Early Childhood Family Education 2018-2019 Catalog | Page 9

Registration
E C F E
Please print clearly
Parent 1
Parent 2
Address
Address (if different)
Family
INCOME (include annual earnings before
City
ZIP deductions from all adults in household)
City
Size
Home Phone
Phone +
$0-$20,163
$20,164-$28,694 $28,695-$37,224 $37,225-$41,100 Home
$41,101
Alternate Phone
Alternate Phone
work | cell
$0-$25,389
$25,390-36,131 $36,132-$46,872 $46,873-$51,700 Email
$51,701 +
Email
$30,616-$43,568 $43,569-$56,520 $56,521-$62,250 $62,251 +
Names $0-$35,841
of adults attending
class
$35,842-$51,005
$0-$30,615
$51,006-$66,168 $66,169-$72,850 $72,851 +
ZIP
work | cell
$0-$41,067
$75,817-$83,400
$83,401
Are you
interested in $41,068-$58,442
joining the District $58,443-$75,816
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.
25%
FREE
Class Course
days number:
per week
1st choice
2nd choice 0
2
3
4
Sibling care
5
50%
75%
Full
Fee
Fee
Fee
Names of all children attending class:
1. MONTHLY FEES (confirmed when income is verified)
2.
3.
$35
$69
$104
0
$48
$95
Fee
Birthdate for each: Allergies, special needs, etc:
Sex:
M | F
M | F
M | F $138
$142
$190
Names $60
of all children attending
$120 sibling care: $180
1.
$72
$142
$214
2.
3.
0
0
Sex: $240 Birthdate for each: Allergies, special needs, etc:
M | F
M | F $285
M | F
Sliding Fee Scale for ECFE Classes and Sibling Care
FEE
No family will be
denied participation
due to inability to pay.
ANNUAL
HOUSEHOLD
INCOME
Include annual
earnings before
deductions from
all adults in
household.
A B
$100,000 and up $182 $75,000–$99,999
(per semester)
C D E
$136 $295 $120 $384
$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
$30 $23 $50 $20 $232
appropriate
box
$0-$19,999
*
Fees Semester I Semester II
First choice ECFE class fee
for first child $
$
Add half 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 $
* 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,
2019. Please contact the ECFE office for details.
Payment:
□ Cash
□ Check #
(payable to ISD 622)
□ Visa
Name on card
□ MasterCard
Signature
#
Exp. date
/
Verification code (3 digit)
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.
E C F E
www.isd622.org/ecfp
Office use:
Date Registration received:
Immunization form complete
Census
Advisory Council
20