Extended Day Contract
(Please complete this form if your child is planning to use Extended Day
(Last Name) (Called by) (Teacher/Grade)
Parent Information:
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:
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
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
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