SY2026–2027 MMLCS Extended Care Program Registration Form (FINAL)

2026–2027 MMLCS Extended Care Program Registration Form

Please complete all required information. Submitting the form does not guarantee placement; enrollment is confirmed only after administrative review, space confirmation, and payment.
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Relationship to Student
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
FACTS Family Account Number
Student 1 Information
Student 1 Full Name

First NameLast Name
Grade
Date of Birth

MonthDayYear
Date
Allergies, if NONE, type N/A
Medical or Supervision Information, if NONE, type N/A
Requested Program
Remaining Seats, if FULL, complete to be waitlisted
Additional Student Information
- Student 2 Full Name
  
  First NameLast Name
- Student 2 Grade
- Student 2 Date of Birth
  
  MonthDayYear
  Date
- Student 2 Allergies, if NONE, type N/A
- Student 2 Medical or Supervision Information, if NONE, type N/A
- Student 2 Requested Program
- Remaining Seats, if FULL, complete to be waitlisted
- Student 3 Full Name
  
  First NameLast Name
- Student 3 Grade
- Student 3 Date of Birth
  
  MonthDayYear
  Date
- Student 3 Allergies, if NONE, type N/A
- Student 3 Medical or Supervision Information, if NONE, type N/A
- Student 3 Requested Program
- Remaining Seats, if FULL, complete to be waitlisted
- Emergency Contacts and Pickup Authorization
- I give permission to the following individuals to act as parent designates to pick up my child(ren) from the Extended Day Program.
- Emergency Contact 1 Full Name
  
  First NameLast Name
- Relationship to Student
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Is this contact also authorized for pickup?
- Emergency Contact 2 Full Name
  
  First NameLast Name
- Relationship to Student
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Authorized Pickup Persons
- Dismissal Details
- Dismissal Method
- Acknowledgments, Signature, and Payment
- SY2026-2027 MMLCS Extended Care Program Tuition Information found here.
  
  In consideration of my child participating in the Extended Day Program, I hereby release Mother Mary Lange Catholic School, Archbishop William Lori, Roman Catholic Archbishop of Baltimore, a corporation sole, and their agents, employees, and principals, of and from any and all liability, claims, demands, actions, and causes of actions whatsoever, arising out of or related to any loss, damage, or injury that may be sustained by my child or children. I hereby grant permission for my child to participate in the Extended Day Program. I acknowledge receipt of the information describing the details of the experience.
- Payment obligations acknowledged
- Attendance and schedule changes acknowledged
- Authorized pickup acknowledged
- Behavior expectations acknowledged
- Emergency procedures acknowledged
- Late pickup fees acknowledged
- Removal from program acknowledged
- Electronic parent/guardian signature
- Signature date
  
  MonthDayYear
  Date
Should be Empty:

2026–2027 MMLCS Extended Care Program Registration Form

Parent/Guardian Information

Student 1 Information

Additional Student Information

Emergency Contacts and Pickup Authorization

Dismissal Details

Acknowledgments, Signature, and Payment