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In the box below answer the following questions:

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• Does your child have any allergy or medical concerns?

• If other was chosen above, what school do you child attend if any?

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• How did you hear about us?

• Provide Emergency contact and phone number

• Student School Name

*Payment Options: Payments may be made with debit or credit card our website. You may also pay by cash, money order, cashier’s check, debit or credit card in our facility. The D-Xperience (DX) no longer accepts personal checks as a form of payment. Fee Payment Policy: Fees are due on or before Monday of the week of care. Fees may be paid in advance for any period of time. If a holiday or snow day occurs on a usual fee collection day, an extra day of fee collection will be added without penalty. Checks or money orders should be made payable to: D-Xperience. Late Payment Penalties: Weekly fees are due on Monday for the week of care. If you are paying daily the late fee is due before your next service. If fees for the week haven't been paid on Monday, a $5 late fee is assessed and a $1 late fee is applied if paying daily. If you will not be making full payment on Friday, remember to make other arrangements for your child. Your child cannot return to our program until full payment of the balance due has been made. A $10 registration fee is due at re-enrollment the following Monday (not the late fee). TERMS: You agree that the Executive Director may authorize the physician of his/her choice to provide emergency care in the event that neither you nor the family physician can be contacted immediately. You give D-Xperience permission to transport your child by facility van/automobileor bus to field trips away from the facility upon acknowledgement of the activity. This authorization is valid from 01/01/2019 to 12/1/ 2022You understand that the facility will notify you each time your child is to participate in an activity that would involve transportation other than daily travel to and/or from school. You have read and agree with all policies and procedures set by D-Xperience. When your child is absent, you understand that your normal weekly rate is required. NO EXCEPTIONS. Weekly fees are not prorated. These Terms are between D-Xperience and its affiliates (collectively, “D-Xperience”), and “you,” the individual completing this form. You agree that this form is like any written negotiated agreement signed by you. BY CLICKING TO ACCEPT THE TERMS, YOU AGREE TO BE BOUND BY THE TERMS THAT APPLY TO YOU AS DESCRIBED ABOVE. ACCEPT TERMS *You must accept the terms of this agreement to submit your application.

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