2020-2021 Before & After School Program Registration Form

Registration Fee is $50 per student or $75 per family. Fee is billed through FACTS.

Student Information

Student's First Namerequired

Student's Last Namerequired

Grade/Teacherrequired

Family Information

Mother's First Name

Mother's Last Name

Address 1

Address 2

City

State

Zip

Mother's Cell #

Mother's Work #

Ext

Mother's Email

Father's First Name

Father's Last Name

Father's Cell #

Father's Work #

Ext

Father's Email

Is Father's address the same as Mother's?

Yes No

Please provide Father's address.

Address 1

Address 2

City

State

Zip

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Please list any known allergies:

Allergies

Authorized to Pick-Up: ID is required at Pick-Up

Please Select Desired Services:

Full Time Before School $600 per child, per year*

Yes No

Part Time Before School $5 per child, per day*

Yes No

Full Time After School Monday - Friday $3000 per child, per year*

Yes No

Part Time After School (Specific Days) $10 per child, per hour*

Yes No

Before School: Non-Registered Drop-in Rate is $7 per child, per day.

After School: Non-Registered Drop-in Rate is $15 per child, per hour.

The drop-in option is used for emergency/unplanned situations only. If a child exceeds 3 drop-ins, you will be required to complete the registration process thus being billed a registration fee.

I agree:

By signing this form below I understand and agree to the following: • Parents/guardians/siblings who are dropping off participating PAC students between 7:00-7:30 am must park and escort them into Gym 2 where they will sign them in. • Several times a year elementary students are dismissed at noon. On these pre-scheduled dates, students must be picked up on time. Aftercare WILL NOT be provided on half days. Here are the half days currently on the calendar; 8/13/19, 10/04/19, 10/28/19,12/18/19, 12/19/19, 12/20/19, 2/28/20, 5/8/20, 5/21/20. • My child(ren) will not be allowed to enter or leave the facility unless escorted by the parent(s), person(s) as authorized above or PAC Personnel. Please note: An ID is required for pick-up. • I acknowledge it is my responsibility to keep all records updated to reflect any changes. • PAC personnel will inform me of any incident, including illness, injury, or exposure to communicable diseases, which may affect my child(ren). • Parents of children who participate in the program are required to read the PAC Program Policies available on the website. • I will send a healthy snack for my child(ren) on days they stay for afternoon PAC.

Yes No

Today's Date (mm/dd/yyyy)

Please Type Full Name