Extended Day Care Program

Extended Day Care Registration

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: 


Street:  City:  State:  


Legal Guardian #1 Information

Full Name: 

Cell Phone  Work Phone 


Legal Guardian #2 Information

Full Name: 

Cell Phone  Work Phone 


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)


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?



Allergies to Food or Medicine

Allergies to Insect Stings

Special Dietary Needs


Spectrum Disorder

One-on-One Aid during the regular school day



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

 AM Only/MonthPM Only/MonthAM & PM/Month
5 Days$183$247$300
4 Days$174$234$286
3 Days$167$224$275
2 Days$132$177$237

Multiple Child Discount




I'm registering my 
How many Days will the student be attending? 
Will your student be a Drop-In? 
When will the student be attending? 
What Days will the student be attending?
 Monday Tuesday Wednesday Thursday Friday
 In signing this contract,
1) I/We are enrolling our child according to the schedule and fee indicated above. Any changes or cancellations in the information above are to be made in writing and given to the Moorestown Township Public Schools Extended Day Care Staff at least thirty (30) days in advance of change. Care for days not regularly scheduled may be arranged by purchasing a Drop-In BOOKLET. NO PAYMENTS will be taken at the sites.
2) I/We agree that the monthly tuition is due the 15th of the previous month and that a $10.00 late fee will be charged for payments not received by the 15th of the month. If there is a security deposit paid on my account, Moorestown Township Public Schools Extended Day Care Program has the right to use said deposit for any current month payment not received by 1st of each month. If payment has not been secured by the 1st of the month, the Extended Day Care staff will notify you by phone to pick up your child and your child will not be able to return until payment is received. Returned checks are subject to a $20 fee.
3) The Extended Day Care Program ends each day at 6pm - late pick up will result in a charge to your account. The fee for late pick up is $20 per child for every 15 minutes beginning at 6:01pm. Accounts will be charged for any late pickups that were not prearranged with the Site Director. I/We also understand that such days are subject to additional fees, in accordance with Moorestown Township Public Schools Extended Day Care costs associated with additional hours and care provided.
4) I/We have read and comply with the policies and information contained in the 2017-2018 Parent Handbook and that my child’s continued enrollment is contingent on my following these policies
Moorestown Township Public Schools Extended Day Care Program believes the following premises should serve as guidelines for our attitudes and actions:
  • 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.
Our Extended Day Care Program operates under the belief that children who are actively involved, surrounded by caring staff & made aware of the Extended Day Care Program behavior guidelines will behave in a positive manner. We foster raising a child’s self-esteem through positive reinforcement. However, sometimes corrective action is required when a child’s behavior is inappropriate, such as when a child:
  • 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.
 I have reviewed the Behavior Guidelines with my student(s). We understand and agree to all of the terms presented in this contract and that the above guidelines are for the parent/guardian as well.
The NON-REFUNDABLE $50.00 FAMILY REGISTRATION FEE ($25.00 if registering before June 15th, 2017). can be paid by mail-in check or online. Mail check payments to Moorestown Extended Day Care Progam 803 Stanwick Road Moorestown ,NJ 08057. You can also make the registration fee payment online on our website www.mtps.com in the Parent Payment Portal under the Item/Fees tab where online check and credit card payments are accepted.
There are several methods to pay for services. Once your student(s) is registered, you will receive a mail in payment booklet. If you elect to pay online, you can access the itemized fees on our website www.mtps.com under the Parents tab in the Parent Payment Portal within the top horizontal Items/Fees tab where online check and credit card payments are accepted. Payments can be mailed or hand delivered to the Administration Building 803 Stanwick Road Moorestown , NJ 08057. 
After Submitting Your Completed Registration Form, You Will Be Directed To The Parent Payment Portal Where You Can Pay The Registration Fee.
Early Registration $25.00 before June 15, 2017 Or $50.00 After June 15, 2017
Signature of Legal Guardian   

Security Measure