2018-2019 Extended Learning Registration
Welcome to the Extended Learning program's 2018-2019 school year registration!
Please fill out this registration form to apply for a spot in our growing program.

All successful registrations will be charged a $35 non-refundable registration fee to reserve your child's spot. You will see this bill in August when it will be sent to your email account associated with MySchoolBucks.com

Our billing is done through MySchoolBucks.com, please create an account on their website to receive your electronic invoices. Please email me at lbotko@nrsd.net if you have any questions regarding billing.
All payments are due on the 28th of the previous month. Payments that are not processed by the 28th of the prior month will result in a $20.00 late free and suspension from the program.
We offer a 10% discount for each sibling. Please fill out a separate form for each child.
We are excited to offer automatic payments through the MySchoolBucks.com website, per parent request!

Registration will be open from May 1st until June 30th. Any registrations after June 30th will be placed on our waitlist, and will be considered after August 20th based on availability.

Email address *
Child First name *
Your answer
Child Last name *
Your answer
School *
Grade *
Student DOB *
MM
/
DD
/
YYYY
Student Gender *
Attendance
Children thrive socially and academically in an environment that provides familiarity and routine. The Extended Learning program takes pride in providing this familiarity for our students. To maintain our students' routines and schedules, we encourage regular attendance.
Please let us know if your child will be absent via email or phone call by 7:30 am for AM program, or 2 pm for PM program. *Failure to inform us of an absence from the program will result in a $10.00 fee.*
In emergency situations, parents may add days on a single basis for $6.00 (AM program) or $37.50 (PM program) per student. To request an extra day, please contact lbotko@nrsd.net AND complete an online change of schedule form, found on our website.
All schedule changes must be on a monthly basis, schedule changes of less than one month in duration will not be considered and WILL NOT be prorated.
All schedule change requests after AUGUST 1ST will be assessed a $15.00 fee.
AM program days per week (7:25 - 8:25 AM)
PM program days per week (3:00 - 6:00 PM)
AM program days of attendance (starts 7:25 am) *
Required
PM program days of attendance (ends at 6 pm) *
Required
Parent and other contact information
Please provide the best way to reach you or other emergency contacts.
Parent First Name *
Your answer
Parent Last Name *
Your answer
Parent email *
Your answer
Parent address *
Your answer
Best phone number to reach parent in case of emergency *
Your answer
Second best phone number to reach parent *
Your answer
Alternative contact FIRST AND LAST NAME *
Your answer
Alternative contact phone number *
Your answer
Alternative contact relationship to student *
Your answer
Alternative contact email (if they would like to receive communications)
Your answer
Emergency contact FIRST AND LAST NAME *
Your answer
Emergency contact phone number *
Your answer
Students relationship to emergency contact *
Your answer
FIRST AND LAST name of alternative pick up person (must be over 18 and have valid ID) *
Your answer
Alternative pick up person phone number *
Your answer
Medical Information
Provide us with a detailed account of student medical information. Please note that there is NO NURSE ON DUTY during these hours. Our staff cannot administer medications, sun tan lotions, bug sprays, or any other over-the-counter products.
Does your child have a life threatening allergy? *
If so, please describe below
Your answer
Does your student use an Epi-Pen? *
Does your child have a non-life threatening allergy? *
If yes, please describe
Your answer
Does your child have any other medical conditions? (Check as many as apply) *
Required
Does your student take any medication that you would like staff to be aware of?
Your answer
Physician name *
Your answer
Physician address *
Your answer
Physician phone number *
Your answer
Dentist Name *
Your answer
Dentist address *
Your answer
Dentist phone number *
Your answer
Social-emotional information
Please provide us with any information about your child's social emotional well-being, so we may best attend to their individual needs. We have an open communication policy with our day schools which allows us to maintain effective, positive behaviors and learning strategies.
Does your student have an IEP, 504 or other special considerations? *
Required
Does your child have any social/emotional sensitivities that we should be aware of?
Your answer
Student Identification
Please help us with some key identifying information, so we can quickly learn who your child is.
Hair color *
Your answer
Eye color *
Your answer
Height *
Your answer
Weight *
Your answer
Identifying marks *
Your answer
Parent Permission Acknowledgments
Please initial below to sign off on each statement.
Please initial to approve student participation in Home Work Time (30-40 minutes) *
Your answer
Please initial to acknowledge that staff has access to IEP, 504, or any other specialized learning plan *
Your answer
Please initial to approve students participation in Friday movie day G or PG *
Your answer
Please initial to approve students participation in walking trips *
Your answer
Please initial to approve students participation in photographs (used for our website, Extended Learning Twitter, and local newspapers only) *
Your answer
Please initial to agree to read the 2018 - 2019 Parent Handbook, and return a signed hard copy of the Extracurricular Activity form to your location's Site Coordinator *
Your answer
Please initial that you understand our billing is done through MySchoolBucks.com which you will need to create an account for your student through the site. All bills will be sent electronically to your email. Payment is due on the 28th of each month August-May. You can waive all program fees for 12 months by signing up for a OnePay Membership, found under My User Profile.
Your answer
Please initial to acknowledge that there is no nurse on duty. Medications, sun screen, bug sprays etc. cannot be administered by Extended Learning staff. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Nashoba Regional School District. Report Abuse - Terms of Service - Additional Terms