I agree to pay a fee of $250 as the total cost for each program scheduled. (We will notify you of
the next program offered and ask you to forward the fee at that time). I understand that the
program will consist of one session for my child (2 hours), one session for the parent(s) (2 hours),
and one session (1 hour) for my child and the parent(s) together.

I understand that this form needs to be signed and returned in order to be scheduled for the next
available program. Once paid, if I need to change my attendance at a program for which I scheduled,
I am required to give Associates of Springfield Psychological a minimum of 5 business days notice
(Sundays not included in the 5 days notice). If I fail to give the 5 business days notice of cancellation
or if I do not come for any part of the program, I agree that I am responsible for payment of the total
program for which I was scheduled (i.e., the 5 hour program). As programs are run when there are
enough participants to meet the minimum required, I understand that under no circumstances will any
refund of fees be paid if any part of the sessions are missed.

I agree to be scheduled for the next available truancy program and understand that no exceptions will
be made to the missed or late cancellation policy. I understand that the program will be run in the
Havertown office on Saturdays and I will be notified of the exact dates and times of the next session.

_________________________________________________________________________
Name, printed (student)

_________________________________________________________________________
Name, printed (parent)

______________________________________________________   __________________
Signature (parent)                                                                                                  Date

Once the forms are returned to the Springfield office, the staff will contact you for the first available
program. You can make a copy of this form to give to appropriate school or court officials. You will
be issued a certificate of completion at the end of the program. Thank you.