Millburn  School  District  24    

2017-­‐18  Reg i s t ra t ion  Fees    One  form  required  for  each  student.      

GRADES  Early  Childhood  through  5            STUDENT  NAME                                                                                                          GRADE               Last                                   First              

Materials  and  Program  Support  Fees   Fee  Received  BEFORE  4:00  PM  on  6/02/17  

O  R  

Fee  Received  AFTER  4:00  PM  on  6/02/17  

Returning  Students  in  Grades  1,  2,  3,  4,  5   $175.00   $225.00  

Returning  Students  in  Early  Childhood   $125.00   $175.00  

TOTAL      

                     

                                                                                                   

Two  ways  to  pay:    

☐  CHECK  PAYABLE  TO  MILLBURN  DISTRICT  24    

☐  CHECK  HERE  IF  USING  REVTRAK  and  ATTACH  PRINTED  RECEIPT                            For  Office  Use  Only      

 

 

CASH  $   CHECK#   CHECK  AMT$   Check  applies  to  more  than  one  in  family?                                    YES  PAID  BY  REVTRAK  –  Confirmation  #   Name  on  check  if  different  from  student  Date  Received   Processed  by  

To pay the lower cos t on the l i st be low , reg is te r on or befo re 4 :00 p .m. on

Fr iday, JUNE 2 , 2017

$

 

 Millburn  School  District  24    

2017-­‐18  Reg i s t ra t ion  Fees    One  form  required  for  each  student.      

GRADES  6  -­‐  8        STUDENT  NAME                                                                                                              GRADE               Last                                   First                                                            

                                                                                               

Two  ways  to  pay:    

☐  CHECK  PAYABLE  TO  MILLBURN  DISTRICT  24  

☐  CHECK  HERE  IF  USING  REVTRAK  and  ATTACH  PRINTED  RECEIPT                              For  Office  Use  Only      

 

Materials  and  Program  Support  Fees     √  Items  you  are  

purchasing  

Fee  Received  BEFORE  

4:00  PM  on  6/02/17  

 OR  

Fee  Received  AFTER    

4:00  PM  on  6/02/17  

Grade  6      (includes  gym  uniform  of  shorts  and  shirt)  

  $195.00   $245.00  

Grade  7             $195.00   $245.00  

Grade  8             $195.00   $245.00  

Additional  PE  Shirt  (6-­‐8)  Optional  Purchase     $        5.00   $        5.00  

Additional  PE  Shorts  (6-­‐8)  Optional  Purchase     $        8.00   $        8.00  

TOTAL        

CASH  $   CHECK#   CHECK  AMT  $   Check  applies  to  more  than  one  in  family?                                      PAID  BY  REVTRAK  –  Confirmation  #   Name  on  check  if  different  from  student  Date  Received   Processed  by  

To pay the lower cos t on the l i st be low , reg is te r on or befo re 4 :00 p .m. on Fr iday,

JUNE 2 , 2017

$

Millburn  School  District  24    2017-­‐18  Activities  and  Fees    These  are  the  ACTIVITIES  that  are  available  for  the  2017-­‐18  school  year.    At  the  appropriate  time/season,  the  coach/sponsor  will   have   forms   available   for   students   to   take   home   and   have   signed   by   a   parent.      All   the  below   activities   cost   $150.00   each.     Fees   are   due  when   the   form   is   returned.       For   an   additional   fee,   for  eligible  students,  an  Activity  Bus  is  available  upon  completion  of  the  Activity  Bus  Registration  form  available  on  the  website.    

             

               These  are  the  CLUBS  that  may  be  available  for  the  2017-­‐18  school  year.      The  sponsor  will  send  home  a  form  to  be  signed  by  a  parent.      All  clubs  are  $50.00  each.    Fees  are  due  when  the  form  is  returned.      For  an  additional  fee,   for   eligible   students,   an  Activity  Bus   is   available  upon   completion  of   the  Activity  Bus  Registration   form  available  on  the  website.    Please  note:    not  all  activities  are  available  at  both  schools.        Note:     In-­‐house  clubs  should  not  be  confused  with  groups  who  rent  space   from  the  district  and  offer   similar  programs  to  our  students.    In-­‐house  clubs  are  supervised  by  district  teachers.        

