Extended Day Contract
(Please complete this form if your child is planning to use Extended Day
Services.)
Child
s
Name:
(Last Name) (Called by) (Teacher/Grade)
L
Number
:
L
Parent Information:
Parent
or Guardian Name (1):
Place of Employment:
Mobile Phone:
Work Phone:
Parent or Guardian
Name (2):
Place of Employment:
Mobile Phone:
Work Phone:
Child’s Home Address:
Medical Information:
Doctor’s
Name:
List any medical problems:
Emergency Contact:
Neighbor or Relative to contact in an emergency: (not an out of town relative)
Name Phone:
Name of person(s) authorized to pick up my child & their relationship to you.
Name: Relationship:
Name: Relationship:
Extended Day runs from 2:45 to 5:30 p.m.
Check one:
$1,115.00 per year payable by September 7, 2018
$145.00 per month payable by the 10
th
of each month
$14.00 per day (not on contract)
Will use Extended Day occasionally (not on contract)
Faculty/Staff (staying on a regular basis)
Faculty/Staff (on occasion)
Extended Day Policies and Acknowledgements: (Please read and check each, then sign below.)
*New Late Fee Policy – The last possible pick-up time for your child is not 5:30. If you arrive later than 5:35 p.m.
you will incur a late fee rate of $5.00 per minute. This is to be paid upon arrival. This late fee will be strictly
enforced. The only acceptable form of payment for this late fee is cash or a check made out to LAES.
I acknowledge that I have read and fully understand the new Late Fee Policy above. I understand that
I will be charged at a rate of $5.00 per minute after 5:35 p.m.
I acknowledge that the Extended Day contract may be cancelled or changed only by written notification
to the elementary school Extended Day coordinator. Regular fees will accrue until receipt of such
notification.
I acknowledge that I have received the TN Dept. Of Ed. Summary of Child Care Approval Requirements
and the video list (available to pick up at Meet the Teacher night).
Signature: Date:
Select Teacher
(Street)
(City)
(ZIP)
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