Camas Extended Day Program
REGISTRATION
2015-16
STUDENT INFORMATION
Name:
Address:
City:
State/Zip:
Gender: Male ☐ Female ☐
Phone:
Birth Date:
Grade:
School:
Teacher:
Room No:
Sibling:
School:
Grade:
Sibling:
School:
Grade:
My child participates in: Special Ed Program/IEP ☐
If checked speech/language only: ☐
PARENT INFORMATION
Father’s Name:
Address (if different):
City:
State:
Phone:
E-mail:
ZIP Code:
Place of Employment:
Work Phone:
Mother’s Name:
Address (If different):
City:
State:
Phone:
E-mail:
ZIP Code:
Place of Employment:
Work Phone:
EMERGENCY CONTACTS
Name:
Relationship to Child:
Phone:
Name:
Relationship to Child:
Phone:
Name:
Relationship to Child:
Phone:
OTHER PEOPLE WITH PERMISSION TO PICK UP YOUR CHILD
Name:
Relationship to Child:
Phone:
Name
Relationship to Child:
Phone:
HOURS OF CARE DESIRED (HOURS OF OPERATION ARE 6:30 AM – 6:30 PM)
Schedule
Before School Arrival Time
Before School Only:
Yes
No
After School Only:
Yes
No
N/A
Early Release Only:
Yes
No
N/A
Full Time:
Yes
No
Part Time: M
T
W
Th
After School Departure Time
N/A
F
REGISTRATION FEE
Non-refundable registration fee of $25 must accompany registration($15 for sibling)
OFFICE USE ONLY
Date registration received:
Monthly Fee:
Amount Paid:
FEES AND PAYMENT PLAN
1.
All fees for full time (monthly) and half time (monthly) care are due on the first of each month. Fees
not paid by the 10 th are delinquent and will be subject to an additional $10 fee. Daily fees are also
payable in advance; daily, weekly or monthly depending on the child’s schedule.
2.
There will be no reduction on monthly rates for holidays, illness or school closure due to inclement
weather. A child staying home does not reduce our operational expense. By making consistent
monthly payments throughout the school year, there will no charge for June care.
3.
Whenever a child will not be attending after school care, parents must call Extended Day at
(360)833-5540 and their child’s specific school.
4.
If fees are delinquent and not paid in full by the end of the m onth, your child’s enrollment may be
terminated. A fee of $25 will be charged for any returned (NSF) checks.
5.
The Extended Day Center closes at 6:30 SHARP. If a child is not picked up by closing time, there will
be an overtime charge of $1.00 per mi nute, per child. More than one late pick-up may result in
termination of enrollment.
6.
A snack is served to all children in after school care.
Camas Extended Day Program Fee Schedule 2015-2016
School-Age Program
(up to 6th grade)
Monthly
Daily
Before School
(6:30am-8:30am)
$185.00
$12.00
After School
(3:30pm-6:30pm &
1:10-6:30pm on Wed.)
$275.00
$15.00 &
$25.00 Wed.
Full Time
(6:30am-6:30pm)
$340.00
NA
I agree with the above and authorize Camas Extended Day Program to care for my child,
Parent/Guardian Signature
Date
Camas Extended Day Program
Annual Student Health Inventory
STUDENT INFORMATION
Name:
School:
Grade:
HEALTH CONCERNS – LIFE THREATENING HEALTH CONDITIONS
If a life threatening health condition exists, a medication/treatment order from a licensed health professional
must be provided to Camas Community Education office. Camas Extended Day will make medical
accommodations with parents and put a plan in place.
Check all that apply:
My child DOES NOT have any health concerns;
Severe Allergic Reaction (e.g. food, medication, etc.) Please specify:
Asthma: Rescue inhaler?
Diabetes:
Type 1
Seizure Disorder
Yes
No
Date last used:
Type 2 Managed by:
Diet only
Oral meds
Type of seizure:
Cancer/Blood Disorder
Insulin injection
Insulin pump
Date of last seizure:
Please specify:
Other life-threatening health concerns:
Other health concerns:
MEDICATIONS
Prior to any medication given at school, a written authorization is required from a Licensed Health Professional
and parent/legal guardian, in accordance with RCW 28A.210.260 and CSD policy 3416. The Authorization for
Administration of Medication form is available from Camas Extended Day.
Is medication needed at home?
Yes
No
If yes, please specify:
Is medication needed at school:
Yes
No
If yes, please specify:
Doctor’s name:
Phone Number:
I understand that the information above will be sh ared in a confidential manner with appropriate school staff
that needs to know in order to provide for the health and safety of my student. I will keep the school informed
throughout the year regarding any changes in health status and/or contact informati on. If parents/legal
guardians or authorized emergency contacts cannot be reached at the time of a medical emergency, and if
immediate care is urgent in the judgment of school authorities, I authorize and direct the school authorities to
request emergency medical services (911). I understand that I may be responsible for the payment of any
services rendered.
Parent/Guardian Signature
Date