Challenge to Excellence Before/After Care (BAC) Enrollment Information/Waitlist 2019-2020
*OUR PROGRAM IS CURRENTLY FULL. PLEASE FILL OUT THE INFORMATION FOR EACH CHILD TO BE PLACED ON OUR WAITLIST. WHEN SPACE BECOMES AVAILABLE, YOU WILL BE CONTACTED FOR FURTHER INFORMATION NECESSARY FOR YOUR CHILD/CHILDREN TO ATTEND OUR BAC PROGRAM.

Welcome to the first step in getting your child/children STARTED IN THE REGISTRATION PROCESS for our 2019-2020 BAC Program. Spaces are limited and final registration is only guranteed after ALL information is on file including payment information. You will receive an offical email from, Katie Unger, our BAC Billing and Information Services Director, letting you know that your child may start attending BAC.

This form must be filled-out and submitted to start the process of getting your child/children started in the paperwork that must be filled out along with all Procare/Tuition Express payment information. A FORM FOR EACH CHILD MUST BE FILLED OUT SEPARATELY. All completed documents must be received and processed by our business office before your child/ren is fully enrolled and eligible to attend our BAC program. If any paperwork/information is missing, your child/children will not be able to attend until it is completed. We need to make sure we have all necessary information to care for your child/ren and make sure your payment preference is on file. Thank you for choosing our BAC program! You will notified when your child(ren) is fully enrolled/registered and payment information has been processed to confirm a start date. Filling this form out does not guarantee a spot in BAC for the 2019-2020 school year. Each submission is timestamped. If full capacity is reached, this form becomes our waitlist.

Email address *
SECTION 1: Student Last Name *
Your answer
Student First Name *
Your answer
Student's Primary Household Address *
Your answer
Student's Birthdate *
MM
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Student's Grade *
Required
SECTION 2: Parent #1 Last Name *
Your answer
Parent #1 First Name *
Your answer
Parent #1 Address *
Your answer
Parent #1 Telephone (Home) *
Your answer
Parent #1 Telephone (Cell) *
Your answer
Parent #1 Employer's Name *
Your answer
Parent #1 Employer's Address *
Your answer
Parent #1 Work Telephone Number *
Your answer
Parent #1 Email *
Your answer
SECTION 3: Parent #2 Last Name *
Your answer
Parent #2 Email *
Your answer
Parent #2 First Name *
Your answer
Parent #2 Address (If the same as Parent #1, type in SAME/Parent #1) *
Your answer
Parent #2 Telephone Number (Home) *
Your answer
Parent #2 Telephone Number (Cell) *
Your answer
Parent #2 Employer's Name *
Your answer
Parent #2 Employer's Address *
Your answer
Parent #2 Work Telephone Number *
Your answer
SECTION 4: Name: Authorization#1 For Release of Child/Emergency Contact *
Name other than parent/guardian.
Your answer
Address *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Name: Authorization #2 For Release of Child/Emergency Contact *
Name other than parent/guardian
Your answer
Name: Authorization #3 For Release of Child/Emergency Contact *
Name other than parent/guardian
Your answer
Name: Authorization #4 For Release of Child/Emergency Contact *
Name other than parent/guardian
Your answer
Address *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
7. Person NOT authorized to pick-up your child.
C2E Before and After Care services must be provided with court-issued documentation that describes any custody arrangements.
Your answer
SECTION 5: Physician Name *
Your answer
Address *
Your answer
Phone Number *
Your answer
Dentist Name *
Your answer
Address *
Your answer
Phone Number *
Your answer
Hospital Preference *
Your answer
Address *
Your answer
Phone Number *
Your answer
SECTION 6: Allergies *
List 'NKA', if none are known.
Your answer
Medications *
Medications: If your child NEEDS regular administration of medications during program hours, you must consult with the Program Director prior to attendance. (A physician's order to administer medication must be on record.) List 'None', if no meds are taken during BAC program.
Your answer
Chronic Health Care Needs/Special Needs *
Please list any chronic or special health conditions or any other information that we may need to know about your child. List 'NONE' if there are none:
Your answer
In case of emergency, I authorize the program staff to directly contact the person(s) named on this Enrollment Form, including the medical/dental providers listed on this form. Additionally: I give C2E Before and After Care permission to seek emergency medical or dental care from any 911 provider which includes, but is not limited to, emergency personnel transporting my child to the nearest hospital. It is understood that a conscientious effort will be made to locate us, the parents/guardians. Any and all expenses associated with such emergency actions will be borne by us, the parents/guardians, and NOT by C2E or the C2E Before and After Care. *
SECTION 7: Insurance Carrier *
Your answer
Group Number. List 'NONE' if there is no group number. *
Your answer
Policy Number *
Your answer
/S/ Electronic Signature *
Typing your name below is your valid signature.
Your answer
Date *
MM
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C2E Before and After Care Handbook *
I have reviewed the C2E Before and After Care Handbook (the "Handbook") and agree to be responsible for, comply with, and abide by the procedures as stated therein. I understand that the policies and procedures stated in the Handbook are subject to change and that I will be notified of any changes should they occur. I further understand and agree that violations of the policies and procedures in the Handbook could result in my child no longer being eligible for C2E Before and After Care services.
Sign-in/Sign-Out Procedures *
I agree to abide by the Sign In/Sign Out procedures stated in the Handbook. I understand that the C2E Before and After Care program is not responsible for my child while enroute to the program prior to being signed in. I also understand that the program is not responsible for my child enroute to his/her home or authorized destination after being signed out. Additionally, I understand that it is my responsibility to ensure my child knows and understands the sign-in/sign-out procedures.
Student Records *
I agree to keep my child's records up to date with current information including, but not limited to, home, work, and cell phone numbers for us, the parents/guardians, emergency contacts, and persons(s) to pick up my child.
Consents *
Required
I do not want my child to participate in the following activities (Please list.  If none, so indicate and initial electronically. /S/
Your answer
Enrolling Parent/Guardian Signature *
I have reviewed each of the above consents and responsibilities and hereby agree to comply with all of the provisions provided herein & in the BAC Parent Handbook.
*Financial Responsibility
The Enrolling Parents/Guardians are financially responsible for the child's account. All C2E Before and After Care program fees will be paid using our Procare/Tuition Express program services. This includes registration fees and any fee balances from prior months/school year including, without limitation, late fees and fees for additional services. Refer to the Handbook for more information.
*You understand your financial obligations to keep your student enrolled in BAC. You agree to keep payment details updated with new bank/credit card numbers and expiration dates. *
/S/ Enrolling Parent / Guardian Electronic Signature *
Typing your name and date here electronically represents your signature and verifies that you are at least 18 years old and the parent/guardian of above named child.
Your answer
Date *
MM
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