Extended Care Form – Clarksville Academy

Child's Full Name:(Required)

Name child prefers to be called:(Required)

Sex:(Required)

Grade:(Required)

Date of Birth:(Required)

Age:(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone:(Required)

Mother's Information

Mother's Name

First Last

Employer

Work Hours

Work phone:

Cell phone:

Father's Information

Father's Name

First Last

Employer

Work Hours

Work phone:

Cell phone:

If parents are divorced, which parent has custody of the child?

Notice: NO ONE WILL BE ALLOWED TO PICK UP YOUR CHILD WITHOUT WRITTEN AUTHORIZATION.

Is there anyone that we should be aware of that should never pick up your child?

PICK UP AND EMERGENCY INFORMATION

Please list all persons authorized to pick up your child and who are authorized to act as a parent in the event of an emergency.

Child's Name

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Employer

Work Hours

Cell Phone

Add additional emergency contact?(Required)

Name (2)

First Last

Address (2)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone (2)

Work Phone (2)

Employer (2)

Work Hours (2)

Cell Phone (2)

I understand that my child MUST be signed out each day.(Required)

Yes

Parent Signature(Required)

Type in full name above.

Clarksville Academy Extended Care Program Contract Options

Clarksville Academy Extended Care offers several options, both full and part time schedules so that you may customize your care according to the needs of your family. Please review the following options and indicate the one(s) that work for you. Contact the Business Office with questions on pricing.

Full Time Options

Cougar Clubhouse (Grade PK-4) (2:45-5:45)

Cougar Den (Grades 5-8) (4:00-6:00)

Part Time Options (Part Time Status = 3 days per week or less)

Cougar Clubhouse (Grades PK-4) (2:45-5:45)

Cougar Den (Grades 5-8) (4:00-6:00)

Check days child will be attending(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Please note that the extended care contracts are based on a semester commitment.

Families have the option of paying in full per semester or paying a monthly rate per semester. Please indicate below the payment option that is best for your family.

I choose to pay my Extended Care contract by:(Required)

Full Amount

Monthly Amount

Signed by(Required)

Type in full name above.

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Name

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