SAM Registration | SAM Child Care Program

Online Registration for SAM Inc.

Required entries have a red asterisk (*).

"*" indicates required fields

Step 1 of 7 - Student Information

Student Registration for 2022-2023 Academic Year

Registering for:

Remainder of this academic year (2022-2023)

Next academic year (2023-2034)

Number of Students Registering*

The family registration fee is $100 for the PM program and $50 for the AM program, for families wanting drop-in availability for the PM program and for families only wanting to send their children on SAM trips on half and vacation days. The registration fee for families needing both SAM AM and PM is $150. There is an additional 3.5% fee for paying by credit card.

Note that for the 2023-24 academic year, the PM registration fee is $125 and the PM+AM registration fee is $175.

Registering For (all programs your family will need):*

Registration Prices:
PM Program Only - $100
AM Program Only - $50
AM + PM Program - $150
PM Drop-in Only - $50
Trips Only - $50
AM Program for Glenwood School Only.

Registering For (all programs your family will need):*

Registration Prices:
PM Program Only - $125
AM Program Only - $50
AM + PM Program - $175
PM Drop-in Only - $50
Trips Only - $50
AM Program for Glenwood School Only.

Hidden

Promotional Code

Please enter the discount code from the mailer.

Total (includes 3.5% credit card fee)

First Student's Information

Student's Name*

First Last

Registering for (First Student):*

PM Program

AM Program

PM Drop-in

Trips Only

Please check all programs your child will need. Do not check both PM Program and PM Drop-in.

School*

Grade*

Gender*

Start Date

MM slash DD slash YYYY

The first day of SAM is Thursday, September 1, 2022.

Approximate AM Schedule (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

You do not need to stick to this exact schedule; it is just for our planning purposes.

Approximate PM Schedule (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

You do not need to stick to this exact schedule; it is just for our planning purposes.

Schedule Comment

Status

New Student

Returning Student

Second Student's Information

Student's Name*

First Last

Registering for (Second Student):*

PM Program

AM Program

PM Drop-in

Trips Only

Please check all programs your child will need. Do not check both PM Program and PM Drop-in.

School*

Grade*

Gender*

Start Date

MM slash DD slash YYYY

Approximate AM Schedule (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

You do not need to stick to this exact schedule; it is just for our planning purposes.

Approximate PM Schedule (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

You do not need to stick to this exact schedule; it is just for our planning purposes.

Schedule Comment

Status

New Student

Returning Student

Third Student's Information

Student's Name*

First Last

Registering for (Third Student):*

PM Program

AM Program

PM Drop-in

Trips Only

Please check all programs your child will need. Do not check both PM Program and PM Drop-in.

School*

Grade*

Gender*

Start Date

MM slash DD slash YYYY

Approximate AM Schedule (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

You do not need to stick to this exact schedule; it is just for our planning purposes.

Approximate PM Schedule (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

You do not need to stick to this exact schedule; it is just for our planning purposes.

Schedule Comment

Status

New Student

Returning Student

Home Information

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Contact Cell Phone*

Primary Contact Email*

This is the email you want SAM to use to communicate with you.

First Parent's Information

Select*

Name

First Last

Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Cell Phone*

Cell Phone

Second Parent's Information

Select*

Name

First Last

Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Cell Phone*

Cell Phone

Pick Up

My child may be released from SAM to the following people (in addition to parents):

First Pick Up Name

First Last

No need to enter parents.

Phone

Relationship

Second Pick Up Name

First Last

No need to enter parents.

Phone

Relationship

Third Pick Up Name

First Last

No need to enter parents.

Phone

Relationship

Medical Information

Doctor's Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Please note any allergies, restrictions to foods (include if vegetarian or non-beef) or activity, medicines taken, special learning, physical or emotional needs and any other information that we need to know to take the best care of your child. Every effort will be made to accommodate medical or other food restrictions.
We are almost always successful but SAM is not a controlled environment. If you have concerns or a potentially urgent medical situation, please speak directly to us to review the situation.

Does the first child

Have any allergies?

Take any medications?

Have dietary restrictions?

Require other special attention?

None of the above

Let us know if the first child has any allergies, takes any medications, has special dietary restrictions or requires special attention. If so, a box will appear where you can enter the information.

Allergies - First Child*

Medications - First Child*

Dietary Restrictions - First Child*

Special Needs / Attention (social, academic, etc.) - First Child*

Does the second child

Have any allergies?

Take any medications?

Have dietary restrictions?

Require other special attention?

None of the above

Let us know if the second child has any allergies, takes any medications, has special dietary restrictions or requires special attention. If so, a box will appear where you can enter the information.

Allergies - Second Child*

Medications - Second Child*

Dietary Restrictions - Second Child*

Special Needs / Attention (social, academic, etc.) - Second Child*

Does the third child

Have any allergies?

Take any medications?

Have dietary restrictions?

Require other special attention?

None of the above

Let us know if the first child has any allergies, takes any medications, has special dietary restrictions or requires special attention. If so, a box will appear where you can enter the information.

Allergies - Third Child*

Medications - Third Child*

Dietary Restrictions - Third Child*

Special Needs / Attention (social, academic, etc.) - Third Child*

Participation in SAM Program

Consent*

I agree with the below statement.

