2019-2020 Extended Care Enrollment Form-Final

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ONE FORM PER FAMILY

Email *

Student First Name-Indicate oldest student here, if siblings list below. *

Student Last Name *

Siblings enrolling in Extended Care (First and Last Name)

Enrollment Status *

Full Time $60 (3 or more days a week, you are obligated to pay for EVERY WEEK of the school year) Part Time $20/Day (2 days or less, you are obligated to pay for every DAY your child attends . Last Tuesday of the Month Only (No Charge if picked up by 3pm)

TUESDAY ONLY (For All School 2:00pm Dismissals)

Registration fee *

$70 for both Full Time and Part Time Status per Student

I understand $70 per student will be billed to FACTS

I am a Tuesday only Family (students will be picked up by 3:00pm)

Half Day Fee *

I understand there will be an additional $10 fee for any half day my student(s) attends Extended Care.

Yes

NA Tues Only

Indicate which Parent's FACTS account will be responsible for Extended Care Billing. *

Both Parents (Joint FACTS account)

Mother

Father

Other:

Person(s) allowed to pick up student(s) from Extended Care - Indicate here only if persons Other than Parents and Emergency Contacts listed on SFA School Enrollment forms.

Indicate Name, Cell # and relationship to student

Is Student(s) restricted from any physical activities-indicate student and activity restriction

Emergency Medical Treatment *

Authorization for Emergency Medical Treatment: If my student should become ill or injured at SFA Extended Care, I understand that the facility will (1) contact me immediately or (2) contact the person(s) I have designated if I cannot be reached. Should the facility be unable to reach me and/or the person(s) designated, they are authorized to contact my child'd physician and/or medical facility to administer emergency medical treatment necessary to ensure the health and safety of my student. I will accept responsibility of payment for the medical services rendered.

Yes

Handbook and Child Care Requirement *

I acknowledge that I have read the Extended Care Handbook and the Tennessee Department of Education Child Care Requirement Summary located on the school website (Listed under Programs>Extended Care)

Yes

SFA Parent Student Handbook *

I understand that Extended Care is a part of St Francis of Assisi School; therefore all rules and regulations set forth in the SFA Parent-Student Handbook must be followed by all students during Extended Care.

Yes

Weekly Fee Schedule *

I have read and understand the registration fee, weekly fee schedule and the full time (3-5 days a week) and part time status (2 days or less). All fees will be paid through FACTS. (A fee schedule can be found on the school website under Programs>Extended Care)

Yes

Status Change *

I understand my student(s) status can only change 1x per semester with Director's prior approval.

Yes

Payment Policy *

I agree to abide by the Payment Policy and I understand the consequences of late payments.

Yes

Refunds *

I understand there are no refunds given and weekly fees will not be rolled over to the next week due to inclement weather or illness.

Yes

Behavior Policy *

I have read and understand the Behavior Policy and "3 Strikes and You Are Out" of Extended Care. I will make sure my student is aware of this policy.

Yes

Cell Phone and Electronics *

I have read and understood the policy for cell phones and all other electronic devices. I will make sure my child is aware of this policy.

Yes

Disciplinary Action *

I acknowledge the Extended Care Program can at any point institute any course of disciplinary action it deems necessary and consistent with the policies and procedures of St. Francis of Assisi Catholic School.

Yes

Name of Parent Completing Form *

Email of Parent Completing Form *

Date completed form *

YYYY

A copy of your responses will be emailed to the address you provided.

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