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Ready To Enroll?

Welcome! We are excited to get to know your child and family better. By filling out these forms, you will help us understand your child's interests and needs, so we can provide the best possible care and education. Thank you for choosing us as your partner for your child's growth.


Samara After-school Program (SAP)

Pronouns Preferred
Grade (2024-2025 School Year)

Parent/Guardian Information

What is your relationship to the youth enrolling?

School History

Current School Placement

Therapies History

Directions: Please list any special services your child is currently receiving or has received in the past two years.


Consent Statement -Medical Release Permission Form

I further acknowledge, understand and agree that by taking part in SAP there is a possibility of physical illness or injury (minimal or serious) and the participant is assuming the risk of such injury by participating.
I accept risks
I allow a hospital or doctor to treat my child without parent’s consent (unless it is a matter of lifeor death), while under the supervision of Samara Learning Center.
I agree

Emergency Contact

Web, Social Media, & Marketing Release Form

Samara Learning Center, Samara's collaborators, news/information-based publication may post photographs and/or videos of my child and their work on electronic media, promotional/news/information material, including but not limited to web pages, social media, or newspaper/magazine articles. Nothing more than my child's age or grade level will be assumed to be allowed to be connected to any use. My child's name will not be associated with any of the images unless I am specially contacted and I express my permission for each occurrence.

Quarterly Enrollment

Directions: Select the days of the week you would like your child to attend. Samara predicts that space will fill quickly. We suggest you select dates for each quarter. Payment is due three weeks prior to each quarter starting to secure childcare. You will be invoiced accordingly. Our fees are $14.50/hr on Mondays, Tuesdays, Thursdays for 3 hours and $14.50/hr on Wednesdays for 4.5 hours. Our cancelation policy is stated in the payment contract that follows.

Quarter 1: 09/09/24-11/08/24

Mondays (10 days): $435.00

Tuesdays (10 days): #435.00

Wednesdays (9 days): $587.25

Thursdays (9 days): #391.50

 payment due: 08/19/2024

Quarter 2: 11/12/24- 02/01/25

Mondays (7 days): $304.50

Tuesdays (9 days): $391.50

Wednesdays (9 days): $587.25

Thursday (8 days): $348.00

 payment due: 10/21/2024

Quarter 3: 02/03/25- 04/11/25

Mondays (7 days): $304.50

Tuesdays (8 days): $348.00

Wednesdays (8 days): $522.00

Thursday (8 days): $348.00

payment due: 01/13/2025

Quarter 4: 04/14/25- 06/20/25

Mondays (8 days): $$348.00

Tuesdays (9 days): $391.50

Wednesdays (8 days): $522.00

Thursday (8 days): $348.00

 payment due: 03/17/2025

Childcare Payment Contract

Directions: Please initial the following statements.. By initialing below, I verify that I have read this policy. I will abide by it or voluntarily choose to forfeit my childcare.

Forms of payment accepted:



Money Order

Credit Card (with 3% QB fee)

Debit Card (with 1% QB fee)

Obligations of Samara After-school Program (SAP):

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