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19-20 Extended Care Enrollment
For the 2019-2020 school year, you will need to complete Extended Care enrollment here. There are 2 steps that are required in order to completely enroll your student(s): STEP 1: Complete ALL required information in this form; STEP 2: Pay the non-refundable $25 registration fee and the first week's fee IN PERSON before the day you are wanting your student(s) to start in Extended Care. Students will not be enrolled into EC until both steps have been completed.
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* Indicates required question
Student #1 First & Last Name
*
Your answer
Student #1 Date of Birth
*
MM
/
DD
/
YYYY
Student #1 Address, City & Zip Code
*
Your answer
Student #1 Grade for 19-20
*
Choose
PreK
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Is Student #1 allergic to any foods, medications, insects, etc.?
*
Yes
No
If yes, please list his/her allergies
Your answer
List any daily medications that Student #1 is required to take, the dosage, time of administration and method of administration (i.e. mouth, eye, etc.)
Your answer
Has Student #1 been approved for Child Care Subsidy through DSS? (You will need to provide a copy of your approval letter prior to receiving services)
*
Yes
No
Unknown
Student #2 First & Last Name
Your answer
Student #2 Date of Birth
MM
/
DD
/
YYYY
Student #2 Address, City & Zip Code (if different from Student #1)
Your answer
Student #2 Grade for 19-20
Choose
PreK
Kindergarten
1st grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Is Student #2 allergic to any foods, medications, insects, etc.?
Yes
No
Clear selection
If yes, please list his/her allergies
Your answer
List any daily medications that Student #2 is required to take, the dosage, time of administration and method of administration (i.e. mouth, eye, etc.)
Your answer
Has Student #2 been approved for Child Care Subsidy through DSS? (You will need to provide a copy of your approval letter prior to receiving services)
Yes
No
Unknown
Clear selection
Do you have anymore Brookside Charter students that you are legally responsible for that you would like to enroll in Extended Care?
*
Yes
No
If yes, please include the following below: student's first and last name, date of birth, grade for 19-20, any allergies and/or medications and if they have been approved for subsidy
Your answer
Parent #1 First & Last Name
*
Your answer
Parent #1 Relationship to Student(s)
*
Choose
Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Aunt
Uncle
Foster Parent/Legal Guardian
Parent #1 Address, City & Zip Code
*
Your answer
Parent #1 Phone Number (list at least one)
*
Your answer
Parent #1 Email Address
*
Your answer
Parent #2 First & Last Name
Your answer
Parent #2 Relationship to Student(s)
Choose
Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Aunt
Uncle
Foster Parent/Legal Guardian
Parent #2 Address, City & Zip Code
Your answer
Parent #2 Phone Number (at least one)
Your answer
Parent #2 Email Address
Your answer
Emergency Contact #1 First/Last Name & Relationship (be sure this person is also listed in your parent portal)
*
Your answer
Emergency Contact #1 Phone Number (at least one)
*
Your answer
Emergency Contact #2 First/Last Name & Relationship (be sure this person is also listed in your parent portal)
*
Your answer
Emergency Contact #2 Phone Number (at least one)
*
Your answer
Emergency Contact #3 First/Last Name & Relationship (be sure this person is also listed in your parent portal)
Your answer
Emergency Contact #3 Phone Number (at least one)
Your answer
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