After School Program Enrollment Form

Before Care Program Enrollment Form

2022-2023
Immaculate Conception Academy Aftercare Program serves students in preschool and Pre Kindergrten

Time: 7:30 A.M. - 8:30 A.M.

Before Care Registration Fee:
The non-refundable Before Care registration fee of $25 is required to complete your child's application. Make checks payable to ICA. Mail payment to ICA 903 Chestnut Street, Douglassville, PA 19518.

Rules: Our program adheres to the philosophy and rules adopted by our school and they are in effect during aftercare. The following rules exist for the safety and well-being of all students.

1. Listen and obey the instruction of the staff.
2. Be responsible for all belongings and be respectful of the belongings of others.
4. Obey the general rules of the school in regard to behavior.

If a child becomes disorderly and behavior problems occur, contact with the parents either in person or via a note will take place. If the problem persists, the child may be removed from the program.

Sincerely,
Immaculate Conception Beforecare Staff
One Form Per Student
Student's Name*

First NameLast Name
Parent's Name*

First NameLast Name
Parent's Phone Number*
Parent's Email*

Confirmation Emailexample@example.com
Parent's Name

First NameLast Name
Parent's Phone Number
Parent's Email

Confirmation Emailexample@example.com
Parent's Name

First NameLast Name
Parent's Phone Number
Parent's Email
example@example.com
Parent's Name

First NameLast Name
Parent's Phone Number
Parent's Email
example@example.com
Grade in fall (2019-2020)*

PreschoolPreK
Please note any known allergies (food or medications) :
Please note any known medical conditions that you would like staff to be aware of.
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number 1:*
Emergency Contact 2

First NameLast Name
Emergency Contact Phone Number 2:
Statement of Fees

BeforeCare costs $5 per day per student.
Statement of Policy
I heareby understand that for the protection of my child, they will not be given permission to leave our Program with anyone not included on their approved pick up llist. It is my responsibility to notify the school office or the Head Teacher of Beforecare, in writing or in case of emergency, by phone if any deletion or additions are to be made to the approved list. Please be advised that in the case of divorce or separation, it is our legal obligation to release children to either parent except in the case of a court stating otherwise.
I have read and understand the Statement of Fees and Statement of Policy contained here.*

Agree
Parent's signature *

Clear
Should be Empty:

Before Care Program Enrollment Form

One Form Per Student

Statement of Fees

Statement of Policy