I allow my child(ren) to attend the SAM program and to participate in the activities (except as specified by me above). I understand that SAM. Inc. will follow the procedures stated in the NJ State Licensing Manual for Day Care Centers in the operation of the SAM program. I acknowledge that if my child’s behavior at SAM is determined by the SAM staff to be detrimental to the program or to the other children in the program, (and such behavior continues to be so after consultation with me and attempts at improvement), I will be required to withdraw my child from SAM if it is the decision of the SAM administration.

Signature*

Date*

MM slash DD slash YYYY

Release for Medical Treatment

Consent*

I agree with the below statement.

In case of an emergency in which, in the opinion of SAM staff, time is of the essence, I give SAM, Inc. permission to seek the nearest medical attention for my child and/or for my child to be attended to and transported by EMTs and ambulance.

Signature*

Date*

MM slash DD slash YYYY

NJ State Notification

Read statement*

I have read the below statement.

In keeping with New Jersey's child care licensing requirements, we are obliged to provide you, as the parent of the child enrolled in our center, with this informational statement.

The statement highlights, among other things: your right to visit and observe our site at any time without having to secure prior permission; the center's obligation to be licensed and to comply with licensing standards; the obligation of all citizens to report suspected child abuse / neglect / exploitation to the State's Division of Youth and Family Services (DYFS).

Please read this statement carefully, and if you have any questions, feel free to contact me at 973-376-3434.

Jennifer Fischkoff
Director

If you have not already done so, you may download the notifications by clicking here.

Signature*

Date*

MM slash DD slash YYYY

Authorization for Transportation

Authorization for Transportation - Part 1*

I agree with the below text.

I authorize SAM, Inc. to transport my child(ren) from their school to SAM at the at the end of the school day.

I understand that my child will be transported by the school buses used by Millburn Township School District.

I understand that this permission form will remain in effect as long as my child(ren) attends a SAM, Inc. program.

Authorization for Transportation - Part 2

I agree with the below text (do not check if you don't agree).

In the unlikely event that my child does not board the bus from school to the SAM program, or the licensed school bus fails during a SAM Vacation Day or Half Day trip and that no licensed school bus replacement can be had within a reasonable time frame, I give permission for a SAM staff member to transport my child using their own vehicle.

I understand that this service is done as a “favor” to me. I understand that it is not a “job requirement” of the SAM employee, that neither the employee nor SAM, Inc. possess any special certification or insurance for this transportation “favor” and that the employee will not be paid for this “favor”.

I understand that this permission form will remain in effect as long as my child(ren) attends a SAM, Inc. program.

If you decline this option, and this event arises, your child's school and/or SAM will contact you for your other arrangements.

Date*

MM slash DD slash YYYY

Signature*

General Field Trip Permission

Consent*

I agree to the below statement.

I permit SAM, Inc. to take my child(ren) on walking trips around the area of Glenwood Elementary School.

These trips include “trick or treating” on Halloween, trip to the Arboretum and the like. These trips are infrequent and will be announced beforehand to parents.

For Middle School students, a walk to town from Millburn Middle School, in the company of a SAM staff member, for an after-school snack is common on days that are Early Dismissal Days for elementary school students (i.e. no younger students present). On the event of this outing, we plan to return to the Middle School by 5:00 pm.

This permission slip does not apply to Half Day or Vacation Day trips, which have a separate sign-up procedure.

I understand that this permission form will remain in effect as long as my child(ren) attends a SAM, Inc. program.

Signature*

Date*

MM slash DD slash YYYY

Student Photo Release Permission

Consent (Optional)

I agree to the below.

This consent is optional, but helpful to SAM to be able to show the Millburn community what the SAM experience is like for the children. Thank you.

I grant Students After-school in Millburn, Inc. (SAM, Inc.) my permission to use the photographs described as:

Photographs of my child at the SAM Program for: publicity, illustration, advertising, and web content. Neither your child’s name nor any identifying information will be published.

Signature

Date

MM slash DD slash YYYY

Anything else we should know about your child(ren)?

How Did You Hear About Us?

SAM flyer

School Website

Friend

Google Search

Other

Click Submit to send the form to SAM or click Previous if you need to make corrections or enter more data.

Registration Fee Payment

Payments must be made by credit card. PayPal is our service provider but you don't need an existing PayPal account.

Select a Payment Method*

Credit Card (PayPal) - adds 3.5% service fee

Service Fee

Price: $0.00

Registration Fee Total with Service Fee

Once you click "Submit", you will be taken to PayPal, our service provider. If you have a PayPal account, you may use it. If you don't have a PayPal account, you can set one up, or simply pay by credit card without setting up a PayPal account by clicking on the "Pay by Credit or Debit Card" button on the bottom of the PayPal page.

Comments

This field is for validation purposes and should be left unchanged.

Online Registration for SAM Inc.

Student Registration for 2022-2023 Academic Year

First Student's Information

Second Student's Information

Third Student's Information

Home Information

First Parent's Information

Second Parent's Information

Pick Up

Medical Information

Participation in SAM Program

Release for Medical Treatment

NJ State Notification

Authorization for Transportation

General Field Trip Permission

Student Photo Release Permission

Registration Fee Payment

Students After-School in Millburn

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