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Safe Place / Club House Registration Form
The Safe Place at Naquag Elementary
The Club House at Glenwood Elementary
Registration Form

Child’s Name_____________________________________________________
Parent’s Name____________________________________________________
Grade as of September___________________________

My child will be attending              AM program              PM program

(Please write in the day your child will be attending)
The day(s) my child will attend are_______________________________________
I would like my child to start on the following date:_________________________

My monthly tuition will be______________________________________________
(Refer to the Fee Schedule for the amount of your tuition payment.)

I understand that tuition payments are due on the 1st of every month.
Parent’s Signature_____________________________________________________
There is a NON-REFUNDABLE registration fee of $20 for each child that is due at the time
of registration. Registration fees will be capped at $50 for families with more than 2 children enrolled in the program.  There is a 10% overall discount for more than 1 child.

Occasional Use of the Safe Place and The Club House
The Safe Place and The Club House can be used on an occasional basis, with approval from the Program Administrator.  Registration in advance is required.  The FEE is $8.00 a day for the AM program and $12.00 a day for the PM program.                                                                                                                                        Revised 6/17/13

Town of Rutland 250 Main Street, Rutland, MA 01543   Disclaimer
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