Extended Care (K-8th)

*Required

ST. MARK'S K-8th EXTENDED CARE
2017-18 ENROLLMENT

This enrollment form must be competed in full before any child may attend the program.
 
Child(ren) Personal Information

Child #1
Name:
 
Gender: Male Female
 
Age: Birth Date:

Grade: Teacher's Name:
 


Child #2
Name:
 
Gender: Male Female
 
Age: Birth Date:

Grade: Teacher's Name:



Child #3
Name:
 
Gender: Male Female
 
Age: Birth Date:

Grade: Teacher's Name:
 


Parent(s)/Guardian Information

Father's or Guardian's Name:
 
Home Telephone:
 
Home Address (if different):
 
If shared custody, describe custodial information*:
 
Employed by:
 
Business phone with extension:
 
Cell Phone:
 
E-mail Address:
 
 
 
Mother's or Guardian's Name:
 
Home Telephone:
 
Home Address (if different):
 
If shared custody, describe custodial information*:
 
Employed by:
 
Business phone with extension:
 
Cell Phone:
 
E-mail Address:
 
*Copy of Court Order Custody Decree must be submitted to the office.
 


Health Report and Comments on Child's Development

Child's Health History and Current Health Problems
List any allergies, special medical or physical conditions or problems the child care staff should be aware of, including chronic health problems.:
Not applicable
 
List any special medications for chronic problems and/or restrictions for child's care below:
Not applicable
 
Use the space below to note any habits, language, or special conditions that the child care staff should be aware of:
Not applicable
 
 
Medication
Only prescription medication (no over-the-counter medication) will be administered. If your child will need medication during program hours, a Medication Authorization Form must be completed. The Medication Authorization Form includes space for staff to record the administration of the medication. Do not send medications with the child. Medicine must be handed to a staff member by the parent. All medications must be kept by the staff in the locked medicine box. Children are not permitted to keep medications in their book bags or pockets.
 
Prescription medication must be in the original container and labeled with the child's name, instruction, including times and dosage amounts, and the physician's name. All non-prescription medication must be in the original container and labeled by the parent(s) with the child's name and instructions for administration, including dosage times and amounts.
 
To my knowledge, my child is in good health, free of disabilities that would endanger him/her or other children in care.
 
 
 
 
Child Care Program Enrollment Agreement
  • I understand that I am financially responsible for the services of care regardless if my child actually attends the program, even in the event of illness.
  • St. Mark's reserves the right to terminate child care services if it is determined the placement is unsatisfactory.
  • I understand that in the event that school is cancelled or dismissed early due to unfavorable conditions (such as bad weather, water main break), program services will also be canceled. There is no refund for services due to unforeseen school cancellations or unscheduled early dismissals.
  • If I choose to participate in the early dismissal or holiday programs, I understand that I must register in advance and pay in full.
  • I understand that care for early dismissal days and/or holiday program will be cancelled if enough registrations are not received 5 days in advance.
  • St. Mark's Extended Care Program provides a recreational environment for school age children with and without disabilities through added support staff, when needed, to facilitate successful participation into the programs.
  • I understand that St. Mark's Extended Care Program will communicate and collaborate with the school on an ongoing basis about my child(ren) and their individual needs while enrolled in the program.
  • Late pick-up (after 6:00 p.m.) will result in an additional fee.
  • Every effort must be made to arrive prior to 6:00 p.m.. If there will be a late arrival the Director must be notified by phone immediately so that staff may be notified.

 
Emergency Contacts
Authorized persons to pick up child from Extended Care Program
List two contacts (not including doctors or parents listed above) authorized to be notified if parent cannot be reached due to a medical emergency, or if the child is left at the program beyond program hours. Provide two persons authorized to take child from program.
 
*1. Name of Contact/Authorized Pickup:

*Relationship to Child:

*Address (Street, City, State, Zip):

*Telephone during program hours:



*2. Name of Contact/Authorized Pickup:

*Relationship to Child:

*Address (Street, City, State, Zip):

*Telephone during program hours:




Permission and Agreements
  • The provider and I have agreed on a plan for continuing communication regarding my child's development, behavior, etc.
  • When my child is ill, it is understood and agreed that she/he may not be accepted for care.
  • I have received a copy of this facility's policies pertaining to the admission, care, and discharge of children.
  • I understand that I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice.
  • If 911 is called and the child is sent to the hospital, the Extended Care Program staff will notify the parents, the Program Director, and the Principal as soon as possible.
 
If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I hereby authorize St. Mark's Extended Care to contact:
 
*Doctor/Clinic Name:

*Address(street, city, state, zip):

*Telephone:

If it is necessary to take your child to a hospital, which do you prefer (Child may be taken to a different hospital if directed by physician)?

Hospital: 
 
Address (street, city, state, zip):
 
Telephone:
 
*Insurance Name:

*Group/Policy/Subscriber ID Number:



I have read and fully understand the Parents Guide to Extended Care*


*Signature of Parent of Legal Guardian:  
*Date: