Extended Day Registration

Extended Day Registration

2020-2021 School Year
Student Information
Student Name *

First Name Last Name
Gender *

Male Female
Date Of Birth *

Month Day Year
Date
Race/Ethnicity *
Upcoming Grade *
Enrollment Date *

Month Day Year
Date
Parent Information
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Who does the Student live with?
Mom, Dad, Grandma, Etc...
Main Phone # *
Please enter a valid phone number.
Cell Phone # *
Please enter a valid phone number.
Mom Work # *
Please enter a valid phone number.
Dad Work # *
Please enter a valid phone number.
Emergency Contact
Emergency Contact #1 *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Emergency Contact #2 *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Alternate Pick-Up
Alternate Pick-Up #1

First Name Last Name
Phone Number
Please enter a valid phone number.
Alternate Pick-Up #2

First Name Last Name
Phone Number
Please enter a valid phone number.
Is there any information we should know about your child?
The Extended Day program is available only on days school is in session.

Hours are from 7:00 a.m. – 8:15 a.m. and from 3:00 p.m. – 5:30 p.m.

There is a late pick-up charge of $1.00 per minute per family for those dropped off before 7:00 a.m. or not picked up by 5:30 p.m.

Extended Day fees are billed on a weekly basis at $50 per week for students in Kindergarten and higher, and $100.00 per week VPK. If for any reason you choose to stop this service, please stop by the office immediately and fill out a dis-enrollment form so that billing will stop.
Parent Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Extended Day Registration

Student Information

Parent Information

Emergency Contact

Alternate Pick-Up