Summer Enrollment Program 2024

Please enable JavaScript in your browser to complete this form.

- Step 1 of 8

DOLORES T. RICHARDSON SCHOOL SUMMER ENROLLMENT 2024

8420 CRENSHAW BLVD
(323) 758-1187
(323) 758-2856 (FAX)

ACCOUNTING DEPT : 8418 CRENSHAW BLVD
(323) 758-1960
(323) 758-2856 (FAX)

Summer Program:
BEGINS June 24th, 2024
ENDS: September 6th, 2024

WEEKLY PAYMENTS

Number of Children	Weekly Rate
1 CHILD	$200.00 EACH WEEK
2 CHILDREN	$280.00 EACH WEEK
3 CHILDREN	$355.00 EACH WEEK
4 CHILDREN	$480.00 EACH WEEK

Payments can be made weekly or biweekly
No monthly plan during the summer

***Payments are due every Monday morning. if not paid, your child cannot return to school until paid in full.

Partial Scholarships are available.

SPECIAL CHARGES:

LATE PICK UP: $30.00 IS CHARGED EACH DAY A CHILD IS PICKED UP AFTER 6 P.M.
LATE PICKUP STARTS AT 6:01 P.M.
LATE PAYMENT IS DUE AT PICKUP THE SAME DAY

LATE DAY CARE: $5.00 CHARGED FOR EACH WEEK YOUR DAY CARE ACCOUNT IS DELINQUENT

The enrollment fees and this form must be submitted when the child is accepted.

PLEASE NOTE: We Accept Crystal Stairs, CalWORKs, the Bridges Program and Pathway

Please read all pages before signing

Child’s name *

Current School *

Current Grade *

D.O.B *

Layout

Age *

Sex *

Parent 1 OR GUARDIAN’S INFORMATION

Layout

Parent name *

Relationship *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home telephone *

Cell phone *

Email *

Layout

Employed by: *

Occupation

Business address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Business Hours

Business Phone

Parent 2 OR GUARDIAN’S INFORMATION

Layout

Parent name

Relationship

Home address

Address Line 1

Address Line 2

City

State

Zip Code

Home phone

Cellphone

Layout

Employed by:

Occupation

Business address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Business Hours

Business Phone

CHILD’S NEAREST RELATIVE:

Name

Relationship

Home address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cellphone

Business telephone

AUTHORIZATION TO REMOVE CHILD FROM SCHOOL

Layout

Last name *

Home Address *

First name *

City *

Phone number *

Driver Lic #

Layout (copy)

Last name

Home Address

First name

City

Phone number

Driver Lic #

Layout (copy) (copy)

Last name

Home Address

First name

City

Phone number

Driver Lic #

Layout (copy) (copy) (copy)

Last name

Home Address

First name

City

Phone number

Driver Lic #

EMERGENCY AUTHORIZATION

Dolores T. Richardson School staff will call the paramedics (911) to attend the child in case of an emergency.

PLEASE SIGN ONE OF THE FOLLOWING AUTHORIZATIONS

In case of an emergency, when authorized people cannot be reached (as listed above), DOLORES T. RICHARDSON SCHOOL staff will take whatever action that is reasonable and appropriate under the circumstances for the welfare of the child

Signature of parent or Guardian

In case of an emergency, when authorized people cannot be reached (as listed above), DOLORES T. RICHARDSON SCHOOL staff will take whatever action that is reasonable and appropriate under the circumstances for the welfare of the child

In case of an emergency, when authorized people cannot be reached (as listed above), DOLORES T. RICHARDSON SCHOOL officials WILL NOT RENDER nor arrange for the medical treatment other than FIRST AID

Signature of parent or Guardian

In case of an emergency, when authorized people cannot be reached (as listed above), DOLORES T. RICHARDSON SCHOOL officials WILL NOT RENDER nor arrange for the medical treatment other than FIRST AID

DOCTOR’S INFORMATION

Doctor’s Name

Doctor Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name of Insurance Provider

Insurance #

PERSONS TO CALL IN CASE OF EMERGENCY IF PARENT OR GUARDIAN CANNOT BE REACHED

Layout

Name: *

Phone number *

Layout (copy)

Name: *

Phone number *

Parents:

Please read and sign this financial agreement statement.

I hereby agree to comply with the rules and regulations of Dolores T. Richardson Elementary School regarding fees and other regulations. I understand that I am enrolling my child/children for the complete summer program term. I agree to notify the school two weeks in advance in writing of withdrawal of my child from
school. If I fail to do so, I am liable for the school fee(s) and payments until a written notice is given. I also acknowledge that no refund can be provided upon withdrawal of my child. All debts must be paid prior to/or at the time I withdraw my child.

By signing this Financial Agreement Statement, I understand and agree to the terms set forth in the attached Fee Statement and the Application for Enrollment Form.

PAY FEES BY ZELLE: msrobinson@dtrlearns.org or in the school's accounting office.
Please include your student’s name in your Zelle transaction.

By signing below, you acknowledge that you understand and agree to abide by all of the terms & conditions set forth in this document.

Date *

SIGNATURE OF PARENT OR GUARDIAN *

RELATION *

Summer Program Media Agreement

I hereby release and discharge Dolores T. Richardson School from all claims and demands arising out of or in connection with the use of all photographs, audio recordings, and videos in which the named student appears as a participant in all classes, events, or programs sponsored by or related to Dolores T. Richardson School. Dolores T. Richardson School has my full consent to publish all above mentioned media. Classes, events, or programs that may occur on or off the premises of Dolores T. Richardson School.

I further agree that Dolores T. Richardson School may, at any time and from time to time, transfer, use or cause to be used, such photographs, audio recordings or videos in Dolores T. Richardson School brochures, newsletters, advertising, posters, displays, websites, slideshows, Facebook page, catalogs, and other like publications or literature, without limitations or reservations.

THIS IS BLANKET CONSENT FOR ALL PHOTOGRAPHS, AUDIO RECORDINGS, AND VIDEOS TAKEN OF MY STUDENT. OPTING OUT OF A SPECIFIC MEDIUM IS NOT AN OPTION.

If you approve, any photograph, audio recording, or video that your child/children are depicted in may be used in any of the above-mentioned media. This includes my student's name, image, likeness, signature, or voice.

If you disapprove, any photograph, audio recording or video that your child/children are depicted in will not be used in any of the above-mentioned media. This includes my child/children name image, likeness, signature, or voice.

Please choose one: *

I DO Approve
I DO NOT Approve

By signing below, you acknowledge that you understand and agree to abide by all of the terms & conditions set forth in this document.

Date *

Signature *

Summer Enrollment Program 2024

DOLORES T. RICHARDSON SCHOOL SUMMER ENROLLMENT 2024

Parent 1 OR GUARDIAN’S INFORMATION

Parent 2 OR GUARDIAN’S INFORMATION

CHILD’S NEAREST RELATIVE:

AUTHORIZATION TO REMOVE CHILD FROM SCHOOL

EMERGENCY AUTHORIZATION

** PLEASE SIGN ONE OF THE FOLLOWING AUTHORIZATIONS **

DOCTOR’S INFORMATION

PERSONS TO CALL IN CASE OF EMERGENCY IF PARENT OR GUARDIAN CANNOT BE REACHED

Parents:

Summer Program Media Agreement

Get in touch

PLEASE SIGN ONE OF THE FOLLOWING AUTHORIZATIONS