BEFORE AND AFTER SCHOOL CARE PROGRAM

2010-2011

 

PLEASE COMPLETE and RETURN TO THE SCHOOL OFFICE. Please PRINT.

 

Family Last Name: ____________________________________

Names of Children: ___________________________________________________  Grade __________

___________________________________________________________________   Grade __________

___________________________________________________________________   Grade __________

** PLEASE NOTE any medical problems/allergies we should be aware of: _______________________

____________________________________________________________________________________

Put a CHECKMARK on the day(s) and CIRCLE the times your child/children will be attending (Standard p.m. fees are reduced to $3.00/hour for additional children within a family; see program guide):

        Before School Care (circle time)                                    After School Care (circle approximate time)

                        ($3.50 per day)                                                $5.00/1 hr.      $10.00/2 hrs.      $15.00/3 hrs.

 

□    Monday          7:00 – 7:40 a.m.                                   2:30 – 3:30      2:30 – 4:30      2:30 – 5:30

□    Tuesday          7:00 – 7:40 a.m.                                   2:30 – 3:30      2:30 – 4:30      2:30 – 5:30

□    Wednesday     7:00 – 7:40 a.m.                                  2:30 – 3:30      2:30 – 4:30      2:30 – 5:30

□    Thursday        7:00 – 7:40 a.m.                                  2:30 – 3:30      2:30 – 4:30      2:30 – 5:30

□    Friday             7:00 – 7:40 a.m.                                  2:30 – 3:30      2:30 – 4:30      2:30 – 5:30

□    Drop-In/Emergency Use Only ($3.50/a.m., $6.00/hour p.m.)

 

I AM AUTHORIZING the following people (including parents’ names) to pick up my child/children (picture ID may be required). Unless notified otherwise, only these people will be allowed to pick up your child/children. Name and day-time/work phone number(s) (include cell phone, please):

 

Mother________________________________­­           Phone number(s):_______________   cell: _______________

Father_____________________________­­­­____    Phone number(s):_______________   cell: _______________

__________________________________­­­­____    Phone number(s):_______________   cell: _______________

_____________________________________­­­­_    Phone number(s):_______________   cell: _______________

In case of an emergency:

Father’s work/cell number(s):____________________  Mother’s work/cell number(s):____________________

 

In case we are unable to reach a parent, please list two people that we can call to handle an emergency/illness during Before or After School Care or to pick up after 5:30 p.m.:

 

_______________________   Relationship: _____________  Phone/cell number(s):______________________

_______________________   Relationship: _____________  Phone/cell number(s):______________________

 

I understand the billing procedures, billing cycle, and that a $50.00 registration fee will be added to the first bill.

 

PARENT SIGNATURE: _______________________________________ DATE: ______________________

 

Office Use: $50.00 Registration Fee 2010-2011                      Date Paid: ____________       Check #: __________