Extended Day Care Form Test

Before and After School Program

$25.00 Registration Fee will be added to your first bill.

Registration Form 2020-2021

* Indicates required field

Today's Date *

Day *

Year *

Grade/Teacher *

Student Name *

First

Last

Parent/Guardian *

First

Last

Student Address *

Line 1

Line 2

City

State

Zip Code

Country

Mother's Name *

First

Last

Mom Home Phone Number *

Mom Cell Number *

Mom Work Number *

Mom Ext *

Father's Name *

First

Last

Dad Home Phone Number *

Dad Cell Number *

Dad Work Number *

Dad Ext. *

Is your child in the custody of both parents? *

Yes No

If Not - Legal Guardian Name *

First

Last

Relationship *

Home Phone Number *

Cell Number *

Work Number *

Ext *

Names of Person(s) of whom the child will be released

Name #1 *

First

Last

Relationship #1 *

Phone Number #1 *

Name #2 *

First

Last

Relationship #2 *

Phone Number #2 *

Name #3 *

First

Last

Relationship #3 *

Phone Number #3 *

Name #4 *

First

Last

Relationship #4 *

Phone Number 4 *

Name #5 *

First

Last

Relationship #5 *

Phone Number #5 *

Medical

Allergies *

Is your child prescibed an EPI Pen *

Yes No

Other Health Concerns *

Is your child prescibed an Inhaler *

Yes No

Medications *

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