Extended Care Form

2023-2024

Extended Care Program

K - 12th Grade Before/After School Enrollment
Student's Name*
Address

Street Address

Street Address Line 2

City/State/Zip CodeState / Province

Postal / Zip Code
Entering Grade*
Homeroom Teacher (if known)
Father's Name
Work/Cell
Mother's Name
Work/Cell
Adults authorized to pick up your child (other than mother and father)
Name
Name
Name
Extended Care Hours: 6:30am to 7:30am and 4:00pm to 6:00pm on regular school days. A charge of $7.00 per minute per student will be assessed for pick-ups after 6:00pm. We understand that we will be billed according to the choice below. Hourly charges must be paid at the end of the month charges were incurred.
Check one option

Before and After school (Monthly Program) - $175 per month/$150 per month (siblings)Hourly Program - $9.00 per hour
TCA has my permission to care for my child in Extended Care.

I will NOT hold TCA or its staff responsible for any accident that may occur. I further understand that enrollment will be automatically billed to my account as indicated above.
Parent Signature*
Date*

MonthDayYear
Date
Should be Empty: