Extend-A-Care | Registration

Registration for the Extend-A-Care Program

The application must be submitted with a $35 enrollment fee for each child that is being registered (plus any payments due: Download Parent Policies during Application Process). 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) which are charged on a sliding-fee scale based on income and family size. A financial assistance appointment is required upon enrollment.

Helpful tips for Enrolling with our Online System: English and Spanish.

After-School Child Care and All-Day Care Registration:

NEW SYSTEM!! Applications are taken online by clicking HERE: REGISTER.

Step 2 : Child's Information
Child Information
Child's Name
Birth Date	Month Day Year
Age
Grade in School
Gender	Male Female
T-Shirt Size
Can your child participate safely in a child care program with a 1:17 adult to child ratio?	Yes No
If no, please explain
Ethnic Background (Check One)	Caucasian African-American Hispanic Native American Asian Other
With whom does this child live? (Check One)	Both Parents Mother Only Father Only Mother and Partner Father and Partner Guardian Foster Parents Other Relatives Other
Space Reservation
Please reserve space for my child in Extend-A-Care for Kids at _________ School.
School the child attends
School Phone Number
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
Authorization for Medical Care
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
Physician/Clinic's Address	Street 1 Street 2 City State Zip Code
Physician/Clinic Phone Number
Section 5 - Student Health Information (Please note if any of the following conditions apply to your child)
Does your child have any of the following
Allergies (bee stings, medications, etc.)	Yes No
If yes, please describe any known allergies that your child has
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
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:
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.
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
Describe any Extend-A-Care activities in which your child may not participate.
Have any other child care facilities refused to provide service to your child.	Yes No
If yes, please explain:
Describe any activities in which you do not want your child to participate.

Step 3 : Parent Releases
Parent 1 Release
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.
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.
I Agree I Disagree
Consent to Request Education Records
The school district named below is authorized to release any and all education records containing information regarding my child to Extend-A-Care for Kids, P. O. Box 6340, Austin, TX 78762-6340. The purpose of the disclosure is to assist Extend-A-Care in meeting my child's needs. I further give my permission for Extend-A-Care staff and school personnel to communicate regarding my child.
Name of Student
Name of School District
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.
Yes No
I understand that my consent is voluntary and may be revoked at any time.
Yes No
Parent 1 Agreement
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

Name of Parent
Date	Month Day Year
Texas Driver's License Number
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.
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.

The application must be submitted with a $35 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.

Extend-A-Care Account Number
If you have an Extend-A-Care Account Number, please enter it below. If not, please enter your child's name.
Extend-A-Care Account Number
Credit Card
Type
Credit Card Number	- - -
Cardholder's Name (as it appears on the credit card)
Expiration Date	Month Year
Security Code (3-digit code on the back of card)

55 North IH 35 Austin, TX 78702 Main Number: 472-9402 Fax Number: 472-2164