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Extended School Program Registration Form 2019-2020

Please complete the form below. Required fields marked * 

-Please do not enter dashes when entering phone numbers. 

Student Information 

Please check the box below to indicate which school your child attends. After-school ESP is not offered at Highland or Greene Technology Center. If you child attends Pre-K at one of these locations, they may ride the bus to Hal Henard each day. If your child is in grades K-5 at Highland, they may only attend ESP during full operation days. *
Answer Required

Parent/Guardian Contact Information

Address
State*
Answer Required

Parent/Guardian Contact Information 

Child's Physician or Family Nurse Practitioner Information

Address
State*
Answer Required
Please check any allergies that apply *
Answer Required
Are student immunization records on file with the school?*
Answer Required
Does your child keep allergy medication and/or an Epi Pen available in the school office or with ESP?*
Answer Required
Does your child take any medication regularly? *
Answer Required
Does your child have any health problems or any recurring chronic illness? *
Answer Required
Does your child have any developmental health concerns such as; problem with speech, seeing, hearing, or walking?*
Answer Required
Fee Payment Agreement- Please check yes or no on the following questions regarding ESP fees. *
Answer Required
Yes
No
I understand and agree that I am responsible to pay the current fees of $10 per day for after-school ESP
I understand and agree that I am responsible to pay the current fee of $18 per day for full ESP days
I understand and agree that I must complete an Income Eligibility form to be considered for any reduced rates.
I understand and agree that any reduced rates will not be applied prior to the date the Income Eligibility application is received.
I understand that I will be billed each week for the days I have indicated my child will attend on a weekly basis.
Fee Payment Agreement Information-please check ONLY the days your child will need to attend ESP each week. *
Answer Required

Emergency Contact-Authorized Pick-Up 

Please list someone to contact, besides parents, in case of an emergency. 

Confirmation Email