(w)
Student Grade:

(c)
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 student
through our TANF grant for free. Please check here if you will be 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 prorated 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.

Before and Aftercare REGISTRATION FORM (Continued)

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 JO Wilson 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

Before and Aftercare REGISTRATION FORM (Continued)

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

JO Wilson Elementary School

660 K St., NE
Washington, DC 20002