AFTERCARE REGISTRATION FORMS

Payment: We offer two payment options.  Contract "A" (automatic withdraw) and Contract "B" (pay-as-child attends).  Payment is due as specified in payment guidelines; on the following page.

CONTRACT "A"

$9/day per child flat rate, including any half days.  Must sign agreement for automatic withdraw scheduled on the 20th of each month along with providing a cancelled check. Usage in addition to that specified in your contract will be billed in the next withdraw.  Chose from the following:

                                                  Withdraw amount per  

        Days per         month for:

         Option        Month             1st Child    2nd child *

*Third child and above, no additional charge.

CONTRACT "B"

$11/day per child. $15/per child for half day dismissal *.  Frequent users, payment due by Friday of week of service provided, for all days attended.  Drop-ins: payment is expected on or before days of After Care Services.  You may pay by cash or check (Checks to be made out to St. Thomas the Apostle School), and deliver to After Care Coordinator or Schools Main Office.  Late payments, fees will be applied accordingly.

Both Contract "A" and "B" users subject to late fees if children are not picked up by 6p.m. $10 from 6:00 to 6:15 and $5 per every 5 minutes after.

After Care Enrollment Contract

Please print.  Complete information is essential to insure accurate processing.  Please return this form to school office by May 28, 2006.  Emergency form is also included for your convenience.

 Student's Name ______________________

Mother's Name ______________________

Father's Name _______________________

Responsible party’s address & phone#'s.

 ____________________________________

 ____________________________________

 ____________________________________

Please check one of the following:

____ I choose Contract "A", option #____

I will forward a canceled check with this completed contract.

____ I choose Contract "B".  I have read the details and understand that I am responsible for weekly payment for services provided as per this contract

____________________________________

Signature of Responsible Party

Date________________________

 After Care Emergency Information

 Student's Name: __________________________________ 

 Grade: _____________          DOB:___________________

Address: ____________________________    Home Phone: ________________

              ____________________________

              ____________________________

Parent/Guardian:

Name: ______________________________   Wk # _____________     Cell # _______________

If Parent/Guardian cannot be reached, notify the following incase of emergency:

1. __________________________________    

Relationship: _________________________

Phone#s:_______________ or _______________     

2. __________________________________     

Relationship: _________________________

Phone#s:_______________ or _______________

Family Physician: _____________________      Phone: _________________

Dentist: _____________________________      Phone: _________________

Any medical conditions: ______________________________________________      

Allergies: ____________________________ 

Daily Medications: ____________________

Med. Ins.: ___________ Cert: ___________

Group: _____________ Type: ___________

************************************

ALTERNATE  INFORMATION

Please list all persons who are designated

 by you to sign out your child/children

 from After Care. 

1. ________________________________

 2. ________________________________

 3. ________________________________

Children will not be released unless signed out by a person listed or unless additional specific information is sent to

 us in writing giving your permission.

Any questions, payments, account inquiries or concerns may be directed to:

St. Thomas the Apostle After Care Program

Dee McLaughlin  (302)654-1790 Or by contacting our Main Office - (302) 654-0746.