South Mebane Online Registration Form 2023-2024

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Your daycare account must be in good standing or a new student to South Mebane.

Email *

When will your child start attending Third St *

YYYY

Student ID Number (not applicable to rising kindergarten or newly enrolled students)

Grade Level For 2023-24 School Year *

Type of care needed *

AM only

AM/PM

PM only

Part time PM (10 visits per month)

Students Name: Last Name, First Name *

Child's Date of Birth *

mm/dd/yyyy

PRIMARY Parent/Guardian names, phone numbers, address, and e-mails *

Format: First & Last Name, Phone #s (specify cell, day, and home), Address, Email (If ABSS employee, please provide both ABSS email and an email address other than your ABSS address.)

Father/Guardian *

Work/Phone extension *

Cell # *

Address *

Email *

Mother/Guardian *

Work/Phone extension *

Cell # *

Address *

Email *

SECONDARY Parent/Guardian names, phone numbers, address, and e-mails *

Format: First & Last Name, Phone #s (specify cell, day, and home), Address, Email (If ABSS employee, please provide both ABSS email and an email address other than your ABSS address.)

Father/Guardian

Work/Phone Extension

Cell#

Address

Mother/Guardian

Work/Phone Extension

Cell#

Address

Is there a separation, divorce or custody concern of which our staff needs to be aware? *

Yes

Yes, please explain

Are you employed by Alamance Burlington School System? *

Yes

If you are an ABSS employee, what location?

Emergency Contact and Pick Up authorization

The following people may pick up the child from the program and/or be reached during an emergency. In the event of inclement weather or an emergency situation. Please make sure you have made arrangements with these individuals to pick up your child/children from the program and they are accepting of this responsibility.**Please note a valid ID will be required to pick up students from daycare.

1st Pickup Name, Relationship, Phone# *

2nd Pickup Name, Relationship, Phone# *

3rd Pickup Name, Relationship, Phone# *

4th Pickup Name, Relationship, Phone#

5th Pickup Name, Relationship, Phone#

6th Pickup Name, Relationship, Phone#

7th Pickup Name, Relationship, Phone#

8th Pickup Name, Relationship, Phone#

9th Pickup Name, Relationship, Phone#

Is there any person prohibited from picking up the child by a court order? *

Yes

If yes, attach a copy of the court order and an explanation

Prohibited Persons Name

Relationship to Child

Important Student Information

Please list allergies and needed medications

Please list any allergies *

Please list any required medications *

Emergency Permission *

I give permission to S. Mebane Elementary School Daycare staff to authorize emergency treatment and transportation of my child to Alamance Regional Medical Center Hospital.

I DO NOT give permission to S. Mebane Elementary School Daycare staff to authorize emergency treatment and transporation of my child to Alamance Regional Medical Center Hospital

Field Trip (If Applicable)

I give permission for my child to attend any off school field trips on teacher workdays. Transportation will be provided by ABSS buses. I give my permission for my child to be transported on buses for daycare field trips.

I DO NOT give permission for my child to attend any off school field trips on teacher workdays. Transportation will be provided by ABSS buses. I give my permission for my child to be transported on buses for daycare field trips.

Clear selection

Movie Permission (If Applicable) *

I give permission for my child to watch PG movies

I do not give permission for my child to watch PG movies

Homework Preference (note this option may not be available at you school please check with each individual location) *

I prefer that my child work on homework during afterschool (1st-5th grade)

I prefer that my child DOES NOT work on homework during afterschool.

Participation and Payment Agreement *

My child and I have read, discussed, and agree to abide by the rules, regulations, and payment schedule for attending S. Mebane Elementary School Before and After School Program.

Questions and comments

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