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The application must be submitted with a $25 enrollment fee for each child
that is being registered (plus any payments due: See Policies). Enrollment fees are non-refundable and non-transferable.
If you have questions about fees, questions
about the application, or need help completing the application, please call the Extend-A-Care for Kids' business office at (512) 472-9402.
Extend-A-Care offers reduced fees to qualifying families (subject to availability). Parents are charged on a sliding-fee scale based on income and family size.
An appointment is required upon enrollment.
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CCS
EAC
Other
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(Must be a physical address. Include apartment number. P.O. Boxes are not accepted) |
Street 1
Street 2
City
State
Zip Code
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| The following persons are also authorized and have agreed to pick up my child(ren) from Extend-A-Care for Kids. A minimum of one person besides Parent 1 and/or Parent 2 must be listed as emergency contacts in case Parent 1 cannot be reached. To add additional names, request an Extended Pickup Form. |
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(Must be a physical address. Include apartment number. P.O. Boxes are not accepted) |
Street 1
Street 2
City
State
Zip Code |
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(Must be a physical address. Include apartment number. P.O. Boxes are not accepted) |
Street 1
Street 2
City
State
Zip Code
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| *Applicants whose parents or guardians fail to complete all sections of the enrollment application form may be denied admission into the Extend-A-Care for kids program. Extend-A-Care further reserves the right to interrupt or terminate child care services without notice to child care customers who have falsified information or failed to provide current and accurate information on the enrollment application form. |
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| Extend-A-Care for Kids does not discriminate against individuals on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages or accommodations of any of Extend-A-Care's facilities. Extend-A-Care for Kids is willing to reasonably accommodate individuals with disabilities in accordance with the Americans With Disabilities Act. Each child needing a reasonable accommodation will be evaluated on a case-by-case basis. Any inquiries by Extend-A-Care regarding your child's physical or mental condition are for the purpose of determining reasonable accommodations. An individual review of your child's needs may include a meeting with the family and the child in the center before enrollment, observing the child in the classroom, assessing the staff person's ability to address the special needs and the child's ability to adapt to the group with reasonable accommodations, and enrolling the child for a trial period. |
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Month
Day
Year |
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Male
Female |
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| Can your child participate safely in a child care program with a 1:17 adult to child ratio? |
Yes
No |
| If no, please explain |
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| (Check One) |
Caucasian
African-American
Hispanic
Native American
Asian
Other |
(Check One) |
Both Parents
Mother Only
Father Only
Mother and Partner
Father and Partner
Guardian
Foster Parents
Other Relatives
Other |
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Please reserve space for my child in
Extend-A-Care for Kids at _________ School. |
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| School the child attends |
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| School Phone Number |
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| Does child have permission to walk home from Extend-A-Care for Kids? |
Yes
No
If yes, what time?
p.m. |
| Does child have current immunization record, to include a record of negative TB testing, on file at the school? |
Yes
No |
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| In the event I cannot be reached to make arrangements for medical attention for my child at the time of an accident or illness while she/he is attending Extend-A-Care for Kids, I authorize Extend-A-Care for Kids to permit EMS, the nearest hospital or minor emergency clinic, or the physician/clinic named below to treat my child. For parents of children under 5 who will be attending Extend-A-Care: The physician listed below has examined my child within the past year and stated that the child is able to participate in the program. |
I Agree
I Disagree |
| Name of Private Physician/Clinic |
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| Physician/Clinic's Address |
Street 1
Street 2
City
State
Zip Code |
| Physician/Clinic Phone Number |
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| Does your child have any of the following |
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| Allergies (bee stings, medications, etc.) |
Yes
No |
| If yes, please describe any known allergies that your child has |
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| Temporary illnesses |
Yes
No |
| Chronic illness |
Yes
No |
| Injuries |
Yes
No |
| Orthopedic impairment |
Yes
No |
| Visual impairment |
Yes
No |
| Speech impairment |
Yes
No |
| Hearing impairment |
Yes
No |
| Diseases communicable through the type of incidental contact expected to occur in child care settings |
Yes
No |
| Hospitalization in last 12 months |
Yes
No |
| Cerebral Palsy, epilepsy, muscular dystrophy |
Yes
No |
| Diabetes |
Yes
No |
| Emotional disturbance/bipolar disorder |
Yes
No |
| Learning disablities |
Yes
No |
| Asthma |
Yes
No |
| Frequent nosebleeds |
Yes
No |
| Limitation on activity |
Yes
No |
| Medically/religiously required Special diet |
Yes
No |
| Diagnosed Food Allergies |
Yes
No |
| If yes, please explain |
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| Uses a wheelchair or other mobility device |
Yes
No |
| Attention Deficit Hyperactivity Disorder (ADHD)? |
Yes
No |
| Attention Deficit Disorder (ADD)? |
Yes
No |
| Autism spectrum disorder/Aspberger's Syndrome |
Yes
No |
| Developmental delay |
Yes
No |
| Mental Retardation (intellectual disability or Down Syndrome) |
Yes
No |
| Any other physical or mental impairment: |
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| Does your child need assistance with |
Toileting
Walking
Eating |
***If you answered "yes" to any of the above questions, Please provide any medical or psychological records and/or information regarding the child's disability and its implications, if any, to ensure safe participation in the programs activities. This information will assist Extend-A-Care for Kids when making an individualized assessment about whether it can meet the needs of the child without fundamentally altering the program and to insure continued compliance with the Minimum Standards and Rules for Child Care Centers. |
| Does your child need daily care from a medical doctor, registered nurse,or other health care provider? |
Yes
No |
| Describe any on-going treatment by a physician or any assistance needed. |
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| Does your child require additional supervision by adults to ensure safety in the home, community, or school setting? |
Yes
No |
