2021-2022 Rudolph Gordon School Extended Day Registration Form
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Student Last Name *
Student First Name *
Student Middle Name *
Grade For 2021-2022 *
Date of Birth *
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Street Address *
City *
State *
Zip Code *
Name of Parent/Legal Guardian #1 *
Email Address for Parent/Legal Guardian #1 *
Employer for Parent/Legal Guardian #1 *
Work Phone Number for Parent/Legal Guardian #1 *
Home Phone Number for Parent/Legal Guardian #1 *
Cell Phone Number for Parent/Legal Guardian #1 *
Name of Parent Legal/Guardian #2 *
Email Address for Parent/Legal Guardian #2 *
Employer for Parent/Legal Guardian #2 *
Work Phone Number for Parent/Legal Guardian #2 *
Home Phone Number for Parent/Legal Guardian #2 *
Cell Phone Number for Parent/Legal Guardian #2 *
Enrollment Information - Check all that apply *
Required
My child is allergic to Bee Stings *
If answer to above question was yes, what instructions should be followed if your child is stung? *
What other medical conditions or allergies should we know about?  If none, please type N/A *
Name of child's Doctor *
Doctor's Phone Number *
Name of Emergency Contact #1 *
Phone Number of Contact #1 *
Relationship to child of Contact #1 *
Name of Emergency Contact #2 *
Phone Number of Contact #2 *
Relationship to child of Contact #2 *
The following people are allowed to pick up my child from Extended Day: *
By responding to this statement, I understand that the school will attempt to contact me in the case of an emergency such as an accident or serious illness.  If I cannot be reached, I authorize the school to contact the doctor listed on this form, and follow the doctor's directions.  If the doctor cannot be reached, I authorize the school to take whatever steps they deem necessary. *
I understand that a one-time per year, non-refundable fee of $40 per family will be required to register.  If the child transfers to another school where the same program exists, the $40 fee will be required again at the new school.  Please type your name below to indicate you understand. *
Payments for the Extended Day Program are due on Fridays by closing time in advance of Extended Day for the following week.  Failure to pay fees will result in the child being withdrawn from the program.  If there is a problem with checks being returned, the Director may require that payments be made in cash.  Parents may not be indebted to the program.  Fees must be paid even if your child does not attend for any reason.  All schools operate on guidelines from Greenville County Schools.  The cost of our program is very much below that of private daycare.  Therefore, fees must be paid whether or not your child attends.  If your situation changes, and you no longer need the services of our program, you may withdraw your child to avoid paying for weeks you do not attend.  If space is available you may re-enroll your child when your circumstances change. *
Name and email of person completing this form.  By adding my name and email here, I understand all rules and regulations of the Extended Day Program.  I understand that I am not assured a spot in EDP until the school has received the $40 registration fee, I have completed the registration form, and received verification from the school that my child is accepted into the program.  In addition to the above, I have read and understand the Parent/Student Handbook for Rudolph Gordon School Extended Day Program. *
Date of Completion *
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