Child's Information

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Enter the grade your child completed at the end of the 16-17 school year.
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Enrollment Information

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Hours of operation are 7am - 6pm.  Our primary programming will be from 8:30am - 4pm.  To be sure we staff appropriately, please provide a general drop off time and pick up time for your child below.

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Parent/Guardian Information - Primary Contact

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Secondary Contact Information

All communications to the primary contact will duplicate to the secondary contact if information is completed.


Emergency/Authorized Pick-up Contact Information

The primary contact listed above will first point of contact in an emergency as is authorized for pick-up.  In the event the primary contact is unable to be reached, we will attempt the secondary contact.  If the secondary contact is not listed, we will continue to this list.  Please list at least one other person that can be reached in the event the primary and secondary are not available.

Contact 1
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First & Last
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Contact 2
Contact 3

Medical Information

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If nothing, please enter N/A
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I do hereby request and give consent to the staff of the Spark Summer Learning Program, or his/her duly appointed representative, for said child to receive such medical or surgical care as may be deemed necessary expedient by a duly licensed or recognized physician or surgeon in case of any emergency when the parents/guardians cannot be reached.  Consent is also given for the staff, or his/her duly appointed representative to transport by medical ambulance for the said child to receive emergency medical treatment.  If the parents/guardians cannot be contacted.

Type name here to electronically sign.

Please read the following statements and sign below:

I give permission for my child to participate in supervised activities, such as filed trips away from the site.  This includes permission to be transported to and from activities.

I have received a copy of the summer calendar for the site my child is assigned to attend for summer 2016.

I understand that I have chosen to enroll my child at either the full-time enrollment category or at the part-time enrollment category.  I understand that if I have chosen the full-time enrollment category, I will be charged for 9 weeks of the Spark program which is based upon a contracted amount of $2,070 ($230/week).  I understand that if i have chosen the part-time enrollment category, I will be charged for 9 weeks of the Spark program which is based upon a contracted amount of $1,440 ($160/week).  I understand that the contracted amount for the enrollment category which I have chosen to register my child will be deducted weekly over the next 9 weeks.  The amount will be deducted from your account or charged to your card bi-weekly.

I understand that there is a one time $50 activity fee per child enrolled into the Spark Summer Learning Program and is to be paid at the time of enrollment.  I also understand that the activity fee is non-refundable should I choose to remove my child from the program.

I understand that there is a deposit due at the time of enrollment.  The deposit amount is the amount of one week per child that I am enrolling plus the activity fee.

I understand that my child's enrollment category is a commitment for the entire summer.  I understand that changes in the enrollment category are not permitted once the program has commenced.  Furthermore, I understand that children enrolled at the part-time category may only use services on Monday, Wednesday and Friday; use of alternate days is not permitted.

I understand the late fee policy and all charges relating to this policy.  All charges incurred as a result of late pick-up are non-refundable.  Late fees are imposed at 6:01pm.  The charge is $20.00 per child.

I consent to the use of my child's photograph in promotion and publicity materials published by the Spark Summer Learning Program and the Foundation for Lincoln Public Schools.

I acknowledge I have been informed of my access to the 2016 Spark Summer Learning Program and understand all policies and procedures as described on the this form.  By signing below, I agree to abide by all of the policies and procedures outlined on the registration form.

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Payment Information

We are only accepting scheduled electronic payments.  ACH is our preferred billing method for Spark.  Please fill out the ACH information below.  This information will be used to debit your account for the deposit and then again twice a month during the program (the first and third Friday of the month).

If you would like to pay with a debit/credit card you may do so but the merchant fees associated with processing this form of payment will be charged in addition to the deposit and the bi-weekly fees for the program.  To pay by debit/credit card, please call our office at 402.436.1612 to get that set up after you click the send button below.

 

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*If debit/credit card option is selected, you will be charged the merchant fees for processing..
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Full-Time amount due $280 & Part-Time amount due $210

AUTHORIZATION FOR RECURRING ACH PAYMENTS

I hearby authorize the Foundation for Lincoln Public Schools, herinafter called the Foundation for LPS, to initiate credit and, if necessary, debit entries and adjustments for any credit entries in error to my account. 

I acknowledge that the authority will remain in effect through August 4th, 2017 on a bi-weekly basis and that the origination of ACH transactions to my account must comply with the provision of the U.S. law.

Please enter your name below to electronically sign the ACH authorization portion of the form.

First & Last