3rd Street Clubhouse Online Registration Form 2020-2021

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Your daycare account must be in good standing or a new student to South Mebane. You may check your balance online . If you have any questions feel free to email Shawn_Wilson@ABSS.k12.nc.us

Email *

Student ID Number (not applicable to newly enrolled students)

Students Name: Last Name, First Name *

Student's Date of Birth *

mm/dd/yyyy

When will your child start attending Third St *

YYYY

Grade Level For 2020-21 School Year *

Type of care needed *

AM only (6:30am-7:30am)

AM/PM

PM only (2:35pm-6:00pm)

Part time PM (10 visits per month)

PRIMARY Parent/Guardian names, phone numbers, address, and e-mails *

Format: First & Last Name, Phone #s (specify cell, day, and home), Address, Email (If ABSS employee, please provide both ABSS email and an email address other than your ABSS address.)

Guardian 1 *

Work/Phone extension *

Cell # *

Address *

Email *

Guardian 2 *

Work/Phone extension *

Cell # *

Address *

Email *

Are you employed by Alamance Burlington School System? *

Yes

If you are an ABSS employee, what location?

Emergency Contact and Pick Up authorization

The following people may pick up the child from the program and/or be reached during an emergency. In the event of inclement weather or an emergency situation. Please make sure you have made arrangements with these individuals to pick up your child/children from the program and they are accepting of this responsibility.**Please note a valid ID will be required to pick up students from daycare.

Emergency contact name and phone number (other than parents/guardians listed above) *

Please list anyone else who is allowed to pick up (first and last names). ID will be required. *

Important Student Information

Please list allergies and needed medications

Please list any allergies

Please list any required medications

If medications are required at Third St, please provide classroom teachers name, or send medication specifically for use at Third St.

Please list any other important information here.

Emergency Permission *

I give permission to S. Mebane Elementary School Daycare staff to authorize emergency treatment and transportation of my child to Alamance Regional Medical Center Hospital.

I DO NOT give permission to S. Mebane Elementary School Daycare staff to authorize emergency treatment and transporation of my child to Alamance Regional Medical Center Hospital

Movie Permission *

I give permission for my child to watch PG movies

I do not give permission for my child to watch PG movies

Participation and Payment Agreement *

My child and I have read, discussed, and agree to abide by the rules, regulations, and payment schedule for attending S. Mebane Elementary School Before and After School Program.

Questions and comments

Send me a copy of my responses.

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