2016-17 Registration Form

2016-17 NEW & CURRENT MEMBER REGISTRATION FORM
Class Registration
Annual Nursery Fees:
$275
First Child ($300)
Second Child($50)
Additional Child (no charge)
Please Note:
•
No refunds on registration and/or nursery fees after 9/30/16.
•
Guests are welcome to attend one meeting. Please make reservations with the Membership Director. The
guest nursery fee is $25 per visit, per child. Space is subject to availability.
•
Financial assistance for tuition and/or nursery costs is available to those for whom the fees are prohibitive.
Confidential inquiries are handled by the Membership Director.
•
There will be a $25 charge for returned checks.
Name:
Spouse’s Name:
Address:
City:
State:
Zip:
Phone:
Email:
Child’s Name*:
DOB:
Nursery (Y/N) Grade*
Child’s Name:
DOB:
Nursery (Y/N) Grade
Child’s Name:
DOB:
Nursery (Y/N) Grade
*Please indicate what grade your child is entering, if applicable.
You will be grouped by your oldest child’s birth date unless you indicate otherwise: _____________________
How did you hear about us? _____ Current Member _____ Friend (Friend’s name: ______________________)
_____ Newspaper _____ Hospital /Doctor _____ Online
_____ Other (please explain): ________________
____________________________________________________________________________________________________
Would you like to be on a committee? _____ Fundraising _____ Special Events _____ Communications
By signing below I acknowledge that neither North Central Parenting Group (NCPG) or Church of the Beatitudes (CB) carry
insurance to cover any injuries to NCPG members or their families. As consideration for participation in the NCPG program, I
hereby release, remise forever, discharge, and agree to save and hold harmless and indemnity NCPG and CB, and the
employees, officers, directors, and agents of each, of and from all liability, claims, demands, causes of action and possible causes
of action whatsoever, arising out of or related to any loss, damage, or injury that including negligence of any of the foregoing. I
agree to defend and indemnify NCPG from and against any and all liability or claims arising out of any loss, damage or injuries
sustained by myself, my minor child or family member participating in any function of NCPG.
Signature
Date:
2016-2017 PAYMENT FORM
Name:
Date:
Address:
City:
State:
Phone:
Zip:
Email:
PAYMENT by credit card:
Class Registration
$275
Nursery (First Child)
$300
Nursery (Second Child)
$50
Credit Card Usage Fee
TOTAL
4% of Total
$ ____________
Credit Card #:
Expiration Date:
Security Code:
Check One: Pay in Full
Two Equal Payments*
*Terms & Conditions
Credit card will be charged for half the total registration/nursery fee(s) upon registration. The second payment will be
automatically charged to the credit card on January 30th regardless of whether member continues with membership or nursery
usage unless the second payment is received prior via cash or check. Policy of no refunds on registration and nursery fees after
9/30/16 remains in effect. Credit card processing fees apply. Credit card information will be kept secure on file until second
payment is made, after which it will be securely destroyed. Must register by December 1st to utilize payment plan.
I acknowledge that I have reviewed and accepted the Terms and Conditions of the Two Equal
Payment Plan and authorize NCPG to charge my credit card upon registration and on January 30th,
2017.
Signature
Date:
(Signature & Date Required)
________________________________________________________________________________
PAYMENT by check:
Class Registration
$275
Nursery (First child)
$300
Nursery (Second child)
$50
TOTAL $_____________
Check # ______________
(If paying only the first half of the total registration/nursery fee(s), you are required to fill out credit card
information above and sign/date after the Two Equal Payment Plan Terms & Conditions.)
Please mail payment and registration form to:
NCPG
P.O. Box 32644 Phoenix, AZ 85064