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EXTENDED CARE REGISTRATION FORM
A FORM IS NEEDED FOR EACH STUDENT IN A FAMILY, AND ALL INFORMATION NEEDS TO BE UP TO DATE
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* Indicates required question
Email
*
Your email
Father's Name
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Mother's Name
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Work Phone
Your answer
EMERGENCY CONTACT: (If Parents are Unavailable)
Name
Your answer
Relationship
Your answer
Home Phone
Your answer
Cell Phone
Your answer
STUDENT(S) INFORMATION
Student's Name
Your answer
Grade
Your answer
Teacher
Your answer
STUDENT(S) MEDICAL INFORMATION
Please fill out a separate medical information for each child. Please check all that apply
Asthma
Hypoglycemia
Diabetes
Bee Sting Allergies
Contact Allergies
Seizures
Inhaler at School for Asthma
Yes
No
Clear selection
Epi Pen at School for Allergies
Yes
No
Clear selection
Other problems:
Your answer
STUDENT(S) INFORMATION
Student's Name
Your answer
Grade
Your answer
Teacher
Your answer
STUDENT(S) MEDICAL INFORMATION
Please fill out a separate medical information for each child. Please check all that apply
Asthma
Hypoglycemia
Diabetes
Bee Sting Allergies
Contact Allergies
Seizures
Inhaler at School for Asthma
Yes
No
Clear selection
Epi Pen at School for Allergies
Yes
No
Clear selection
Other problems:
Your answer
STUDENT(S) INFORMATION
Student's Name
Your answer
Grade
Your answer
Teacher
Your answer
STUDENT(S) MEDICAL INFORMATION
Please fill out a separate medical information for each child. Please check all that apply
Asthma
Hypoglycemia
Diabetes
Bee Sting Allergies
Contact Allergies
Seizures
Inhaler at School for Asthma
Yes
No
Clear selection
Epi Pen at School for Allergies
Yes
No
Clear selection
Other problems:
Your answer
STUDENT(S) INFORMATION
To help us anticipate staffing needs, please check the days of intended use and indicate approximate drop-off and/or pick-up time.
Morning Program: (Beginning at 7:00 a.m.)
Please select days intending to use
Monday
Tuesday
Wednesday
Thursday
Friday
Please select days intending to use
Monday
Tuesday
Wednesday
Thursday
Friday
Clear selection
Approximate Time of Drop Off
*
Time
:
AM
PM
Afternoon Program: (Additional Charges after 6:00 p.m.)
Please select days intending to use
Monday
Tuesday
Wednesday
Thursday
Friday
Please select days intending to use
Monday
Tuesday
Wednesday
Thursday
Friday
Clear selection
Extended Care Fees
EXTENDED CARE FEES for 2022/23 school year: A deposit of $25 will be required on account. If your account falls below $25 your child will not be able to attend EC. $1.75 per half hour or any portion of the half hour. A “late pick-up” fee will be charged to parents picking up their children after 6:00 pm. Late pick up fee is $5.00 for every fifteen minutes or fraction thereof for students being picked up after 6:00 pm. Fees are charged per child. Billing is sent out weekly and payments are due by the 10th of the month. There will be a $10 late fee for payments after the 10th of each month.
Authorization Release
Students will be released to their parents ONLY! Authorization to release their child(ren) to anyone else besides the parents must be listed on this sheet. A handwritten note or a person-al phone call to the school office on the day someone else (not listed below) will be picking up will also be sufficient and necessary. Please advise the person picking up the children they must have some type of identification with them. This is for your child’s protection.
List of Authorized Person(s) for Pick-up
*
Your answer
List of Authorized Person(s) for Pick-up
Your answer
Parent Permission
Student Name
Your answer
Parent Signature
Your answer
MM
/
DD
/
YYYY
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