2024-2025 Extended Day and After-School Enrollment Form

2024-2025 Extended Day and After-School Enrollment Form
Extended Day has a few spots available for the 2024-2025 school year.

After-School (K5-8th) is at capacity and no longer accepting registrations.

Due to staffing and space limitations, After-School Care (3-5:30 pm) is available only for working parents and their MRCA children. Thank you for your understanding!
How many children would you like to register for Extended Day and/or After-School?*

123
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade for 2024-2025 School Year*
Teacher
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade for 2024-2025 School Year*
Teacher
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade for 2024-2025 School Year*
Teacher
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Mother/Legal Guardian Name*

First NameLast Name
Mother/Legal Guardian Email Address*
example@example.com
Mother/Legal Guardian Cell Number*

Area CodePhone Number
Mother/Legal Guardian Work Number

Area CodePhone Number
Father/Legal Guardian Name*

First NameLast Name
Father/Legal Guardian Email Address*
example@example.com
Father/Legal Guardian Cell Number*

Area CodePhone Number
Father/Legal Guardian Work Number

Area CodePhone Number
Which email address would you like to receive important After-School communication?*

Mother/Legal GuardianFather/Legal Guardian
My child will attend Extended Day and/or After-School the following hours and days. Please check the days for each time you desire:
K3 and K4, 12:00 - 3:00 pm

MondayTuesdayWednesdayThursdayFriday
Where will you pick up at 3:00 pm dismissal?

Elementary Car LineMiddle School Car Line
Grades K5 - 8th

MondayTuesdayWednesdayThursdayFriday
How long will your K5-8th grader stay at After-School?

3 - 4 pm3 - 5 pm3 - 5:30 pm
If your child is absent from the program for any reason, the Extended Day/After-School fees for the days you selected on this form must still be paid. A late pick-up fee of $1.00/minute will be assessed if your child is picked up after the time chosen on this contract.
Please list any other people authorized to pick up your child:
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Do you want to list additional people that are authorized to pick up your child?

YesNo
Others authorized to pick up your child:
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Do you want to list additional people that are authorized to pick up your child?

YesNo
If you would like to add additional people to your child's authorized pick-up list, please email afterschool@mitchellroadchristian.org with the person's necessary information (name, relationship to child, and phone number).
Please list any person who is NOT ALLOWED to pick up your child:
Name

First NameLast Name
Relationship to Child
Why is this person not allowed to pick up your child?
Do you want to list additional people that are NOT AUTHORIZED to pick up your child?

YesNo
Please list any person who is NOT ALLOWED to pick up your child:
Name

First NameLast Name
Relationship to Child
Why is this person not allowed to pick up your child?
Do you want to list additional people that are NOT AUTHORIZED to pick up your child?

YesNo
Please list any person who is NOT ALLOWED to pick up your child:
Name

First NameLast Name
Relationship to Child
Why is this person not allowed to pick up your child?
Do you want to list additional people that are NOT AUTHORIZED to pick up your child?

YesNo
If you would like to add additional people that are NOT AUTHORIZED to pick up your child, please email afterschool@mitchellroadchristian.org with the person's necessary information (name, relationship to child, and reason).
Please list any allergies, medical needs, and/or restrictions we should know about your child.
Please click here to see Extended Day/After-School's Fees and Informaiton for the 2024-2025 school year.
I have read and agree with the Extended Day/After-School Fees and Information. I have read, signed, and agree to the terms of the After-School Enrollment Form (this form).*

Yes, I agree.
I understand that my child will attend on the day(s) he/she is registered. I agree to pay the monthly fees even if my child does not attend all the days for which they are registered.*

Yes, I understand.
I understand that my child must be picked up at the designated time to avoid a $1 per minute charge and that any late fees will be applied to my next monthly statement.*

Yes, I understand.
I agree to email the ASC coordinators by the adjustment deadlines (October 18, December 20, March 7) if I want to change my child’s attendance days for the following quarter. I understand that the newly modified schedule will remain in effect for the remainder of the school year unless I notify ASC of another change request before the next adjustment deadline.*

Yes, I agree.
Parent's Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: