Extended Care

Registration Form 2021-2022

In the event of an emergency, or your child becomes ill at Extended Care, it is imperative we have up to date information so that you can be notified and arrangements can be made. You will be called first, and only if you cannot be reached will other steps be taken.

Student(s) Information

Please include all children in your family that will attend extended care.

Full Name(s) and Grade(s) for 2021-2022 school year*

Answer Required

Home Address*

Answer Required

Allergies, Medical, or Special Needs

Answer Required

Student's Physician & Phone Number*

Answer Required

Student's Dentist/Orthodontist & Phone Number*

Answer Required

Parent 1 / Guardian Information

Full Name*

Answer Required

Email Address*

Answer Required

Phone Number*

Number Required

Alternate Phone Number

Number Required

Parent 2 / Guardian Information

Full Name

Answer Required

Email Address

Answer Required

Phone Number

Number Required

Alternate Phone Number

Number Required

Authorizations

Additional people who may pick up your child:*

Answer Required

I hereby give permission for my child to receive the following at Extended Care when necessary:*

Answer Required

Benadryl

Ibuprofen

Tylenol

Family provided medicine with instructions

None

The staff of Assumption-St. Bridget's Extended Care will take the steps indicated in case of injury or illness to my child.*

Answer Required

I hereby authorize

Emergency Contacts

Used in case you cannot be reached. These contacts may also be called if Extended Care is closed and a parent/guardian has yet to pick up your child(ren).

Emergency Contact 1 Full Name*

Answer Required

Emergency Contact 1 Phone Number*

Answer Required

Emergency Contact 2 Full Name*

Answer Required

Emergency Contact 2 Phone Number *

Number Required

Emergency Contact 3 Full Name*

Answer Required

Emergency Contact 3 Phone Number*

Number Required

Rates & Billing Information

Extended Care is $10 per hour/per child. All billing will be invoiced to your FACTS account.

Parent/Guardian Signature: *

Answer Required

Please fix the highlighted areas below before submitting.

Extended Care

Registration Form 2021-2022