23/24 QECP Before/After-school Program Form
Please fill out the following in detail
Sign in to Google to save your progress. Learn more
Email *
Do you give consent to be added to our SeeSaw account?
SeeSaw will be used as our primary communication
 *
Child's full name/nickname *
Male or Female *
Required
Birthday *
MM
/
DD
/
YYYY
Address *
Parent/Guardian 1
1. Name
2. Home phone
3. work phone
4. Cell phone
5. Email
6. Relationship to the child
 *
Parent/Guardian 2
1. Name
2. Home phone
3. work phone
4. Cell phone
5. Email
6. Relationship to the child
 *
Parent's relationship  *
Any Custody issues?  Yes? (Please explain) No? 
(Confidential)
 *
Authorized Pick-ups 
Only people listed on this list will be allowed to pick up your child (ID will be required)
Person 1
1. Name
2. Home phone
3. work phone
4. Cell phone
5. Email
6. Relationship to the child
 *
Person 2
1. Name
2. Home phone
3. work phone
4. Cell phone
5. Email
6. Relationship to the child
 *
Emergency Pick-up/Contact
Person 1
1. Name
2. Home phone
3. work phone
4. Cell phone
5. Email
6. Relationship to the child
 *
Emergency Pick-up/Contact
Person 1
1. Name
2. Home phone
3. work phone
4. Cell phone
5. Email
6. Relationship to the child
 *
Child's Medical Information
Health Card Number *
Please list all known allergies (please include medicine, food, etc) *
Does your child use: *
Required
Physician's Name
Clinic's address
Clinic's phone number 
 *
Medical Release: In case of an emergency involving the child listed on the form, I authorize QECP Before/After-school program, to use the medical information listed for emergency medical treatment under the following conditions: 

1. An emergency or unexpected condition to my child, requiring immediate medical attention and,
2.  Reasonable attempts to contact the parent/guardian/emergency contacts have failed.

**By choosing yes, you are giving the QECP before/after-school program permission to use medical information**
 *
Please initial and date *
Plans
Fees are to be paid by the 1st of the month
E-transfer: qepreschool@gmail.com
Here are the plans we offer: 
**Please note:  WE DO NOT RUN ON PD DAYS**
 *
Required
Our program has a zero tolerance policy in regards to verbal/physical abuse.  Any verbal/physical abuse towards staff members, and/or other children in the program will not be tolerated.  Withdrawal from the program will be immediate.  Payment for the month of withdrawal will not be refunded.  Please initial
Please initial and date
(by initialing and dating, you are agreeing to the payment plan and our zero tolerance policy)
 *
Rules and regulations:  will be updated as needed
1.  Your child must come directly from their classroom to the gym (or preschool classroom).  Please remind them to grab all of their belongings before coming to the gym.
2.  Please do not bring toys from home or any electronics.  
3.  Snacks are permitted and encouraged.  Please keep them healthy and NUT FREE!
4.  Drop off and pick up will occur at the gym doors on Taylor Street.  Doors will be unlocked. Please come in and sign out your child. Please encourage your child(ren) to clean up their mess before they leave. (If the doors need to be locked, we will let you know via our SeeSaw app.)
5.  Attendance will be kept daily.  Please inform us of any changes to your child's information form. Please keep all information up to date.  
6.  Please respect drop off and pick up times.  We open at 7:30am and close at 6pm.  Failure to follow these times will result in an extra fee ($20/15 mins will be charged).
7.  Fees are due on the 1st of the month.
Failure to follow these rules, can result in being removed from the program.
Please initial and date (by initialling and dating, you are agreeing to our rules)
 *
Untitled Title
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms