330 Hookstown Grade Rd, Moon Twp, PA 15108, (412) 264-9392
2020-2021 Study Care Program Fee Agreement/Contract
Child #1:
First and Last Name: [Participant-1] Date of Birth: [Participant-1-Birthday]
School Name and District: [District-1] Grade: [Grade-1]
Child #2:
First and Last Name: [Participant-2] Date of Birth: [Participant-2-Birthday]
School Name and District: [District-2] Grade: [Grade-2]
Child #3:
First and Last Name: [Participant-3] Date of Birth: [Participant-3-Birthday]
School Name and District: [District-3] Grade: [Grade-3]
Other Participants:

Total Number of Children Enrolling: [participants]

The Study Care Program provides the following items for your child while accessing their school’s online program in a safe environment during your work day:

  1. A SPACE for your child
  2. SUPERVISION of your child
  3. Limited academic direction
  4. Extension cords
  5. Face shields
  6. Hand Sanitizer
  7. Bottled water

YOU must provide the following items for your child:

  1. All supplies needed to complete assignments (i.e., tablet, laptop, chargers, calculators, pens/pencils, etc.).
  2. A bag lunch that includs a drink and eating utensils. The lunch must be ready to eat.  A refrigerator or microwave will NOT be available.
  3. A face mask that must be worn during arrival and dismissal.

FEE Schedule: (if paying by check, please make it payable to IMPACT CHRISTIAN CHURCH)

  1. Non-refundable Application Fee: $25.00/one-time fee paid with submission of application. This can be paid by a check or credit/debit card.
  2. Study Care Program Fee: $100/week paid on the FIRST AND THIRD MONDAY of the month FOR A TWO WEEK PERIOD through auto pay account. (No refunds will be given for days absent.) This fee secures a space for your child regardless of how many days they actually attend. Based on the number of children enrolling, your cost per week excluding any late pickup fees for the above services is: $[Total]
  3. Late Pickup Fee: $15/ 1 to 15 minutes after 3:00 pm, paid by check or credit/debit card on Fridays.
  4. Recess Activities: $0/included in the Study Care Program Fee

Please select the days for your child(ren)'s regular attendance: 7:30 AM - 3:00 PM:

Additional Items:

  1. Medical Care, if required, will be paid for by the parent(s)/guardian(s).
  2. Transportation to and from the center will be provided by the parent(s)/guardian(s).
  3. No off premises activities will be offered.

Digital Signature:
I hereby affirm the information provided above is accurate: [Affirmation]
Today's Date: [Today]
Initials and First/Middle/Last Name (i.e., JDS John Dean Smith):
Form Version Date: 08/14/2020