After-School Sign-Up

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After-School Sign-Up

Use this form to sign up for the After-School for Saint Adalbert Catholic School for the 2021 - 2022 School Year

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Email *

Parent / Guardian Full Name: *

Full Address of Family including apartment number, if applicable: *

Parent / Guardian Contact Phone Number #1: *

Parent / Guardian Contact Phone Number #2: *

Emergency Contact Phone Number and relationship to child #1: *

Emergency Contact Phone Number and relationship to child #2 *

Please list five people and their relationship to the child who are permitted to pick up your child(ren). If there are not five people who given permission, please write "N/A" in the remaining spaces. *

Name of Child #1 *

Grade Level of Child #1: *

Please list any allergies of Child #1: *

Name of Child #2:

Grade Level of Child #2:

Please list any allergies of Child #2:

Name of Child #3:

Grade Level of Child #3:

Please list any allergies of Child #3:

How do you intend to pay for After-School this year? Payments for After-School on due on the first Friday of each month prior to services beginning. *

Direct Debit from Bank Account (preferred method)

Cash

Credit Card

Please check below indicating that you're read the following statement and your needed cost per family: I understand that our After-School Program costs $75 per child for the full month and that family discounts are offered as outlined below. *

One child at $75 per month

Two children at $140 per month

Three children at $200 per month

I have more than three children to pay for each month

Please read the following statement and check the bullet-point indicating your knowledge of this statement: *

My child will follow all school rules in the After-School Program, as well as be in compliance with the school handbook. Cell phones are not permitted in Aftercare and students will listen to all Aftercare staff as they would regularly listen to their parent, teacher, or adult on campus. I understand that if my child does not comply with the school rules while in Aftercare, they may be removed from Aftercare permanently.

Required

Please read the following statement and check the bullet-point indicating your knowledge of this statement: *

My child is not permitted to leave the After-School care during the school day and return at a later time. They may not leave to go the Recreation Center, local store, a friend's house, back to their classroom, visit a sibling, etc. They will remain in Aftercare and under the care of the Aftercare staff until their parent / guardian arrives.

Required

Please read the following statement and check the bullet-point indicating your knowledge of this statement: *

The After-School program ends daily at 6:00. Any child that is picked up later than 6:00 will be assessed a late-fee of $10 per child for every fifteen minutes past 6:00 that they are not picked up.

Required

Please read the following statement and check the bullet-point indicating your knowledge of this statement: *

Families that do not pay for the After-School Program by the second Friday of the month will not be permitted to attend Aftercare until payment is received in full.

Required

Please read the following statement and check the bullet-point indicating your knowledge of this statement: *

My child will not bring any toys or electronic devices into the the After-School Program. they are present in school for ANY REASON, they will remain off and in their bookbags at all times

Required

I give the After-School Program staff permission to use my child's image in photos or videos on the school website or in promotional images. *

Yes, I agree

No, I do not agree

I give permission for my child to participate in any additional the After-School Program-based activities with community members, such as the library visiting, reading aides, college or high school tutors, or local company programs. *

Yes, I agree

No, I do not agree

Please enter the name of the person completing this form as well as today's date below: *

A copy of your responses will be emailed to the address you provided.

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