St. Clare
Before and
After School Care
Registration
Form for 2007-2008
State law requires all lines to be completed. A separate form is required for each child
Questions? Call (503)
244-8747
(Please Fill-in Both Sides
of the Page)
Date______________
Child's Name ___ ______ Grade __________
Address ___ __________
Home Phone __ Birth date: ________
PARENT INFORMATION
Legal Custody: Both _______ Mother _______
Father _______ Joint _______
Doctor's Name,
Address and Phone
_____
Dentist's Name,
Address and Phone
_____
List two names of persons to be
contacted in case of an emergency, OTHER THAN PARENT:
Name Home
Ph Work
Ph
Name Home
Ph Work
Ph
Child may be released to:
Name Relationship
Name Relationship
Name Relationship
(We are unable to release your
child to anyone who does not have authorization to do so -- this includes
coaches. )
EMERGENCY
INFORMATION AND RELEASE
I authorize St. Clare
Before and After School Care (BASC) to arrange medical treatment at my expense
for my child. I understand that the
efforts will be made to call one of the persons I have designated to be emergency
contacts before this action is taken. I authorize St. Clare BASC to call an
ambulance to transport my child to a hospital if they deem that necessary.
Parent's
Signature___________________________________________________Date__________
Preferred Hospital ___________________ _____
Medications taken, if any
Important Medical
Information: Please record any information that you feel is important for us to
know about your child such as asthma, bee sting, or food allergy, heart
condition, etc.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Before and
After School Care (BASC)
REGULAR
DESIRED SCHEDULE
Date
Child's
Name ___ Grade ____________
Please check
the appropriate box for the type of care you will need:
Drop-in Care Only
Regularly Scheduled Care (see below)*
*REGULARLY
SCHEDULED CARE – DAYS AND TIMES DESIRED
PLEASE
CHECK THE APPROPRIATE BOXES
|
|
Cost: |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
|
Before
School: 7:00
- 8:00 am |
$4.00 |
|
|
|
|
|
|
After
School 1: 3:00
- 4:30 pm |
$6.00 |
|
|
|
|
|
|
After
School 2: 3:00
- 6:00 pm |
$12.00 |
|
|
|
|
|
After School 3:
(Tuesdays only)
|
$4.00 |
|
|
|
|
|
Drop-in care only
|
$5.00/hr |
|
|
|
|
|
o
REGULAR
SCHEDULED CARE REGISTRATION FEE ($50 for
first child, $35 for each child thereafter)
CHECK NO. ________________
AMOUNT$__________________ Split
with______________________
o
DROP-IN
AND EMERGENCY CARE REGISTRATION FEE ($35 each)
CHECK NO. ________________
AMOUNT$__________________ Split with______________________