Extended Care Enrollment (Distant Learning)
Brookside Charter is offering Extended Care services during the school day for families needing assistance with Distant Learning or care due to work schedules.  Please complete this form to officially enroll your student(s) in these services.  
First Day of School/Services: Monday, September 14th
Payment Due: Initial payment Friday, September 11th and each Friday thereafter for the following service week.
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Email *
Student #1 First Name *
Student #1 Last Name *
Student #1 Date of Birth *
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Student #1 Grade for 2020-2021 *
Is Student #1 allergic to any foods, medications, insects, etc.? *
If yes, list allergies. Otherwise, enter NONE. *
List any daily medications that Student #1 is required to take.  Include dosage, time of administration and method of administration (mouth, eyes, etc.).  Otherwise, enter NONE. *
Does Student #1 have an IEP and/or a Section 504 Plan? *
Has Student #1 been approved for child care subsidy through DSS? *
Student #2 First Name
Student #2 Last Name
Student #2 Date of Birth
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DD
/
YYYY
Student #2 Grade for 2020-2021
Is Student #2 allergic to any foods, medications, insects, etc.?
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If yes, list allergies.  Otherwise, enter NONE
List any daily medications that Student #2 is required to take. Include dosage, time of administration and method of administration (mouth, eyes, etc.).  Otherwise, enter NONE.
Does Student #2 have an IEP and/or a Section 504 Plan?
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Has student #2 been approved for child care subsidy through DSS?
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Do you have anymore Brookside Charter students that you are legally responsible for that you would like enrolled in Extended Care? *
If yes, please include the following information for each additional student (otherwise, enter No Additional Students):  FIRST/LAST NAME, DATE OF BIRTH, GRADE FOR 20-21, ALLERGIES, MEDICATIONS, IF YOUR STUDENT HAS AN IEP OR 504 PLAN AND IF THEY'VE BEEN APPROVED FOR SUBSIDY.                                                                 *
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