Extended Day Program

Extended Day Care Program Form

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