EXTENDED CARE REGISTRATION FORM
A FORM IS NEEDED FOR EACH FAMILY, AND ALL INFORMATION NEEDS TO BE UP TO DATE
Email address *
Father's Name *
Home Phone *
Work Phone *
Cell Phone
Mother's Name
Home Phone
Work Phone
Cell Phone
EMERGENCY CONTACT: (If Parents are Unavailable)
Name
Relationship
Cell Phone
STUDENT(S) INFORMATION
Student's Name
Grade
Teacher
STUDENT(S) MEDICAL INFORMATION
Please check if it applies
Allergies
Other Conditions:
Asthma
Inhaler at School for Asthma
Clear selection
Other problems:
STUDENT(S) INFORMATION
Student's Name
Grade
Teacher
STUDENT(S) MEDICAL INFORMATION
Please check if it applies
Allergies
Other Conditions:
Asthma
Inhaler at School for Asthma
Clear selection
Other problems:
STUDENT(S) INFORMATION
Student's Name
Grade
Teacher
STUDENT(S) MEDICAL INFORMATION
Please check if it applies
Allergies
Other Conditions:
Asthma
Inhaler at School for Asthma
Clear selection
Other problems:
To help us anticipate staffing needs, please check the days of intended use and indicate approximate drop-off and/or pick-up time.
Morning Program: (Beginning at 7:00 a.m.) *
Required
Approximate Time of Drop Off *
Time
:
Afternoon Program: (Additional charges after 6:00 p.m.) *
Required
Approximate Time of Pick-up
Time
:
EXTENDED CARE FEES for 2020/21 school year: A deposit of $25 will be required on account. If your account falls below $25 your child will not be able to attend EC. $1.75 per half hour or any portion of the half hour. A “late pick-up” fee will be charged to parents picking up their children after 6:00 pm. Late pick up fee is $5.00 for every fifteen minutes or fraction thereof for students being picked up after 6:00 pm. Fees are charged per child. Billing is sent out weekly and payments are due by the 10th of the month. There will be a $10 late fee for payments after the 10th of each month.
Students will be released to their parents ONLY! Authorization to release their child(ren) to anyone else besides the parents must be listed on this sheet. A handwritten note or a person-al phone call to the school office on the day someone else (not listed below) will be picking up will also be sufficient and necessary. Please advise the person picking up the children they must have some type of identification with them. This is for your child’s protection.
Authorized Persons(s)
SPORTING EVENT ATTENDANCE: Students in grades 5-8 may attend home sporting events. Student in these grades are to report to Extended Care and will be dismissed at the beginning of the event (approximately 4:00) providing a SIGNED PARENT PERMISSION SLIP IS ON FILE. Students in grades K, 1st, 2nd, 3rd and 4th may on occasion attend the sporting events but are required to sit with one of the Extended Care Supervisors. Since parental permission is required for students 5th -8th grade to attend sporting events, no Extended Care fees will be charged for the time they are attending the event. Extended Care fees will be charged from 3:30 until the time they are dismissed and sign out. Also, Extended Care fees will be charged if the sporting event is over prior to the student being picked up. If not picked up before the sporting event is finished, the student will be required to again report and sign in to Extended Care for supervision and fees will be charged. I give my permission for my children in 5th, 6th, 7th and 8th grade to attend any or all home sporting events.
Student Name(s)
Parent Signature:
MM
/
DD
/
YYYY
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