After-School Enrollment Form

Child's Name

Grade

Teacher

Address

Home Phone

Date of Birth

Date

Mother's Name

Mother's Cell Number

Father's Name

Father's Cell Number

Mom's Work Number

Dad's Work Number

Email Address Which Is Checked Most Often

example@example.com

My child will attend After-School the following hours and days. Please check the days for each time you desire:

K3 and K4, 12:00 - 3:30 pm*

Monday Tuesday Wednesday Thursday Friday

*Where will you pick up by 3:30 pm?

Playground Middle School Car Line Elementary Car Line

K3 and K4, 12:00 - 6:00 pm

Monday Tuesday Wednesday Thursday Friday

Grades K5 - 8th, 3:00 - 6:00 pm

Monday Tuesday Wednesday Thursday Friday

Your child must be picked up at or before the time chosen on this contract, or a late pick-up fee of $1.00/minute will be assessed. If your child is absent from the program for any reason, your fee must still be paid.

Others authorized to pick up your child:

1) Name / Relationship

Phone number

2) Name / Relationship

Phone Number

People NOT ALLOWED to pick up your child:

1) Name / Relationship

Phone Number

Why is this person not allowed to pick up your child?

2) Name / Relationship

Phone Number

Why is this person not allowed to pick up your child?

Allergies, medical needs, and/or restrictions

My child may be given (check all that apply):

Tylenol Benadryl Advil

Please read over carefully and sign:

I have read and agree with the After-School Fees and Information. I have read, signed, and agree to the terms of the After-School Agreement Form and the After-School Enrollment Form (this form). I understand that the After-School Program is not a drop-in program. My child will come on the days specified. I also understand that fees are due even if my child is absent from the program. I understand that my child must be picked up at the designated time and that the late fees listed above will be applied on my next monthly statement. I understand that any changes must be approved by an After-School employee and sent in writing.

Parent's Signature

Clear

Date