| If yes, describe the level of supervision needed for safety |
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| Describe any Extend-A-Care activities in which your child may not participate. |
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Have any other child care facilities refused to provide service to your child. |
Yes
No |
| If yes, please explain: |
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| Describe any activities in which you do not want your child to participate. |
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| I understand and agree that Extend-A-Care for Kids staff members have frequent contact with my child's teachers or other school officials to enhance my child's after-school experience. I further understand that Extend-A-Care for Kids may need to access my child's educational records and I give Extend-A-Care permission to contact my child's school and obtain educational records. This agreement also permits my child's school to release and exchange confidential information with Extend-A-Care for Kids. I also permit Extend-A-Care for Kids to consult with and receive information from any prior child care programs in which my child participated. |
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I Agree
I Disagree |
| I understand that Extend-A-Care for Kids may need to access my child's medical/mental health records and/or contact my child's health care provider to ensure continued compliance with the Texas Minimum Standards for child care centers and other applicable federal laws. |
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I Agree
I Disagree |
| Name
of Student |
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| Name of School District |
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| Records to be released include, but are not limited to: (1) Cumulative Records (2) Health Records (3) Special Education Records [including Individual Education Plans (IEPs)] and the latest Full Individualized Evaluation (FIE), behavior plans, 504 plans] |
| I have been fully informed and understand Extend-A-Care's request for my consent, as described above. |
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Yes
No |
| I understand that my consent is voluntary and may be revoked at any time. |
Yes
No |
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| I give my child permission to participate in water activities supervised by Extend-A-Care for Kids staff, except when I send a note to the contrary. |
Yes
No |
| Extend-A-Care for Kids has my permission to use photographs/videotape taken of my child during the regular program, for use in promoting the goals of Extend-A-Care for Kids. |
Yes
No |
| Extend-A-Care for Kids has my permission to transport my child away from the center, with prior notification, for field trips, water activities and special activities, and I understand that permission for each trip is not required. |
Yes
No |
| If it is necessary for my child to miss a specific field trip or activity for reasons other than absence, I will advise the center staff ahead of time and I agree to pick up my child from the center no later than 3 p.m. and will assume responsibility for the care of my child during the time of the field trip. I understand that if my child is not picked up by 3 p.m. he/she will attend the field trip. |
I Agree
I Disagree |
| I acknowledge by submission of this application, that I agree and understand how to access the Extend-A-Care for Kids 2009-2010 Policies at www.eackids.org or by calling 512-472-9402 to have one mailed and that I understand and agree with the terms of the Extend-A-Care for Kids 2009-2010 policies. |
Yes
No |
| On behalf of myself and my child(ren), I hereby waive any and all claims arising under state or federal law which I may have now or in the future against Extend-A-Care for Kids and Extend-A-Care, Inc. and all of its past, present, and future officers, directors, employees and representatives, and any and all persons, corporations, and entities which may be in privity with any of them as a result of any of their acts or omissions under this agreement. I also agree to indemnify and hold harmless Extend-A-Care for Kids, the school districts and their respective officers, agents, employees and volunteers from any and all claims, demands, or suits arising under state and federal law which may be brought against them due to any act of omission of myself or anyone acting on behalf of my children while under care, custody of Extend-A-Care officers, agents or volunteers. No amendments or changes shall be allowed to this paragraph, and if any amendments or changes are made they shall be void. |
I wish to enroll my child at the center I have indicated. I understand after-school care will be provided Monday through Friday from school dismissal time (see 2009-2010 Policies) to 6:30 p.m. in Austin ISD, Del Valle ISD, and Hays CISD. I understand that all-day care hours are from 7:15 a.m. to 6:30 p.m. in Austin ISD, Del Valle ISD and Hays CISD. I understand that all-day care requires separate fees and a separate application. I accept financial responsibility to pay the agreed upon fee(s). I understand enrollment will be effective when Extend-A-Care for Kids confirms my child's enrollment. |
I Agree
I Disagree |
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| Name of Parent |
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| Date |
Month
Day
Year |
| Texas Driver's License Number |
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| By
checking the box on the left, I attest that all of the
information that I am about to provide on this form is true and
accurate to the best of my knowledge. Furthermore, I understand
my ethical obligation to answer all questions asked on this form
in a forthright and truthful manner.
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Extend-A-Care for Kids complies with the Americans with Disabilities Act (ADA) and does not discriminate on the basis of disability. Extend-A-Care for Kids provides children and parents with disabilities with an equal opportunity to participate in the child care centers' programs and services. Extend-A-Care for Kids will make reasonable modifications to policies and practices to integrate children, parents, and guardians with disabilities into programs unless doing so would constitute a fundamental alteration of the program. Extend-A-Care for Kids will make individualized assessment about whether it can meet the particular needs of a child with a disability without fundamentally altering its program. Extend-A-Care for Kids is a non-profit organization, does not discriminate in employment, enrollment, or nutrition programs on the basis of race, color, religion, national origin, sex, marital status, disability, handicap, veteran status, or any other status protected under local, state, or federal laws. |
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The application must be submitted with a $25 enrollment fee for each child
that is being registered (plus any payments due: See Policies). Enrollment fees are non-refundable and non-transferable.
If you have questions about fees, questions
about the application, or need help completing the application, please call the Extend-A-Care for Kids' business office at (512) 472-9402.
Extend-A-Care offers reduced fees to qualifying families (subject to availability). Parents are charged on a sliding-fee scale based on income and family size.
An appointment is required upon enrollment.
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