Attendance Change of Contract

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Please correct the field(s) marked in red below:

1
Child(ren)s Name: (First and Last)
 *
2
Parent Name: (First and Last)
 *
3
Contact Phone Number:
 *
4
Email:
 *
5
Site Location:
 *
6
Are you currently enrolled in Auto-Pay?
 *
Are you currently enrolled in Auto-Pay?

PLEASE COMPLETE THIS SECTION TO CHANGE THE DAYS THAT YOUR CHILD ATTENDS THE PROGRAM.

7
Please select the days your child(ren) will be attending:
Please select the days your child(ren) will be attending:
AM PM Full Day (Summer or Lil Squirts)
Monday
Tuesday
Wednesday
Thursday
Friday
8
 Please check the box below if your child(ren) will not be attending the program
9
My child will be absent from the program on the following days?
10
What day will this change be effective?
 *
11
Is this a permanent change in your child's schedule?
 *
Is this a permanent change in your child's schedule?

PLEASE COMPLETE THIS SECTION IF YOU WISH TO WITHDRAW YOUR CHILD FROM THE PROGRAM.

12
I wish to permanently withdraw my child from the BASE program as of the listed date and understand that will be charged the $25 re-enrollment fee is I wish to attend in the future.
13
If there are any special circumstances or additional information we need to know, please indicate here
14
I understand that I am responsible to pay the amount owed due to this change of contract. I understand that if this form is not received by a City of Buckeye staff or electronically submitted by 7pm on the Friday before the week meant for changes that I will be responsible to pay the amount originally contracted for an any associated fees:
 *