Early Childhood Family Education 2017-2018 Catalog | Page 7

Registration
E C F E

Registration

Please print clearly
Parent 1 Address City Home Phone Alternate Phone Email
ZIP
work | cell
Parent 2 Address( if different) City Home Phone Alternate Phone Email
ZIP
work | cell
Names of adults attending class
Are you interested in joining the District 622 Early Childhood Advisory Council? □ Yes □ No Join our Facebook group,“ Families of ISD622 Early Childhood Programs,” to share pictures and information and stay informed.
Course number: 1st choice 2nd choice
Names of all children attending class: 1. 2. 3.
Sex: M | F M | F M | F
Birthdate for each: Allergies, special needs, etc:
Sibling care:
Names of all children attending sibling care: 1. 2. 3.
Sex: M | F M | F M | F
Birthdate for each: Allergies, special needs, etc:
Gross Annual Household Income
Sliding Fee Scale for ECFE and Sibling Care Classes( PER SEMESTER)
Fee A
Fee B
Fee C
Fee D
Fee E
*
□ $ 100,000 and up
$ 182
$ 136
$ 295
$ 120
$ 384
□ $ 75,000- $ 99,999
$ 151
$ 115
$ 250
$ 100
$ 353
□ $ 50,000- $ 74,999
$ 121
$ 92
$ 200
$ 80
$ 323
□ $ 35,000- $ 49,999
$ 91
$ 69
$ 150
$ 60
$ 293
□ $ 20,000- $ 34,999
$ 60
$ 46
$ 100
$ 40
$ 262
□ $ 0-19,999
$ 30
$ 23
$ 50
$ 20
$ 232
Please X the appropriate combined family income. Write
the fee in the space provided on the right. Payments are
confidential. No family will be denied participation due to
inability to pay.
* Monthly payment will be accepted for the Parent-Child
Preschool Class( Fee E). The first month’ s payment is due at
time of registration. The remaining payments will be due the
first of each month through April 1, 2018. Please contact the
ECFE office for details.
Fees
Semester I
Semester II
First choice ECFE class fee for first child
$
$
Add 1 / 2 the class fee selected for each additional
$
$
child attending the same class
Sibling Care Fee
$
$
Nature Family Fun Class($ 5 / child / class)
$
$
Total for Semesters I and II
$
Total amount of payment
$
Payment: □ Cash □ Check #( payable to ISD 622)
□ Visa □ MasterCard
Name on card # Exp. date / Verification code( 3 digit) Signature
Note: Registration is not complete without immunization record and payment.
Immunization records can be faxed directly from your clinic to the ECFE office at 651-702-8496.
Office use: Date Registration received: Immunization form complete Census Advisory Council
E C F E www. isd622. org / ecfe