Extended Day Center Program
2020-2021 Registration for Before and After School Child Care
Hours of Operation:  Monday - Friday 6:30 am - 6:00 pm

(This form must be completed and submitted prior to your child being considered enrolled.)
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Session needed for Child Care *
Required
Extended Day Center Location *
Child's Information
Child's Name (First, Middle, and Last) *
Child's Date of Birth *
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Child's Age *
Child's Home Address (Street, City, State, and Zip) *
Child's Home Phone or Cell Number *
Child's Grade *
Child's Teacher
Demographics:  Information used for data collection
Ethnicity
Clear selection
Race
Clear selection
Sex
Clear selection
Medical
Family Doctor's Name
Family Doctor's Phone Number
Medical Insurance Company
Ambulance Preference
Hospital Preference
Child's Allergies
Medical Condition(s)
My child received the chickenpox vaccine on
MM
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DD
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My child had the chickenpox on
MM
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Special Instructions
Parent Information
Please check the box(es) below to indicate who has legal custody
Legal Custody
Parent/Guardian #1 - Name (First and Last) *
Parent/Guardian #1 - Address (Street, City, State, and 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, and Zip)
Parent/Guardian #2 - Home or Cell Phone
Parent/Guardian #2 Workplace, Phone number and when Workday Ends
Email Address for Invoices *
In Case of Emergency
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 Number
My child may NOT be released to the following individuals:
Payment and Attendance
I agree to pay my childcare fee every Monday for the previous week's childcare was provided.  My child is expected to attend daily unless a schedule is provided by the parent/guardian that states otherwise.  I understand that the school reserves the right, in extreme circumstances, to terminate the enrollment of any child if the coordinator, director, and/or the associate superintendent determines that continued attendance would not be in the best interest of either my child or the school. In case of an emergency involving my child, it is the policy of the EVSC to give first aid treatment while contacting the parent/guardian for further instructions.  In the event the parent/guardian cannot be contacted, school officials will contact 911.  If I am late picking up my child, then a late fee will be charged to my account if my child has not been picked up and my emergency contact designee cannot be reached, then the Department of Child Services will be contacted.

By entering your name below, you agree to the payment and attendance terms and policies.  Your typed name will serve as your legal signature on this form.
Parent/Guardian #1  Signature *
Date *
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Parent/Guardian #2 Signature
Date
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