CHESS  CLUB   GAME  CLUB  ART  CLUB   MATH  CLUB  STUDENT  SERVICE  CLUB   NEWSPAPER  YEARBOOK   CREATIVE  WRITING  ECOLOGY  CLUB    

   

MILLBURN  MIDDLE  SCHOOL  JAZZ  BAND  THEATER  (Grades  4-­‐8)  DANCE  TEAM  CHEERLEADING  SCHOLASTIC  BOWL  BASKETBALL  CROSS  COUNTRY  (Grades  5-­‐8)  WRESTLING  (Grades  5-­‐8)  SOCCER  TRACK  

MILLBURN  ELEMENTARY  SCHOOL  BAND  CHOIR  THEATER  (Grades  4-­‐8)  CROSS  COUNTRY  (Grades  5-­‐8)  WRESTLING  (Grades  5-­‐8)  

 

2017-­‐18  Act iv i ty  Bus  Fee      ❏      My  child  should  be  included  on  the  Bus  Roster  for  the  sport/activity  in  which  he  or  she  is  participating.  

   Note  to  Middle  School  Parents:    If  your  child  is  not  eligible  for  regular  bus  service,  then  bus  service  for  activities  or  clubs  is  also  not  available.      STUDENT  NAME_____________________________________________________        GRADE  _________            

Activity   Full  Year  Option  Only  

       

Sport/Activity*   Seasonal  Cost  

 Any  Activity  held  outside  the  school  day          

1  day  a  week  

   

$80.00  

 All  seasonal  sports    

 $80.00  

 Any  Activity  held  outside  the  school  day  

2  days  a  week  

 $120.00  

     

NOTE:  if  your  child  participates  in  three  or  more  sports/or  activities,  the  cost  for  busing  for  the  year  will  not  

exceed  $200.00.  

 Any  Activity  held  outside  the  school  day        

3  days  a  week  

 $150.00  

 Any  Activity  held  outside  the  school  day      

 4  or  5  days  a  week  

 $200.00  

 Homework  Hut  –  2  days  a  week  

 $120.00  

   

How  to  Pay?  • A  check  made  payable  to  “Millburn  School  District  24”    • RevTrak  (online  payment  system)  Include  a  copy  of  the  receipt  with  this  form.  

   

 

For  Office  Use  Only  CASH  $   CHECK#   REVTRAK   Name  of  check  if  different  from  student  

Check  applies  to  more  than  one  in  family?                                    YES   Date  Received   Processed  by  

Millburn CCSD #24 exists to create a culture of learning that inspires and empowers students to enrich our community.

Millburn Community Consolidated School District 24 Yearly iPad Accident Protection Plan

Millburn School District 24 is providing and administering an accident protection plan for students and parents as part of our iPad Learning Initiative. Enrollment in this plan is required for students who wish to take their iPad home. Students who are not enrolled in the plan will check their iPad in and out of the classroom each day. This plan covers “accidental damage” to the device and is designed to limit a family’s financial responsibility for any damage as described in the coverage section below. In addition each device is covered under a manufacturer's warranty that covers the normal operation of the device to ensure that it is functioning properly.

Program Rate/Coverage ● $30 Non-refundable Annual Premium ● Limit of Liability: $400

Effective Coverage/Expiration Date ● Effective Date: Based on the receipt of signed

agreement. ● Expiration Date: Last day of school for the current

school year or date of last day of attendance if transferring out of the district.

Coverage (Subject to Deductible Plan Below)

● Accidental Damage: Pays for accidental damage caused by liquid spills, drops, or any other unintentional event.

● Theft: Pays for loss or damage of the iPad due to theft. The claim requires a police report to be filed.

● Fire: Pays for loss or damage of the iPad due to fire. The claim must be accompanied by an official fire report from the investigating authority.

● Electrical Surge: Pays for damage to the iPad due to an electrical surge.

● Natural Disasters: Pays for the loss or damage of the iPad caused by natural disasters.

