Extended Day Authorization Form
Saint John XXIII Catholic School Extended Day FACTS Authorization Form
Welcome to St. John XXIII Catholic School’s Extended Day program! We sincerely hope that
this service will be a rewarding experience for both you and your student(s). In order to ensure
that the program is consistent with your expectations, we are requesting that you review the
Extended Day Policy - which can be found on the website under the Parents tab in the Parent-
Student Handbook, as well as the Extended Day Overview /FAQ – which can be found on the
website under the Parents tab, Extended Day.
Extended Day is offered Monday through Friday, K-8th Grade, from school dismissal until
5:30pm. The Extended Day Program will be offered every day that school is in session except
for those days noted on the school calendar. If school is not in session, there will be no
Extended Day.

Extended Day Fees:
 Monthly - $250
 Daily - $20
 After 5:30 pm pickup: $5 per minute
 Extended day fees are billed monthly

Your consent below will serve as acknowledgement that you have reviewed the Extended Day
Policy and the Extended Day Overview/FAQ, have read and understand the terms, and that you
authorize us to bill your FACTS account for any charges that may be incurred in connection with
this program in accordance with the terms set forth in the Policy Statement.
We are always available to answer any questions you have regarding the Extended Day
Program. Please contact Debi Murphy, Director of Extended Day, for any inquiries about our Extended Day Program. Laura Bentzin, Assistant to the Finance Director, is available to answer billing questions.

Parent's Full Name *
Your answer
Child's First Name 1 *
Your answer
Child's Last Name 1 *
Your answer
Child's First Name 2
Your answer
Child's Last Name 2
Your answer
Child's First Name 3
Your answer
Child's Last Name 3
Your answer
Child's Full Name 4
Your answer
I have reviewed the Extended Day Policy and the Extended Day Overview/FAQ, have read and understand the terms, and authorize St. John XXIII to bill my FACTS account for any charges that may be incurred in connection with this program in accordance with the terms set forth in the Policy Statement. *
Required
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