Summer Camp Financial Agreement Form - Grand View Health

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Grand View Health > Grand View Health Children’s Center > Summer Camp > Summer Camp Financial Agreement Form

Name(s) of Child(ren)
Child 1 Name * Required
First Last
Child 1 Age * Required
Child 2 Name
First Last
Child 2 Age
Child 3 Name
First Last
Child 3 Age
Are you a Grand View Employee? * Required
- Yes
- No
For GVH Employees
Please select the number of days you will be contracting:
- 20 contracted days from 6/20-8/26 = $890
- 30 contracted days from 6/20-8/26= $1250
- 45-50 contracted days from 6/20-8/26 = $1355
Please select the payment plan:
- I will make equal payments by check due on June 6, June 20, July 18 and August 1, 2016
- I will pay in full by check on June 20, 2016
- I will have tuition withdrawn by GVH payroll deduction beginning with the pay of June 9 and concluding with the pay of August 18, 2016 (Grand View Employees Only)
Would you like the Registration Fee to be payroll deducted?
- Yes
- No
For Community Members
Please select the number of days you will be contracting:
- 20 contracted days from 6/20-8/26 = $950
- 30 contracted days from 6/20-8/26 = $1340
- 45-50 contracted days from 6/20-8/26 = $1580
Please select the payment plan:
- I will make equal payments by check due on June 6, June 20, July 18, August 1, 2016
- I will pay in full by check on June 20, 2016
Agreement
By typing my name below, I agree to make the payments by the scheduled dates. I understand that there is no refund for early withdrawal. Extenuation circumstances may be reviewed. I also understand that the daily rate will apply for additional days that are added in addition to my contracted days.
Parent Signature * Required
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Name
This field is for validation purposes and should be left unchanged.

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