Extension Registration & Contract 2022-2023

Extension Registration & Contract
2022-2023 ACADEMIC YEAR

Family Name*

Select No.of Students*

Student 1 Name

First NameLast Name

Grade in Fall 2022

Student 2 Name

First NameLast Name

Grade in Fall 2022

Student 3 Name

First NameLast Name

Grade in Fall 2022

Student 4 Name

First NameLast Name

Grade in Fall 2022

Mother/Guardian Name*

First NameLast Name

Email

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone Number

Work Phone Number

Cell Phone Number*

Father/Guardian Name*

First NameLast Name

Email

example@example.com

Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone Number

Work Phone Number

Cell Phone Number*

Extended day program fees will be collected using FACTS Management. Payment Options include 10 monthly payments, bi-annual or annual payments. You can select payments to be made by ACH withdrawal, credit card or check. Monthly program fee payments begin in August and end in May.

Registration Fee $125 (per student)
This fee is non- refundable and will be collected through your FACTS account.

Note: If you are unsure about signing up for an extension at this time, you may register at the start of school.

Extension Costs are on a Per Child Basis (10 month contract from Aug. to May)

Payment Options	Time and Grades	Per Year	OR	Per Month
Option A	Time: AM ONLY (7:00 am to 7:45 am) Grades: TK - 8th	$1,150.00	OR	$ 115.00
Option B	FULL OR PART TIME (3:00 pm to 6:00 pm) Grades: 1st - 8th Grade	$2,550.00	OR	$ 255.00
Option C	Grade: TK and KINDER CARE Time: 2:00 p.m. – 3:00 p.m	$1,150.00	OR	$ 115.00
Option D	Grade: TK and KINDER CARE Time: 2:00 pm - 6:00 pm	$2,650.00	OR	$ 265.00

Please select the options from the following for student 1:

Option AOption BOption COption D

Total monthly amount:

Please select the options from the following for student 2:

Option AOption BOption COption D

Total monthly amount:

Please select the options from the following for student 3:

Option AOption BOption COption D

Total monthly amount:

Please select the options from the following for student 4:

Option AOption BOption COption D

Total monthly amount:

Name of Father/Guardian 1*

First NameLast Name

Name of Mother/Guardian 2*

First NameLast Name

Father/Guardian Signature*

Mother/Guardian Signature*

Contract Execution Date

Submitter's Email*

example@example.com

Parent Information