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Exceptional Student Education / Student Services 1939 SE (City of Oakland)

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MARTIN COUNTY
Exceptional Student Education / Student Services 1939 SE Federal Hwy, Stuart, FL 34994 (772) 219-1200 ext. 30339
SCHOOL YEAR EXTENDED DAY REGISTRATION - OFFICIAL RECEIPT
REGISTRATION DATE:
PLEASE PRINT
Child's Name
Grade
Homeroom
Sex
Date of Birth
Student
(Last name first)
Teacher
M
F
ID
1st Child:
2nd Child:
3rd Child:
4th Child:
Parent/Guardian Name:
Parent/Guardian Name:
Address:
Address:
City, State, Zip:
City, State, Zip:
Home Ph #:
Work Ph #:
Home Ph #:
Work Ph #:
Cell Ph #:
Cell Ph #:
Email:
Email:
1.
I understand I am responsible for supplying the EDP Program with my child's schedule and tuition payment every week in advance.
Payment envelopes are accepted between Monday and Wednesday for the following week. Envelopes turned in after 6 p.m. Wednesday
will be subject to a $20.00 late fee. Fees must be paid in advance.
2.
In the event there is a change in my child's schedule, I must send a note to the homeroom teacher and notify the Extended Day site manager.
3.
I understand that my child must obey all Extended Day conduct rules and safety procedures. If my child is having problems in the program, a
conference will be arranged between the parent and program manager. If the child continues to behave inappropriately, the Extended Day site
manager reserves the right to suspend/terminate the student from the program.
4.
I understand that if regular school is cancelled due to unforeseen circumstances, such as weather, the Extended Day program will also be closed.
5.
I acknowledge that EDP closes at 5:30 p.m. on non school days and 6:00 p.m. on regular and early release days. I agree that I must pick up my child
at the designated closing time and that there will be a $1.00 per minute charge payable immediately to the Extended Day program for late pick up.
6.
I understand that the Martin County Extended Day Program cannot be held responsible for students not registered in the program, or who have not
been properly scheduled in advance of their intent to participate.
7.
I grant permission for my child to attend field trips that are authorized by the Martin County Extended Day Program.
8.
In the event of an emergency, I grant permission for my child to have immediate first aid treatment and/or admission to the nearest hospital.
9.
I understand that NO credits will be issued unless deemed an emergency by the proper School Board personnel.
10.
I understand that I am responsible for signing my child in on the official Extended Day sign-in sheet on Full Days. Upon child pick-up, I am responsible
for signing my child out on the official Extended Day sign-out sheet. In addition, I will include the time I sign my child in and out.
11.
I give authorization for the MCSD to permit my child to be photographed, filmed, or videotaped for a period of 12 months, and grant consent, pursuant to Florida
Statute 1002.221 and 20 U.S.C. 1232g, for the District to publish, post, or release my child's name, photograph, or video image. I understand that by giving my
permission, my child's name, photograph, or video image may be published online or in printed materials produced by the above named school, the MCSD
organizations, or other persons or entities. I do hereby release and waive any and all claims, demands, or objections against the above named school and the MCSD in
connection with or arising out of the use of my child's name, photograph, or video image. Check here if you do NOT give authorization to #11
12.
Important Notice: Parents will inform the EDP when their child(ren) will not be attending. To exit and discontinue use of the program
and tuition charges, parents need to inform EDP in writing, the week prior, that their children will no longer be enrolled.
Due to staffing, field trips, and snack requirements, Full days must be scheduled with payment by Wed. the week prior to attending.
Full days not scheduled by Wed. the week prior to attendance are subject to a $20.00 late fee.
13.
The Undersigned shall indemnify, protect, defend and hold harmless the School Board of Martin County, its agents, officers, elected officials
and employees from and against any and all claims, actions, liabilities, losses (including economic and non-economic losses), and costs arising
out of any actual or alleged claim for bodily injury, sickness, breach of contract, disease or death, damage to reputation or injury to or destruction of tangible
property (including the loss of use resulting therefrom) that is alleged to be incurred as a result of the negligence of any of the above regarding
the Extended Day Program in any way, including but not limited to not only the child's participation in Extended Day but also the administration of same.
14.
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU
ARE AGREEING THAT EVEN IF MARTIN COUNTY SCHOOL DISTRICT USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR
CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY
WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD'S RIGHT AND YOUR RIGHT TO RECOVER FROM
MARTIN COUNTY SCHOOL DISTRICT IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT
RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY AND/OR IF MARTIN COUNTY SCHOOL DISTRICT AND/OR ITS EMPLOYEES OR
AGENTS ARE IN ANY WAY NEGLIGENT EVEN IN THE ADMINISTRATION OF THE EVENT ITSELF. YOU ARE WAIVING YOUR RIGHT TO SUE THE MARTIN COUNTY
