Extended Day and After-School Enrollment Form

Extended Day and After-School Enrollment Form
Child's Name
Grade
Teacher
Address
Home Phone
Date of Birth

MonthDay Year
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*

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

PlaygroundMiddle School Car LineElementary Car Line
K3 and K4, 12:00 - 6:00 pm

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

MondayTuesdayWednesdayThursdayFriday
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):

TylenolBenadrylAdvil
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

MonthDay Year
Date
Should be Empty: