CCS Before & After Care Program Registration (24/25)

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This program is available for Middle School and High School students, 6th grade and older.

Before Care hours are 7:00am-8:15am.

After Care hours are 3:30pm - 5:30pm.

Email *

Child's Name: *

Child's Grade: *

Home Address: *

Mother's Name: *

Mother's Employer:

Mother's Cell Phone: *

Mother's Work Phone:

Father's Name: *

Father's Employer:

Father's Cell Phone: *

Father's Work Phone:

Are there any Restraining Orders? If yes, copies must be submitted. *

Yes

Primary Emergency Contact Name & Phone (other than parents). *

Secondary Emergency Contact Name &Phone (other than parents).

List any medical problems, medications, allergies, or special needs:

Please check all that apply indicating days of the week your child will be in attendance: *

Full Time Before School Care

Full Time After School Care

Monday Morning

Tuesday Morning

Wednesday Morning

Thursday Morning

Friday Morning

Monday Afternoon

Tuesday Afternoon

Wednesday Afternoon

Thursday Afternoon

Friday Afternoon

My child will be staying on an as needed basis in the MORNING

My child will be staying on an as needed basis in the AFTERNOON

Required

The $25 registration fee will be billed to your FACTS account. If you are full time, the first month will also be billed. Please type your name first and last below to confirm. *

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