Early Childhood Family Education 2016-2017 Catalog | Page 11

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Please print clearly
Mother/Guardian Name_______________________________
Address___________________________________________
City, Zip ___________________________________________
Home Phone_______________________________________
Alternate Phone ____________________________ work/cell
E-mail address______________________________________

Father/Guardian Name_______________________________
Address (if different)_________________________________
City, Zip ___________________________________________
Home Phone_______________________________________
Alternate Phone ____________________________ work/cell
E-mail address______________________________________

Parent(s) a ending classes: Mother
Father Other ______________________________
School District residence: District 622 Other (list) _______________________________________
Does any other family live at the address listed above? Yes
No

Check here if you are interested in joining the District 622 Early Childhood Advisory Council
Join the FaceBook group tled “Families of ISD622 Early Childhood Programs” to stay informed and share pictures and informa on
**Limit one class per child per semester
Class Number:
1st choice ______
2nd choice ______

Sibling Care:

Names of all children a ending class:
1. __________________________________
2. __________________________________
3. __________________________________

Sex:
M/F
M/F
M/F

Birthdate for each:
_______________
_______________
_______________

Allergies, special needs, etc.:
______________________
______________________
______________________

Names of all children a ending sibling care:
1. __________________________________
2. ___________________________________
3. ___________________________________

Sex:
M/F
M/F
M/F

Birthdate for each:
_______________
_______________
_______________

Allergies, special needs, etc.:
______________________
______________________
______________________

Sliding Fee Scale for
ECFE and Sibling Care Classes
(PER SEMESTER)

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

$

$

Gross Annual Household Income

Fee A

Fee B

Fee C

Fee D

Fee E
*

Sibling Care Fee

$

$

$100,000 and up

$182

$136

$295

$120

$384

Nature Family Fun Class ($5/child/class)

$

$

$




$75,000-$99,999

$151

$115

$250

$100

$353

Total for Semesters I and II



$50,000-$74,999

$121

$92

$200

$80

$323

Tax deductible donation to ECFE

$

Total amount of payment

$



$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 confiden al. No district family will be denied par cipa on due to
inability to pay.
* Monthly payments will be offered for the Parent-Child
Preschool Class (Fee E). Contact the ECFE office for details.

Payment: Cash
Visa

Check #__________ (payable to ISD 622)
MasterCard

Name on card ____________________________________
#_______________________________________________
Exp. date ___________Verifica on code (3 digit)_________
Signature________________________________________

Note: Registra on is not complete
without immuniza on record and payment.
Immuniza on records can be faxed directly from your clinic to the ECFE office at 651-748-7292.
Office use: Date Registration received: __________Immunization form complete _________ Census _________ Advisory Council _________

www.isd622.org/ecfe

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