2021-2022 Extended Day Registration Form
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Student Last Name *
Student First Name *
Student Middle Name *
Grade For 2021-2022 *
Birth Date
Street Address
City *
State *
Zip Code *
Father's Name *
Father's Email Address *
Father's Employer *
Father's Work Phone number *
Father's Home Phone Number *
Father's Cell Phone Number *
Mother's Name *
Mother's Email Address *
Mother's Employer *
Mother's Work Phone Number *
Mother's Home Phone Number *
Mother's Cell Number *
Legal Guardians Address( If different from above if not put N/A) *
Enrollment Information : Check all that apply *
My child is allergic to Bee Stings *
IF answer above was yes: What instructions should be followed if your child is stung? *
What other medical conditions or allergies should we know? If there are none , please type N/A *
Child's Doctor *
Doctor's Phone Number *
First Emergency Contact Name *
First Emergency Contact Phone Number *
First Emergency Contact Relationship to Child *
Second Emergency Contact Name *
Second Emergency Contact Phone Number *
Second Emergency Contact Relationship to Child *
The following people are allowed to pick my child up from the after school program. *
By responding to this statement, I understand that the school will attempt to contact me in the case of an emergency such as an accident or serious illness, If I cannot be reached, I authorize the school to contact the doctor listed on this form and follow doctor's directions. If the doctor cannot be reached, I authorize the school to take whatever steps they deem necessary. *
I understand that a one-time a year, non-refundable fee of $40 per family will be required. If the child transfers to another school where a program exits, the $40 fee must be paid again. Please type your name below that you understand. *
Payments for the after school program are due on Fridays by closing time in advance of after school care for the following week. Failure to pay fees will result in the child being withdrawn from the program. If there is a problem with checks being returned, the director may require that payments be made in cash. Parents may not be indebted to the program. Fees must be paid even if your child does not attend for any reason. All schools operate on guidelines from Greenville County Schools. The cost of our program is very much below that of private daycare; therefore, fees must be paid whether or not your child attends. If your situation changes , and you no longer need the services of our program, you may withdraw your child to avoid paying for weeks you do not need. If space is available you may re-enroll your child when your circumstances change. *
Name and email of person completing this form. By adding my name and email here, I understand all rules and regulations of the Extended Day program. I understand that I am not assured a spot in EDP until the school has received the $40 registration fee and I have verification from the school that my child is accepted into the program *
Date *
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