Public School Extended Care Enrollment Form Public School Extended Care Enrollment Form Child’s Name * Date of Birth * Grade in September * School Attending * Select your program need * AM only PM only AM and PM **Parent Drop off time * **Parent pickup time (Maximum 5 hour day) * Home Address (Street, City, State, and Zip code) * Home phone number * Mother’s Name * Best phone number to be reached by * Email * Name and Address of Employer * Business Telephone * In the event of an emergency please identify an authorized person to contact or pick up your child if neither parent/guardian is available in the fields below: Name 1 * Relationship to Child * Address (Street, city, state, and Zip code) * Phone number 1 * Phone number 2 * Name 2 * Relationship to Child * Address (Street, city, state, and Zip code) * Phone number 1 * Phone number 2 * Acknowledgement: By signing below, I give permission to The Academy of ELCC to seek medical care for my child as deemed necessary. I also agree to abide by all policies and procedures, submit all forms completed, to make all registration/book fees and tuition payments as scheduled, and understand that non-compliance by me, my representative, or my child will result in the immediate dismissal of my son or daughter. Type your name below (this will be your signature) * Date * Child’s Name * Child’s Date of Birth * Grade in September * Is your child under any medical/physical restrictions? * Yes No If Yes, then check all that apply: Asthma Hearing Loss Diabetes Convulsions Others (please provide details below) Other Is your child taking any medication? * Yes No If yes, please list Has your child been under a doctor’s care or hospitalized within the last three years? * Yes No If yes, please explain Is your child allergic to any medications/foods/insect stings? * Yes No If yes, please list Family Health care provider’s Name: * Phone number * Address (Street, city, state, and Zip code) * Medical Acknowledgement As a parent/guardian of the above participating child, I certify that he/she is in good physical health, has no special needs, and may participate in all of the activities of the Center’s program, except as noted above. Parent/Guardian Signature: * Date * Text If you are human, leave this field blank. Submit Your Application