MOIS Extended Day Program

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The following form is an application for the Extended Day Program at Mount Olive Intermediate School. Please read the memo regarding payment and guidelines before applying. COMPLETING THE APPLICATION DOES NOT AUTOMATICALLY BEGIN ATTENDANCE. You will receive a call to notify you of acceptance to the program. Students will only be sent to Extended Day once contact has been made with the parent or guardian as to acceptance in the program. This service is available at a first come, first serve basis.

Email *

Child's First and Last Name *

Option 1

Clear selection

Gender *

Female

Male

Grade *

Third Grade

Fourth Grade

Fifth Grade

Home Address *

Telephone Number *

Mother's/Guardian's Name *

Father's/Guardian's Name *

Medication(s) Currently Taking {If not applicable, please type not applicable.) *

Is your child currently covered by health insurance? *

Yes

Insurance Provider *

Policy Holder Name *

Policy Number *

Doctor's Name *

Doctor's Phone Number *

Emergency Contacts, other than the Parents/Guardians, allowed to pick up the child (must show a photo I.D.). *

Does the school have permission to seek medical treatment if unable to reach the parents? *

Yes

Parent Signature (please type your first and last name below.) *

Submit

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