SCHOOL DISTRICT FOR SUCH NEGLIGENCE. YOU HAVE A RIGHT TO REFUSE TO SIGN THIS FORM AND MARTIN COUNTY SCHOOL DISTRICT HAS THE RIGHT
TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
(Parent/Guardian signature) (Date)
MARTIN COUNTY
Exceptional Student Education / Student Services 1939 SE Federal Hwy, Stuart, FL 34994 (772) 219-1200 ext. 30339
SCHOOL YEAR EXTENDED DAY REGISTRATION - OFFICIAL RECEIPT
Child's Name
1st Child:
3rd Child:
2nd Child:
4th Child:
I am a MCSD employee My child utilizes services from ELC
MEDICAL INFORMATION
If medication is to be administered by EDP, a Form #135A signed by a physician with a recent photo attached must be
provided by parent/guardian. All medication must be in it's original prescription bottle with the description/dosage clearly
labeled.
My child/children have:
Special Needs
Health Problems
Allergies
Child's Name
Brief Description
Medication to be given by EDP
1st Child:
2nd Child:
3rd Child:
4th Child:
Family Physician:
Phone Number:
AUTHORIZED PICK UP LIST
In addition to the parents/guardians listed on page 1, the following persons are authorized to pick up my child/children.
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Name:
Phone :
Relationship:
Special Concerns:
________________________________________________ ___________________________________
(Parent/Guardian signature) (Date)
Martin County School District Extended Day Program
Read and Review Receipt
I, the undersigned, acknowledge that the below items have been read and reviewed. I am aware that I can find the Extended Day parent
handbook with additional information on the Extended Day page of the Martin County School District website at
www.martinschools.org . I am aware that the Extended Day parent handbook contains information and policies for my review.
I understand that all students will be held accountable for their behavior and that failure to abide by the guidelines for student behavior
can result in the discipline outlined in the Extended Day parent handbook.
➢
All payments for the Extended Day Program are due on a weekly basis one week prior to attendance. Payment must be made in the
form of a check or money order. No cash payments will be accepted. All payments must be enclosed in the appropriate payment
envelope. This envelope must be returned to the Extended Day school site no later than closing time each Wednesday one week in
advance. A $20.00 late fee will be assessed for envelopes received after Wednesday’s closing.
➢
Participation in the Extended Day Program will be denied for the following week if a payment including the late fee has not been
received by the close of business Friday prior to the week of attendance.
➢
Extended Day closes promptly at 6:00pm on school days and 5:30pm on full days. Failure to pick up a child at the designated
closing time will result in a $1.00 per minute fee. Service may be suspended after three incidents of being late. The Extended Day
program reserves the right to notify and/or turn over children who are being picked up habitually or excessively late to the proper
authorities.
➢
During Extended Day full days, drop-off is from 7:30am-9:30am. Pick-up is from 3:30pm-5:30pm. Please note that pick-up and
drop-off between the hours of 9:30am-3:30pm is discouraged but if necessary, parents will need to call the Extended Day program
upon arrival.
➢
Extended Day will not be providing parents with a yearly printout of payments. Please keep track of payments for tax purposes.
The MCSD tax ID# is 59-6000-742.
➢
Parents must notify - in writing - the front office, their child’s teacher, and the Extended Day Manager of any change in their child’s
prearranged after school schedule. Notifying all parties is necessary to ensure that the student will be properly routed to Extended
Day. Failure to comply with this policy will result in suspension of services.
➢
Extended Day pick-up begins at 2:15pm. Pick-up will be in the normal Extended Day dismissal area. When picking up students, all
visitors will be required to wear masks while on school grounds. All authorized pick up people will be required to show ID and
must sign their child(ren) out, then wait there for their child(ren) to arrive. Extended Day staff will NOT allow children to walk
unattended to their car.
➢
Should a child require prescription or over the counter medicine during the Extended Day program, an Extended Day Medical
Authorization form #135A must be on file with the site manager prior to the administering of any drug. The doctor prescribing the
medicine must sign the authorization form #135A. All prescription drugs must remain in their original container with correct dosage
indicated on the label.
➢
Students are not permitted to use cell phones while at the Extended Day Program. Cell phones should be in the off position and
concealed out of sight. If a student needs to call a parent or family member they may utilize the Extended Day phone.
➢
Masks will be optional for all students, parents/guardians, pick-up persons, and staff when on campus and school grounds.
Student Name(s): Student Grade(s):
School attending:
Parent/Guardian Name (please print):
Parent/Guardian Signature: Date:
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Exceptional Student Education Student Services 1939 SE (City of Oakland)

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Completed 12 October 2021

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