Community Services - Notice of Fee Change, Temporary Absence, or Withdrawal Form

NOTICE OF FEE CHANGE, TEMPORARY ABSENCE OR WITHDRAWAL

If for any reason you decide to change or drop your child's enrollment from the Peoria AM/PM Recreation Program, notification must be submitted by Thursday for the following week. You may use this form for notification. Please complete the form fields and submit the form when done.

*Parent's Name:	*Child's First Name:
*School:	*Child's Last Name:
*Email Address:		*Home Phone:

*Required Fields

PLEASE CHECK ONE OF THE FOUR OPTIONS BELOW (changing-absent-inactive-withdrawing):

1. I will be changing fee contracts. (Please check the applicable days on your new program)

Effective Date of Change:

Please 'X' ALL DAYS ATTENDING	Mon.	Tue.	Wed.	Thu.	Fri.
AM 6:30 AM Until - School Opens ($5 per day)
AM/PM Both morning and afternoon ($14 per day or $56 for 5 days)
K-2nd Grades Only AM and 1st Hour PM** ($10 per day)
K-2nd Grades Only 1st Hour PM** ($5 per day)
PM School dismissal - until 6:00 PM ($9 per day)

2. Will be absent beginning returning for AM PM 1st Hour PM

3. Will be inactive until further notice, effective (date)

4. Will be withdrawing permanently, effective (date)

Reason for withdrawal:

Additional Information/Comments:

Check this box if:
I am currently scheduled on Quick Pay/EFT. Please charge my existing account according to the changes listed above. By submitting this form, I understand that I am amending my existing Quick Pay/EFT contract and agree to continue to abide by the policies and guidelines as originally signed.

By submitting this form, I understand that I am amending my existing Fee Attendance Contract and I agree to continue to abide by the policies and guidelines as originally signed.