MoorestownTownship Public Schools

Moorestown Township Public Schools 

Extended Day Care Program Registration Form 2017-18 School Year

One Form Per Student

Student' Full Name:   Gender  Male   Female

Attending School in 2017-18:  Grade in 2017-18: 

Address

Street:  City:  State:  

Zip: 

Legal Guardian #1 Information

Full Name: 

Cell Phone  Work Phone 

E-Mail 

Legal Guardian #2 Information

Full Name: 

Cell Phone  Work Phone 

E-Mail 

Has there been a divorce or seperation?  Yes  No

If Yes, who has Custody? 

Joint/non-custodial parent to be contacted in an emergency Yes No (Provide Custody Order)

AUTHORIZATION FOR PICK-UP

Your child will only be released to an authorized person listed on this form (parent/guardian and/or emergency contact). In case of emergency or an unforeseen circumstance, please indicate the name and phone number of any other person/s who you authorize to pick up your student on your behalf.

Contact #1 Name  Phone Number 

Contact #2 Name  Phone Number 

Contact #3 Name  Phone Number 

Medical Information

Has your Student been diagnosed or treated for any of the following?

None

Asthma

Allergies to Food or Medicine

Allergies to Insect Stings

Special Dietary Needs

Seizures

Spectrum Disorder

One-on-One Aid during the regular school day

ADD/ADHD

Other: 

Provide details about anything checked above: 

List all current medications, prescribed and over the counter:  

Any additional information that may be useful for us to know. 

I give my permission for the Extended Day Care Personnel to seek qualified medical attention for my student(s) in the event of any emergency if a parent/guardian cannot be contacted.

 I understand my student(s) will not be released to any person not listed on this form. I understand that it is my responsibility to notify each person listed that a picture ID is required to release my student(s) from Extended Day Care.

 I understand my student(s) must be picked up by 6pm. If not, I will be charged $20 per child for every 15 minutes the student is left in Extended Day Care. If no contact has been made with the parent/guardian or the emergency contacts by 6:30 pm, the authorities will be notified.

Basic Rates

Multiple Child Discount

1 ST CHILD – FULL TUITION

2 ND CHILD – 10% OFF MONTHLY TUITION APPLIED TO 2ND CHILD ONLY

3 RD CHILD – 15% OFF MONTHLY TUITION APPLIED TOWARD 3RD CHILD ONLY

• People are RESPONSIBLE for their actions.
• We will always RESPECT each other and the environment.
• HONESTY will be the basis for all relationships and interactions.
• We will CARE for ourselves and those around us.

• Requires constant attention from staff.
• Inflicts physical or emotional harm on self or others.
• Abuses the staff, equipment or the facility.
• Ignores or repeatedly disobeys the behavior guidelines.