Before & After School Childcare Request Form

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Please register your child for the Before/After School Program using the form below. Submit one form per K-6th grade student in your family. Please visit the Program website for more information including childcare rates and downloadable, required forms.

Child's Name *

Child's Grade *

Parent's Name *

Parent's Email *

Parent who is financially responsible for childcare charges *

Please choose your childcare needs below (select all that may apply): *

Before School (7:30-8:00am) Mon-Fri ($2.25/child)

Before School (7:30-8:00am) Drop-In Basis ($2.25/child)

After School (3:30-4:30pm) Mon-Fri ($4.50/child)

After School (3:30-4:30pm) Drop-In Basis ($4.50/child)

After School (3:30-5:30pm) Mon-Fri ($9.00/child)

After School (3:30-5:30pm) Drop-In Basis ($9.00/child)

Required

I have read the Childcare Payment policy on the Program website and understand I will be billed in FACTS each month for using the Before/After-School Program. *

Yes

Required

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