Extended Care Enrollment

Extended Care Enrollment

Extended Care is available Monday - Thursday from 3:00 - 6:00pm and Friday from 1:45 - 4:30pm. Students must have a completed Extended Care Enrollment form in order to participate in the program.
Student Name *

First Name Last Name
Student Date of Birth *

Month Day Year
Date
Student Name

First Name Last Name
Student Date of Birth

Month Day Year
Date
Student Name

First Name Last Name
Student Date of Birth

Month Day Year
Date
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Cell Phone Number *
Please enter a valid phone number.
Parent/Guardian Work Phone Number *
Please enter a valid phone number.
Parent/Guardian E-mail Address *
example@example.com
Parent/Guardian Name

First Name Last Name
Parent/Guardian Cell Phone Number
Please enter a valid phone number.
Parent/Guardian Work Phone Number
Please enter a valid phone number.
Parent/Guardian E-mail Address
example@example.com
Please list any allergies/medical conditions/special needs of student(s): *
Monday Expected Pick-Up Time *
Tuesday Expected Pick-Up Time *
Wednesday Expected Pick-Up Time *
Thursday Expected Pick-Up Time *
Friday Expected Pick-Up Time (*Remember that Extended Care ends at 4:30 on Friday) *
Please share any other information which may be helpful to know about your student(s).

Fee Schedule
10-15 hours per week	$60
5-10 hours per week	$45
Up to 5 hours per week	$25

Students unscheduled for Extended Care or picked up after 6:00pm (Monday - Thursday) or 4:30pm (Friday) will be charged $1/minute that they are late. Individual who picks up will be required to sign an acknowledgement of their arrival time and that a fee will be assessed for late pick up. No discounts are available for late pick up.

Billing for Extended Care will take place via Quickbooks and will occur the week following service. Sign In/Out Sheets will be used to determine the fees per week. Invoices must be paid within 5 business days or a $10 late fee will be applied.

Should a student not be signed out by the individual picking up, it will result in an automatic sign out at the close of the day (6:00 M-Th, 4:30 F). Students picked up after closing are subject to all late fees.

Families will be charged based on total hours utilized. There is no sibling discount during Extended Care because discounts are built into each higher time bracket.

I have read and understand the Fee Schedule and Policies for Extended Care and agree to pay for services renedered in a timely manner.

Signature of Parent/Guardian

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