Extended Day & Childcare

Extended Day Care Program Form

(Must be filled out and completed no later than Sept. 1st if you are planning on using these services starting September 14, 2020)

Morning Program 6:50AM - 7:30AM - Afternoon Program 2:15PM - 5:30PM

$25 Registration fee will be added to your first bill

Please fill out one form for each child registered at Saint Michael School.

* Indicates required field

Date/Month *

Day *

Year *

Grade/Teacher *

Student Name *

First

Last

Student Address *

Line 1

Line 2

City

State

Zip Code

Country

Mother's Name *

First

Last

Mother's Cell Number *

Mother's Work Number *

Father's Name *

First

Last

Father's Cell Number *

Father's Work Number *

Is your child in the custody of Both Parents? *

Yes No

Legal Guardian Name *

First

Last

Legal Guardian Cell Number *

Legal Guardian Work Number *

Name(s) of Person(s) to whom child will be released

Contact #1 *

First

Last

Relationship #1 *

Phone Number#1 *

Contact #2 *

First

Last

Relationship #2 *

Phone Number #2 *

Contact #3 *

First

Last

Relationship #3 *

Phone Number #3 *

Medical Information

Allergies *

Is your child prescibed an Inhaler? *

Yes No

Health Issues *

Is your child prescibed an Epi Pen? *

Yes No

Medications *

Parent/Guardian Signature

Name of Parent / Guardian who filled out online form:

Name *

First

Last

By checking the box below, I am stating that all the information filled out on this form and is true and accurate:

True and Accurate *

Checked box confirmation

Submit