St. Theresa Catholic School

Extended Day Care Registration

2024-2025 School Year
Please complete one form for each child.

All questions must be answered - if a question does not apply, enter "N/A".

Grade 2024-2025: *
Homeroom (answer TBD unless the school year has already begun):

PARENT INFORMATION: If same as student, you may enter "same".

Does some person or agency other than parents have legal custody of the child? *

Emergency Care Information and Authorizations

Please note – Extended Day Care does not have access to the school clinic. If your child has an allergy that requires emergency medication (i.e. inhaler, EpiPen), these medications MUST be provided before admittance into EDC.


Occasionally there are opportunities for the students to help out the faculty or staff after school (setting up a game in the gym, delivering UPS boxes to classrooms, and similar activities). If you agree to let your child be one of the helpers when this does occur, please check the appropriate box below: *


  1. St. Theresa Catholic School Extended Day Program agrees to notify the parent(s)/guardian whenever the child becomes ill and the parent(s)/guardian will arrange to have the child picked up as soon as possible.

  2. The parent(s)/guardian authorizes the St. Theresa Catholic School Extended Day Program to obtain immediate medical care if any emergency occurs when the parent/guardian cannot be located immediately.

  3. The parent(s)/guardian will inform the Extended Day staff within 24 hours or the next business day after his/her child or any member of the immediate household had developed any reportable communicable disease, as defined by the State Board of Health. Life threatening diseases must be reported immediately.
Parent Signature below: (Director will sign and date upon completion.) *

All information requested is required by the Department of Social Services under code 22VAC15-30-110

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