Exclusions ● Dishonest, Fraudulent, Intentional, Neglect or

Criminal Acts: Will not pay if damage or loss occurs in conjunction with dishonest, fraudulent, intentional, negligent or criminal act. The student/parent will be responsible for the full amount of the repair/replacement.

● Consumables: Parent will pay 50% of consumables including but not limited to the case ($60-$100), the charger ($29), and software.

● Cosmetic Damage: that does not affect the functionality of the device. This includes but is not limited to scratches, dents, and broken plastic ports/parts or port covers.

● “Jail-breaking” or otherwise voiding the manufacturer’s warranty by altering the software.

● Millburn D24 is not liable for any loss, damage (including incidental, consequential, or punitive damages) or expense caused directly or indirectly by the equipment.

Annual Deductible Per Claim If a student loses an iPad more than once, take home privileges

will be revoked Deductible per Occurrence

$50

Damage/Repair or

Lost/Stolen

If a student is unenrolled from Millburn District 24 for any reason, this accidental protection plan agreement becomes null and void on that date. There are no refunds once this agreement becomes active on the date the iPad is issued. The iPad must be returned on the last day of student attendance.

PLEASE COMPLETE THE INFORMATION ON THE NEXT PAGE AND RETURN THE FORMS TO SCHOOL WITH PAYMENT TO YOUR CHILD’S SCHOOL OFFICE.

Parentspaythepricebelowreflecting50%ofthepriceshownforeachitem.______RuggedCap-$2.50

______RuggedCradle&Cap-$30

______RuggedFrame-$12.50

______RuggedCover–$12.50

______RuggedKeyboard–$24.50

______LighteningCable–$9.50

______12WPowerAdapter-$9.50

______CompleteCase-$49.50

Appl icat ion for Fac i l i t ies Use – 2017-18 MILLBURN C. C . SCHOOL DISTRICT 24 • www.mi l lburn24.net

Updated 02/22/2016

☐ M i l lburn E lementary Schoo l •18550 M i l lburn Road • Wadswor th , IL 60083 • PH 847-356-8331•FAX 847-356-9722 ☐ M i l lburn M idd le Schoo l • 640 Freedom Way • L indenhurst , IL 60046 • PH 847-245-1600 •FAX 847-265-8198 FAC IL IT IES CHARGES District 24 is charging rental fees in an attempt to cover the costs incurred for overtime, custodial, supplies, and utilities as

approved by the Millburn Board of Education.

CATEGORY CHARGES NOTE: PAYMENT IS DUE IN ADVANCE OF THE SCHEDULED EVENT Custod ia l Fee District Sponsored, PTO and Foundation

Waived Waived

Charitable and Non-Profit (requires proof of tax-exempt status) ➤ $5 per classroom; for 2 or more classrooms - $10 each ➤ $50 for gym ➤ $50 for cafeteria

$37 per hour*

Colleges and Universities

$750 per course $37 per hour*

Commercial

Whichever is greater: 15% of gross revenue realized through location OR $15 per classroom/$75 per gym or cafeteria. Whichever is greater, for daily, exclusive school-year use: the rental charge will be a minimum of $4250 per classroom or 20% of gross revenue. If anticipating using % of revenue, a $50 refundable deposit is required with application. A check for the full amount of charges or the $50.00 deposit as listed, is due with this application. Checks are made payable to “Millburn District 24.”

$37 per hour*

Field Use $20 per field** *This additional fee will be charged when a custodian needs to be scheduled during non-working hours (including clean up)

**Lindenhurst Park District is exempt. Contact Person: Email Mailing Address, City, State, Zip Phone GROUP INFORMATION Name of Requesting Group: (Scout groups must include troop/den number and grade level) Check one: ❐ D is t r ic t Organ izat ion ❐ Commerc ia l ❐ Non-Pro f i t ❐ Co l leges and Un ivers i t ies Purpose and Nature of Activity (briefly) Anticipated Number of Participants: Activity will be open for ❐ General Public ❐ Group Members Only ❐ Restricted to: DATE and T IME REQUESTED Dates will only be approved when school is in session.

