Before and After Care – Principle Academy Charter

Before & after care

BEFORE & AFTER CARE PROGRAM

Registration is now open. The Before & After care program is open to all PAC students. To register for the Before & After Care Program, please complete and submit the form below.

Program Days: Monday-Friday – Beginning September 23rd

Program Hours: Before Care: 7am; After Care: 4pm-6pm

One-time registration fee: $15 – Registration fee is due on September 23rd

Cost: Before Care $5/child; After Care $10/child – Discount provided for multiple children in the same household.

Feel free to contact us should you have any questions, info@principleac.org or 609-498-6350.

I. Child's Name

Gender

Grade

II. Child's Name

II. Gender

II. Grade

III. Child's Name

III. Gender

III. Grade

IV. Child's Name

IV. Gender

IV. Grade

Address

City

State

Zip Code

Phone

Intended Child Care Schedule (please check one)

Before Care AM Session only Before Care and After Care AM & PM Sessions After Care PM Session only Emergency Drop off

Parent/Guardian Information I:

I. Parent/Guardian Name

Cell Phone #

Home Phone #

Work Phone #

I. Parent/Guardian Address

City

State

Zip Code

I. Parent/Guardian Employer

Parent/Guardian Information II:

II. Parent/Guardian Name

Cell Phone #

Home Phone #

Work Phone #

II. Parent/Guardian Address

City

State

Zip Code

II. Parent/Guardian Employer

Please check below if you have a court order that would prevent anyone from removing your child from the program. The PAC Before and After School Program Must have a copy of this document in order to enforce it.

Yes, I have provided PAC with a court order that would prevent anyone from removing my child from the program.

Emergency Local Contact (not a parent). Please provide at least two (2):

I. Name

Phone #

II. Name

Phone #

Additional Authorized People for Pickup

1. Name

Phone #

2. Name

Phone #

3. Name

Phone #

4. Name

Phone #

Medical Information:

Child’s Doctor

Doctor’s Phone Number

Name of Insurance Company

Name of Policy Holder

Insurance ID Number

Relationship

Please provide us with any information that you feel would be useful in meeting your child’s needs including medical information such as asthma, allergies, diabetes or any other medical conditions or special needs:

I understand that if emergency medical care is necessary by a physician and I cannot be contacted, I authorize the Principle Academy Charter childcare provider to act on my behalf in granting permission for my child, named above, to receive treatment as follows:

Any child experiencing illness will be attended by a PAC Before and After Care Program childcare provider. The parent or emergency contact will be contacted. In the event of a serious injury, an ambulance will be called first. This will be followed by a call to the child’s parent or the emergency contact. The childcare provider will then accompany the child until the arrival of a parent or emergency contact.

PAYMENT

Cost: Before Care $5/child; After Care $10/child - Discount provided for multiple children in the same household.

One-time registration fee: $15 - Registration fee is due on Monday, September 20th

PAC accepts checks or money orders only as payment for the PAC Before and After Care Program.

Print/Sign Name:

Before & after care

BEFORE & AFTER CARE PROGRAM

info@principleac.org

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