PARENTS: PLEASE REMEMBER THAT
APPLICATIONS RECEIVED AFTER 8/15/08 MAY NOT BE ABLE TO START THE
PROGRAM UNTIL SEPTEMBER 2ND. THE FOLLOWING SCHOOLS HAVE A
WAITING LIST:
DEL VALLE, ELM GROVE, HORNSBY, OAK HILL,
SCIENCE HALL, TRAVIS HEIGHTS
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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 also are authorized and have agreed to pick up my child(ren) from Extend-A-Care for Kids. A minimum of two people besides Parent 1 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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(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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| 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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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 4-year-old 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 |
| Existing illnesses? |
Yes
No |
| Existing injuries? |
Yes
No |
| Previous serious illnesses/injury? |
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 |
| Medication taken on long-term, continuous basis? |
Yes
No |
| Frequent nosebleeds? |
Yes
No |
| Diabetes? |
Yes
No |
| Asthma? |
Yes
No |
| Limitation on activity? |
Yes
No |
| Special diet? |
Yes
No |
| Wheelchair bound? |
Yes
No |
| Impaired mobility (braces, crutches, etc.)? |
Yes
No |
| Hearing impaired? |
Yes
No |
| Cerebral Palsy? |
Yes
No |
| Blind/visually impaired? |
Yes
No |
| Serious emotional disturbance? |
Yes
No |
| Attention Deficit Hyperactivity Disorder (ADHD)? |
Yes
No |
| Attention Deficit Disorder (ADD)? |
Yes
No |
| Bipolar? |
Yes
No |
| Autism? |
Yes
No |
| Learning disabled? |
Yes
No |
| Developmentally delayed (Down Syndrome, etc.)? |
Yes
No |
| Other |
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| Does your child need assistance with |
Toileting
Walking
Eating |
| Does your child need daily care from a medical doctor or registered nurse? |
Yes
No |
| Describe any on-going treatment by a physician or any assistance needed. |
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| Does your child require one-on-one care? |
Yes
No |
| Describe any Extend-A-Care activities in which your child may not participate. |
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| Additional Notes |
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| ***If you answered "yes" to any of the above questions, any special assistance/
accommodations you child may require must be described on a Medical Information Form of Special Needs Packet, whichever is applicable. Please contact an enrollment representative at the business office to obtain one of these forms. This form must be filled out and submitted to the business office at the time of enrollment. |
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| I understand that Extend-A-Care for Kids staff members have frequent verbal contact with children’s teachers or other school staff to provide each child with the most positive after-school experience possible. Regular contact may occur to clarify homework assignments, discuss behavior, share accomplishments, offer guidance, and for other purposes. In addition, Extend-A-Care may occasionally need to review a child’s records. If this is necessary, I give Extend-A-Care permission to contact my child’s school to obtain education records that may be useful in meeting the needs of my child. |
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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)] |
| 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 have received and read copies of the
Extend-A-Care for Kids Policies for the school year
in which I am enrolling my child. |
Yes
No |
| On behalf of myself and my child(ren), I hereby waive any claims which I or my child may have in the future against Extend-A-Care for Kids, the school districts and their respective officers, agents, employees and volunteers as a result of any of their acts or omissions under this Agreement. I also agree to indemnify and defend Extend-A-Care for Kids, the school districts and their respective officers, agents, employees and volunteers from any and all claims, demands, or suits which may be brought against them due to any act or omission of myself, any person acting on my behalf, or my child(ren) while under the care, custody or control of Extend-A-Care, its officers, agents, employees 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 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 |
| Social Security Number |
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| 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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