B. Everett Jordan/Alamance-Burlington Daycare Student Registration 2020

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B. Everett Jordan/Alamance-Burlington Daycare Student Registration 2020 - 2021

Pre-Registration Required with front office?(School Use Only) *

Student ID Number (not applicable to kindergarten) *

Email address *

Grade Level For 2020 - 2021 School Year *

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

Fifth Grade

Students Name: Last Name, First Name *

Child's Date of Birth *

mm/dd/yyyy

PRIMARY Parent/Guardian names, phone numbers, address, and e-mails *

Format: First & Last Name, Phone #s (specify cell, day, and home), Address, Email (If ABSS employee, please provide both ABSS email and an email address other than your ABSS address.)

Father/Guardian *

Work/Phone extension *

Cell # *

Address *

Email *

Mother/Guardian *

Work/Phone extension *

Cell # *

Address *

Email *

SECONDARY Parent/Guardian names, phone numbers, address, and e-mails *

Format: First & Last Name, Phone #s (specify cell, day, and home), Address, Email (If ABSS employee, please provide both ABSS email and an email address other than your ABSS address.)

Father/Guardian *

Work/Phone Extension *

Cell#

Address *

Email *

Mother/Guardian *

Work/Phone Extension *

Cell# *

Address *

Email *

Is there a separation, divorce or custody concern of which our staff needs to be aware? *

Yes

Yes, please explain *

Are you employed by Alamance_Burlington School System? *

Yes

If you are an ABSS employee,at what location? *

Emergency Contact and Pick Up authorization

The following people may pick up the child from the program and/or be reached during an emergency. In the event of inclement weather or an emergency situation. Please make sure you have made arrangements with these individuals to pick up your child/children from the program and they are accepting of this responsibility.**Please note a valid ID will be required to pick up students from daycare.

1st Pickup Name *

Relationship *

Phone# *

2nd Pick Up Name *

Relationship *

Phone # *

3rd Pick Up Name *

Relationship *

Phone# *

Is there any person prohibited from picking up the child by a court order? *

Yes

If yes, attach a copy of the court order and an explanation *

Prohibited Persons Name *

Relationship to Child *

Important Student Information

Please list allergies and needed medications

Please list any allergies *

Please list any required medications *

Emergency Permission *

I give permission to B. Everett JordanElementary School Daycare staff to authorize emergency treatment and transportation of my child to Alamance Regional Medical Center Hospital.

I DO NOT give permission to B. Everett Jordan Elementary School Daycare staff to authorize emergency treatment and transporation of my child to Alamance Regional Medical Center HospitalOption 2

Field Trip (If Applicable) *

I give permission for my child to attend any off school field trips on teacher workdays. Transportation will be provided by ABSS buses. I give my permission for my child to be transported on buses for daycare field trips.

I DO NOT give permission for my child to attend any off school field trips on teacher workdays.

Movie Permission (If Applicable)

I give permission for my child to watch PG movies

I do not give permission for my child to watch PG movies

Clear selection

Homework Preference (note this option may not be available at you school please check with each individual location) *

I prefer that my child work on homework during afterschool

I prefer that my child DOES NOT work on homework during afterschool.

Participation and Payment Agreement *

My child and I have read, discussed, and agree to abide by the rules, regulations, and payment schedule for attending B. Everett Jordan Elementary School Before and After School Program.

Questions and comments

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