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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
*
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
Grade/Teacher
*
Pre-K3- Woodworth
PreK 4A- Bada
PreK 4B- Kooken
Kindergarten-Shanahan
1st-Merrill
2nd-Calos
3rd-Dejadon
4th-Houde
5th-Piskopanis
6th-Demers
7th-Lutton
8th-Minch
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
(only if someone other than parents)
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
Home
About
Faculty & Staff
Lunch Program
Athletics
Catholic Identity
Alumni
Volunteers
Extended Day Program
Student Handbook
Our Parish
Admissions
Visit
Inquire
Apply
Re-Enroll
Tuition and Fees
From the Principal
Calendar
Support SMS