2023-2024 Extended Day Center Application
2023-2024 Registration for Before and After School Child Care
Hours of Operation:  Monday - Friday 6:30 am to 6:00 pm

This form must be completed and submitted prior to your child being considered for enrollment.  A new form must be submitted every school year.  You will receive an email with your enrollment status update within 72 business hours of submission.

RATE CHANGE EFFECTIVE 8/7/2023:
Morning Care
Full-time $20 per week (3-5 days)
Part-time $15 per week (1-2 days)

Afternoon Care
Full-time $40 per week (3-5 days)
Part-time $25 per week (1-2 days)

Morning Care & Afternoon Care
Full-time $60 per week (3-5 days)
Part-time $40 per week (1-2 days)

REQUIREMENT: VALID EMAIL ADDRESS FOR EXTENDED DAY CENTER NOTIFICATIONS
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Email *
Session need for Child Care (If you need morning & afternoon care, please select both) *
Required
Extended Day Center Location (mark only one) *
CHILD'S INFORMATION
Child's Name (first and last name) *
Child's Date of Birth *
MM
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DD
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YYYY
Child's Age *
Child's Home Address (Street, City, State, and Zip) *
Child's Grade (during 2023-2024 school year) *
Child's Teacher
Does this child have an IEP? *
Social and Emotional Needs
DEMOGRAPHICS:  INFORMATION USED FOR DATA COLLECTION
(OPTIONAL)
Ethnicity
Race
Sex
CHILD'S MEDICAL INFORMATION
Physician's Name
Physician's Phone Number
Medical Insurance Company
Ambulance Preference
Hospital Preference
Child's Allergies
Medical Condition(s)
My child received the chickenpox vaccine on
MM
/
DD
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YYYY
My child had the chickenpox on
MM
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DD
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YYYY
Special Instructions (Any additional information we may need to know to effectively care for your child)
PARENT INFORMATION
Please check the box(es) below to indicate who has legal custody.
Legal Custody *
Required
Parent/Guardian #1 - Name (first and last) *
Parent/Guardian #1 - Address (Street, City, State, & Zip) *
Parent/Guardian #1 - Home or Cell Phone *
Parent/Guardian #1 - Workplace, phone number, and when workday ends *
Parent/Guardian #2 - Name (first and last)
Parent/Guardian #2 - Address (Street, City, State, & Zip)
Parent/Guardian #2 - Home or Cell Phone
Parent/Guardian #2 - Workplace, phone number, and when workday ends
EMERGENCY CONTACTS
When parents cannot be reached, the individuals listed below may be called and/or authorized to pick up child.
Emergency Contact #1 - Name and Relationship *
Emergency Contact #1 - Home and/or Cell Phone *
Emergency Contact #2 - Name and Relationship
Emergency Contact #2 - Home and/or Cell Phone
My Child may be RELEASED only to the following persons.
Please add additional information if necessary behind their names.  Identification will be required.
#1 Name and Relationship
#1 Home and/or Cell Phone
#2 Name and Relationship
#2 Home and/or Cell Phone
#3 Name and Relationship
#3 Home and/or Cell Phone
#4 Name and Relationship
#4 Home and/or Cell Phone
My child may NOT be released to the following individuals:
SIGNATURE
By entering your name below, you agree that the information you have entered is true and accurate to the best of your knowledge.  Your typed name will serve as your legal signature on this form.
Parent/Guardian #1 - Signature *
Date *
MM
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DD
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YYYY
Parent/Guardian #2 - Signature
Date
MM
/
DD
/
YYYY
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