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Extended Learning Registration Form
A registration form must be completed for each child attended the extended learning program. (i.e. If two siblings will be attending extended learning two forms need to be completed.)
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* Indicates required question
Student Start Date
*
Extended Learning services begin the first day of school and ends the last day of school.
MM
/
DD
/
YYYY
Tuition Rate
*
Please read the list of tuition rates.
AM Services Only ($50.00 per month)
PM Services Only ($120.00 per month)
AM & PM Services ($170.00)
PM ONLY DAILY RATE ($10.00 a day for child(ren) attending less than 10 days in the month.) PARENT MUST PROVIDE A CALENDAR OF WHICH 9 OR LESS DAYS THE CHILD WILL BE ATTENDING PRIOR TO THE BEGINNING OF THE MONTH
Middle School Part-time ($50.00 per month)
AM ONLY DAILY RATE ($ 4.00a day if attending less than10 days in the month. ) PARENT MUST PROVIDE A CALENDAR OF WHICH 9 OR LESS DAYS THE CHILD WILL BE ATTENDING PRIOR TO THE BEGINNING OF THE MONTH
Middle School Daily Rate AM Only ($2.50)
Other:
Required
Priority Contact Information
This is the person I will contact in regards to late monthly payments, registration information, etc..
Priority Contact Name
*
Your answer
Priority Contact Email Address
*
Your answer
Priority Contact Cell#
*
Your answer
Student Enrollment Information
Student's Name
*
Your answer
Grade
*
Choose
Pre-Kdg
Pre-Kdg (Spanish Classroom)
Kdg
Kdg (Spanish Classroom)
1st
1st (Spanish Classroom)
2nd
2nd (Spanish Classroom)
3rd
4th
5th
6th
7th
8th
Date of Birth
*
Month/Day/Year
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Parent/Guardian Information
Mother's Name
Your answer
Mother's Cell Phone #
Please include area code
Your answer
Mother's Work Phone#
Your answer
Mother's Home Phone#
Your answer
Father's Name
Your answer
Father's Cell Phone#
Please include area code
Your answer
Father's Work Phone#
Your answer
Father's Home Phone#
Your answer
Emergency Contact Information
In case of emergency please list two additional people to contact.
Name of emergency contact #1
Your answer
Emergency Contact #1 Phone and/or Cell Number
Your answer
Name of emergency contact # 2
Your answer
Emergency Contac t#2 Phone and/or Cell Number
Your answer
Checkout/Pickup Information
Please add up to (3) additional people that will be allowed to pick up your child.
The first additional person that will be allowed to pick up my child is listed below
Your answer
The second additional person that will be allowed to pick up my child is listed below
Your answer
The final person that will be allowed to pick up my child is listed below
Your answer
Do you have additional children enrolled in the Extended Care Program?
*
GENTLE REMINDER: All students (siblings) enrolled must have a registration form. Please complete an online form for all children/siblings attending the program
None at this time
Yes
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