Extended Day Registration Form (Page 2 of 2) in pdf

Extended Day Registration Form Page 2

parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent,

as an emergency contact for events occurring during school or day care activities.

AGREEMENTS

Blessed Sacrament School Extended Day Program (BSSEDP) agrees to notify the parent(s)/guardian(s) whenever the child

becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by BSSEDP.

The parent(s)/guardian(s) authorize BSSEDP to obtain immediate medical care if any emergency occurs when the

parent(s)/guardian(s) cannot be located immediately.**

The parent(s)/guardian(s) agree to inform the BSSEDP within 24 hours or the next business day after his child or any member of

the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life

threatening diseases which must be reported immediately.

SIGNATURES

_______________________________________________________________________

____________________________

Parent(s) or Guardian(s)

Date

_______________________________________________________________________

____________________________

Director of BSSEDP

Date

**If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that states

the objection and the reason for the objection.

NOTE: (Proof of identity is maintained in the main school records)

Check each period for which you wish to regularly enroll your child.

Time period

Occasional use

Regular use

List what days per week

7:00 am - BSC - Regular use (all grades)

8:00 am - **GSECCS BSC Regular use

11:45 am to 3:00 pm - Regular use (Preschool)

1:30 pm to 3:00 pm - Regular use (RB & SS)

3:15 to 6:00 pm - Regular use (*RB, SS, Sun, K-8 only)

12:00pm to 3:15 pm on "Early Release" Days

STARTING DATE _______________________________

* Other preschool students with approval of the Principal or Director. ** Grade School ECC Sibling

Date Child Entered BSSEDP: ___________________________

Date Child Left BSSEDP: ______________________________

Extended Day Registration Form Page 2