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Elementary
Principal: Savannah Demeester
Assistant Principal: Lauren Cecil and Quentin Turner
Extend Day Director: Bertha Massey
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* Indicates required question
Student 1: Name
*
Your answer
Student 1: Date of Birth
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MM
/
DD
/
YYYY
Attendance: Choose One: Full Time or Part-Time
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Full-Time ( $80/wk 4-5 Days )
Part-Time ($70/wk Minimum 3 Days Choose Days Below)
Required
Part Time (Choose 3 Days)
Monday
Tuesday
Wednesday
Thursday
Friday
Extended Day Start Date
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MM
/
DD
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YYYY
Grade Level
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Choose
K
1st
2nd
3rd
4th
5th
PreK
Student Home Address
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Your answer
Please List Any Allergies or Type None:
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Your answer
Teacher Name (Skip if Unknown)
Your answer
Primary Parent or Guardian Name:
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Your answer
Primary Parent or Guardian Email:
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Your answer
Primary Contact Address
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Your answer
Primary Contact Cell Phone Number
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Your answer
Primary Place of Employment
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Your answer
Work Phone Number
Your answer
Are you a Madison City Schools Employee
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Yes
No
Secondary Parent or Guardian Name:
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Your answer
Secondary Parent or Guardian Email:
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Your answer
Secondary Contact Cell Phone Number
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Your answer
Place of Employment
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Your answer
Work Phone Number
Your answer
Name of Insurance Company
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Your answer
Group Policy Number
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Your answer
Pick-up and Emergency Contacts Name
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Your answer
Pick-up and Emergency Contacts Relationship
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Your answer
Pick-up and Emergency Contacts: Phone Number
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Your answer
Things to Check Off
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I have verified that the information on registration form is correct.
I have added my insurance information.
I will pay the $60.00 Non-refundable registration and first week's tuition for each child.
I have read and understand the discipline plan for the Extended Day Program.
I have read and understand all the policies governing the extended day program and will abide by them.
Required
Additional Student: Sibling Rate Applies
*
Yes
No
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