Extended Day Registration Form 2023-2024
Complete ALL sections of this form before submitting 
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Student Name (First and Last) *
Age *
DOB *
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Sex *
Home Address *
Parent/Guardian's Email Address  *
Teacher *
Grade *
Mother's Name/Guardian's Name (First and Last) *
Mother/Guardian's Cell Phone Number (with area code) *
Mother/Guardian's Work Phone Number (with area code)
Father/Guardian's Name (First and Last)
Father/Guardian's Cell Phone Number (with area code)
Father/Guardian's Work Phone Number (with area code)
Who does the child live with? *
What is the relationship between the child and who they live with (person listed above)? *
Parents Status: Is there separation, divorce or custody agreement in which the coordinators should be aware of? *
Emergency Contact Person's Name (first and last) *
Emergency Contact Person's Phone Number *
Emergency Contact Person's Phone Number
Emergency Contact Person's Phone Number
Authorized person who may pick your child up from extended day:
PLEASE PUT FIRST AND LAST NAME 
If someone other than parents/guardians or person(s) listed below have to pick up your child, you MUST contact Mrs. Brown or Mrs. Young through remind (Text @bluejay68 to the number 81010) . An ID will be required for pick-up. Emergency contacts are considered as authorized. 
Phone Number for above Authorized person
Authorized person who may pick your child up from extended day:
PLEASE PUT FIRST AND LAST NAME 
If someone other than parents/guardians or person(s) listed below have to pick up your child, you MUST contact Mrs. Brown or Mrs. Young through remind (Text @bluejay68 to the number 81010) . An ID will be required for pick-up. Emergency contacts are considered as authorized. 
Phone Number for above Authorized person
Does the child have Allergies *
If "yes" to above question (Child's Allergies) please list:
Any concerns that the Extended Day Staff should be aware of:
Registration Fee: $30 (nonrefundable)
Weekly Tuition: Check ONE below
 *
ALL payments must be online - NO personal checks or cash
Click Here to pay the drop-in fee. ONLINE PAYMENT
After 3 drop-ins, a registration fee must be paid before another drop-in will be allowed. 
I hereby grant permission for my child(ren) to participate in the Cedarcrest Southmoor Elementary Extended Day Program. I have read the Extended Day handbook and understand the policies and procedures in the handbook. *
PLEASE TYPE YOUR FULL FIRST AND LAST NAME
I hereby grant permission for my child(ren) to participate in the Cedarcrest Southmoor Elementary Extended Day Program. I have read the Extended Day handbook and understand the policies and procedures in the handbook. *
PLEASE fill out TODAYS date
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EXTENDED DAY CONTRACT: READ CAREFULLY!

EXTENDED DAY CONTRACT:  READ CAREFULLY BEFORE SIGNING

  • I understand that extended day fees are non-refundable and cannot be applied to future days. Credits will not be given due to student absence or non-attendance in the program. Unexpected cancellations of afterschool activities by the EBRP School Board are non-refundable. Days missed will not be prorated. 

  • I understand that serious and/or chronic, and consistent behavior problems will result in my child being dismissed from the Extended Day Program.  I will be notified by the coordinator after the first offense. If any other offenses occur, my child will be dismissed from the program by the principal. 

  • I understand that I am responsible for paying tuition on the days and time applicable on the application form. I also understand that there is a $10.00 late fee if payment is not made by 11:59 p.m. on the Monday of the week of attendance.

  • I understand that once my child is enrolled in the Extended Day Program, I am responsible to pay every week, even if my child(ren) has not attended or is absent from school. It is the parents’ responsibility to inform the coordinator(s)  if your child will no longer attend the Extended Day program.

  •  I understand that if payment is not submitted  on or before the due date, school officials reserve the right to put the child(ren) on the bus at the end of the school day. Office personnel or the Extended Day Coordinator(s)  will contact the parent and inform them in the event this happens. I understand that my child(ren) will not be allowed to return to the Extended Day program until all fees are paid in full. 

  • I understand that Extended Day afternoon hours are from 3:30 p.m. to 5:30 p.m. daily. There is a $1.00 a minute late fee assessed per child for any time after 5:30 p.m. (i.e., if you pick your child up at 5:45 p.m. there will be a $15 late charge that is due at the time you pick up your child.). Children are only allowed 3 late pick-ups before possible dismissal  from the Extended Day program is considered.

  • I understand that I am responsible for any outstanding balances before my child is able to register for the current school year.

I agree to adhere to the stated policies and procedures of the Extended Day Program as stated in the above contract.
Please type your FULL FIRST and LAST NAME
I agree to adhere to the stated policies and procedures of the Extended Day Program as stated in the above contract.
Please fill out TODAYS DATE
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