MS/HS Extended Day Permission Spring '23
The extended day program is back and begins in January. This form is for you to complete if your child wishes to participate in any of the program activities. Activities run from 2:30 pm-4:30 pm Monday-Thursday when school is in session. Snacks are provided. Transportation is provided for on site programs for students who typically ride the bus. There is NO program on half days, early release days or the days before a long weekend. The first day of the Winter/Spring program offerings are 1/30/23 and run until 5/24/23. If you have any questions, please feel free to reach out. You can contact me via email at mbutler@southseneca.org.
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Email *
Parent Name: *
Student Name: *
Student Grade: *
Monday:
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Tuesday:
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Wednesday:
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Thursday:
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Are there any known food/medical allergies or other conditions we should be aware of? If so, please list:
Bus to address:
Bus will provide transportation to this alternative address:
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On what days will the alternative address be used?
Walker (If a student walks to and from school, they are considered a walker for the after school program.)
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Parent/Designee will pick up:
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Approved list of people who may pick up my child:
Additional Emergency Contact and Phone Number:
 *
Parent/Guardian Phone Number:
 *
I give my child, named above, permission to participate in the after school program. I will make a reasonable effort to notify Mrs. Butler or Ms. Mosher of any absences or adjustments. Additionally, he/she will sign out with Mrs. Denmark if not staying for the program. The transportation arrangement listed below will be adhered to. 
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