GISD After School Care Registration

Gunter

Independent School District

GISD After School Care Registration

Student Information

Child’s Name (Last Name, First Name): ______

Gender: Male Female

Grade for 2016-2017 School Year:

Please note: 3 & 4 year olds enrolled in a full day Pre-K program automatically have care until 6 p.m.

K 1st 2nd 3rd 4th 5th 6th

Guardian 1 Information: (Please list the person whom you want called first in any circumstance.)

Guardian 1 Name: (Last, First): ______

Best phone number to reach you: ( ) ______- ______(required)

Alternate phone number: ( ) ______- ______

Email Address: ______

Home Street Address: ______

City, State, Zip ______

Guardian 2 information: (Please list the person who would be called in the event we could not reach Guardian 1.)

Guardian 2 name: (Last, First): ______

Best phone number to reach them: ( ) ______- ______(required)

Alternate phone number: ( ) ______- ______

Email Address: ______

Home Address –Same as Guardian 1 (Place checkmark in the box)

Home Street Address (if different from Guardian 1) ______

City, State, Zip ______

Emergency Contact Information: (This will be the 3rd person called in case of emergency. We will always begin withGuardian 1 and then Guardian 2. If we cannot reach those contacts, this contact will be called.)

Emergency Contact Name: (Last, First) ______

Best phone number to reach them: ( ) ______- ______(required)

Alternate phone number: ( ) ______- ______

This person is authorized to pick up my child: (please check the appropriate box)

Yes, anytime. Yes, only when we have called in advance. No

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Medical Information (Please be specific regarding this information and your child. If the question does not apply to your child, please put NA for not Applicable.)

Current Medications: ______

Allergies: ______

Special Needs/Limitations: ______

Medical Conditions: ______

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Statement of Agreement/Guidelines

Please initial each statement to indicate that you have read and agree with the statements: I agree to the following statements:

____ My child is enrolled at a Gunter school for the 2015-2016 school year.

____ I agree to follow the policies set forth in the Student Handbook

____ I agree to pay $20 for registration, and understand that it may take up to 2 business days before my child may attend extended care.

____ I understand that the extended care program price is $100/ month. (A discount is available for staff and qualifying families.)

____ I understand that the extended care hours end at 6:00 p.m. and will pick up my child by that time, or be assessed a penalty charge.

____ I understand that repeated late pick up might result in expulsion from the program.

____ I understand that registration is not complete until payment is made in person at the Gunter Elementary Campus.

Parent/Guardian Signature ______