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