S.A.C. & JK School Year Registration Form

Student's Information

1.
*

Last Name,          MI,         First Name,          (Nickname)

2.
*

Student's Address                                                              Phone #

3.
*

Birthdate                           Teacher

4.
*

Grade Level (2016-2017 school year)

Junior Kindergarten - Please note -JK students may only register if they have completed the JK program.
Kindergarten
First
Second
Third
Fourth
Fifth

Please fill out all days in your child's schedule.  (Days registered for, are days payment is required.)

5.

S.A.C. AM Session 6:00-8:00am

Monday
Tuesday
Wedneday
Thursday
Friday
6.

S.A.C. PM Session 2:45pm-6:00pm

Monday
Tuesday
Wednesday
Thursday
Friday
7.

JK Wrap 7:45am-12:00pm

Monday
Tuesday
Wednesday
Thursday
Friday
8.

JK Wrap 10:45am-2:45pm

Monday
Tuesday
Wednesday
Thursday
Friday
9.

JK Wrap 7:45am-2:45pm

Monday
Tuesday
Wednesday
Thursday
Friday
10.

If your child needs transportation to and from JK Wrap please check the box yes.

Yes
11.
*

Children with irregular schedules must provide by the last week of the prior month a monthly calendar of care dates. (Example: Last week of January for all February attendance dates.  Last week of February for all March attendance dates, etc.)

Example:

Week 1 - M,W,F

Week 2 - M,T

(1 required)
If applicable I will provide a monthly calendar
12.
*

Child's Starting Date

13.
*

I will give a two week notice if my child's main schedule changes and I will fill out the contract change form.  Please initial below.

14.
*

Non-School day payment is $37.00.  Flyers will be provided before non-school days.  You must be pre-registered to attend. Would you like flyers for non-school day's?

Yes
No

Parent/Guardian  1

15.
*

Name                                                       Relationship                

16.
*

Address                                                        Home Phone #

17.
*

Employer                                                 Work Phone #

18.
*

Cell #                                    Fax #                                   E-mail

Parent/Guardian   2

19.

Name                                                       Relationship

20.

Address                                                    Home Phone #

21.
*

Employer                                                 Work Phone #

22.

Cell #                                      Fax #                                    E-mail

23.
*

Who will be liable for child-care payment?

In case of an emergency and we cannot locate the parent/guardian, please call

24.
*

Name:                                                     Relationship:

25.
*

Address:                                                                   Phone #

26.
*

Name:                                                     Relationship:

27.
*

Address:                                                                  Phone #

 

All About Me!  Please fill out child's infomation below:

28.
*

My favorite activity is:

29.
*

Do I have siblings:

Yes
No
30.

Names of siblings

31.
*

My alleriges:  Please state "none" if there are none.

32.
*

My medications:  Please state "none" if there are none.

Staff will administer Tylenol/Ibuprofen with current medication permission form . Medication must be in original bottle.

33.
*

My Doctor's Name                            Clinic/Hospital                        Phone #

34.
*

My Dentist's Name                           Dental Office Name                          Phone #

35.

Insurance Company                                                        Policy #

36.
*

Do you have an IEP?

Yes
No
37.
*

Do you have special needs?

Yes
No
38.

If yes, please explain.

39.
*

Do you have any restrictions at play?

Yes
No
40.

If Yes, please explain.

41.
*

Do you have any additional Information to provide?

Yes
No
42.

If Yes, please provide.

43.
*

Parents/Guardians:  Would you be interested in volunteering? 

Yes
No
44.

Special Interests/Talents:

45.
*

I have read and filled out this form completely.  I understand that should any changes in this contract occur, I will notify Somerset S.A.C./JK Wrap two weeks prior to changes. Contract change form is located online.

PARENT/LEGAL GUARDIAN SIGNATURE (By typing my name in this box I am verifying that I am the parent/legal guardian of the above mentioned participant. I am also verifying this electronic signature is approved and sent by me; the parent/legal guardian of participant.

The Transportation From MUST be completed in order for registration to be processed. 
The form is located on the School Age Care home page under transportation.

* Enter Your Email Address:

Type in the text that you see above:

  

Last Updated: 1/26/17
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  • School District of Somerset
  • P.O. Box 100, 639 Sunrise Drive, Somerset, WI 54025
  • Phone: (715) 247-3313 | Fax: (715) 247-5588