2022-23 After School Care Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out this form indicating your family's need for the After School Program.

EMS After School Care program is available for any EMS student in grades K-5. Care is provided in the EMES multi-purpose room from 3:00-5:30 p.m. after every regular school day. A snack is provided as well as time for homework, outdoor play, and crafts or activities. A parent or approved person must sign out the student at or before pick up time.

ASC offers a flex option for families who wish to pick up by 3:30 each day. Students signed up for this service may go to ASC until 3:30 p.m. at a reduced rate.

After School Care Quarterly Rates:
5-Days per week - $350/quarter
4-Days per week - $310/quarter
3-Days per week - $240/quarter
2-Days per week - $187/quarter
Individual Daily Rate - $12.50 per day billed in arrears on the next quarter
5-Days per week Flex Pick-up option (by 3:30 p.m.) - $172/quarter

A late fee will be assessed if child is picked up after 5:30 p.m. ($5 per 15 minutes).

Email *

Student Name (Please fill out a separate form for each child in your family.) *

Grade *

Required

Please sign up for the days you plan to send your child to After School Care. If you need to change these, be in touch with Jen Stoltzfus and director Brynn Hinegardner (leahbrynn07@gmail.com). *

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Flex option (pick up by 3:30 p.m.)

Incidental/As needed (Will contact)

Required

I will need childcare on early release days. *

Yes

About what time do you expect to pick up your child each day? *

Please provide first and last names of people authorized to pick up your child(ren). *

Please provide your name and a phone number where you can be reached. *

Are there any health or dietary needs of which we should be aware? *

Yes. If so, please explain below.

Other:

Health or Dietary Needs

I agree to have my FACTS account charged for this service based on the above rates. *

Yes

By selecting Yes above and entering your full name below indicates you are agreeing to the terms and information explained in this form. *

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

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Eastern Mennonite School. Report Abuse

Forms