FAC IL IT IES REQUESTED OTHER NEEDS

❐ East Gym (does NOT inc lude Stage) ❐ C lassroom ❐ Tab les ❐ B leachers

❐ West Gym ❐ Soccer F ie ld (see be low for f ie ld ass ignment a t E lem Sch)

❐Cha i rs

❐Other ❐ Ca fe ter ia (does NOT inc lude K i tchen) ❐ O ther

CERTIF ICATE o f L IABIL ITY A Certificate of Liability Insurance with Millburn School District 24 listed as an additional insured on a primary - noncontributory basis, in the following amounts is needed: • General liability- $1,000,000 per occurrence /$3,000,000 general aggregate. • Auto liability: $1,000,000 per occurrence. • Workers Compensation- $1,000,000/$1,000,000/ $1,000,000

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Check one: ☐ Single Meeting Date ☐ Series of Meetings Date(s) Requested: Day of Week: Start time of activity: AM or PM End time of activity: AM or PM

All non-school related groups must supply adequate supervision to ensure proper care and use of school facilities. The non-school related group is responsible to the Board for the use and care of the school facility. All adult supervisors must have cell phones with them at all times. Sufficient, competent adult supervision must be provided and the adult supervisor must ensure that no minor is left alone after the activity. Only assigned classrooms, the dafeteria, auditorium, gymnasium, and assigned athletic fields, along with needed hallways and parking areas, are avilable for community use. Entering any room or ara not in use by the group is prohibited. The adult supervisor will vacate the facility at the scheduled end time. Use of the school facility is not permitted past the agreed end time. No tables, bleachers, furniture or equipment may be moved without prior approval from the Building Principal. Signs, displays, or materials may not be attached, nailed, or otherwise affixed to walls.

_______Initial here to agree to above statements. All non-school related groups must agree to: • Indemnify and hold harmless the District and its agents and employees for and from any and all loss including attorneys’ fees, damages, expense, and liability arising out of its use of school property. • Pay any damages to school facilities, furniture, or equipment arising out of its use of school property whether such damage was accidental or deliberate. The cost of damages will be based on the repair or replacement cost, the choice of which is at the School Board’s discretion. • Supply proof of insurance naming MILLBURN SCHOOL DISTRICT 24 as an additional insured and verifying that the group maintains adequate insurance coverage against personal injury and/or property loss: Insurance provider name and contact number_________________________________________________________________________________________

_______Initial here to agree to above statements. If the request involves a physical fitness facility, the non-school related group must:

• Designate at lease one adult supervisor who agrees to be an emergency responder. All emergency responders are encouraged to be trained in CPR and AED use. • Be given a copy of the District’s plan for responding to medical emergencies to each designated emergency responder. • Require that 9-1-1 be called for medical emergencies and whenever an AED is used. • Ensure that each designated emergency responder knows the location of first aid equipment and any AED. • Ensure that only trained AED users operate an AED, unless the circumstances do not allow time for a trained AED user to arrive. • Arrange for at least one emergency responder to have a tour of the facility before the activity. • Ensure that if an AED is used, the Superintendent is informed and all appropriate forms are completed.

_______Initial here to agree to above statements.

➨ If charitable or non-profit organization, proof of tax-exempt status is attached. I certify that I am authorized to act for the above-named organization. I understand that: (1) the granting of this request does not constitute recognition of my organization as a school-related group or activity, and (2) my organization may not represent itself or any of its activities as school-related.

I agree to: (1) abide by the conditions stated in this application, and (2) adhere to all Board policies and administrative procedures applicable to this use of the school’s facility.

Applicant name (please print) Telephone number

Address Email address

✎ Applicant signature Date

M i l lburn E lementary School SOCCER FIELD ASSIGNMENT ❐ A Northwest Field ❐ B Northeast Field

❐ C Center-west Field

❐ D Center-east Field

❐ E South Field

For Office Use Facilities Use ❐APPROVED ❐ DENIED O ther Needs ❐ APPROVED ❐ DENIED ✎ Principal Signature _____________________________________________ Date____________________ Dates NOT included with this application

Room Assignment

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