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".

Student Last Name: *

Student First Name: *

Nickname:

Date of Birth: * +

Grade 2024-2025: *

Homeroom (answer TBD unless the school year has already begun):

Student Street Address *

Student City *

State *

Zip Code *

Home Phone Number *

Allergies or Intolerances to food or medicine AND action to be taken in an emergency: *

Physical Issue / Pertinent Developmental Information / Special Accommodations Needed *

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

Mother First Name *

Mother Last Name *

Street Address *

City *

State *

Zip Code *

Mother Cell Phone Number *

Mother Email Address *

Mother's Place of Business: *

Mother's Business Phone: *

Address of Mother's Place of Business: *

Father First Name *

Father Last Name *

Street Address *

City *

State *

Zip Code *

Father Cell Phone Number *

Father Email Address *

Father's Place of Business: *

Father's Business Phone: *

Address of Father's Place of Business: *

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

Yes

No

If YES, enter name, address, phone, and email address:

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.

Child's Physician: *

Physician's Phone: *

Medical information you would like to indicate about your child:

Emergency Contact #1 if Parent Not Available: *

Street Address *

City *

State *

Zip Code

Phone Number *

Emergency Contact # 2 if Parent Not Available: *

Street Address *

City *

State *

Zip Code

Phone Number *

Name of Person #1 Allowed to Pick Up Student: *

Name of Person #2 Allowed to Pick Up Student: *

Any Persons NOT Allowed to Pick Up Student (Appropriate paperwork such as Custody Papers shall be attached if parent is not allowed to pick up the child. Please include a photograph if available):

WAIVER AGREEMENT

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: *

I ALLOW my child to occasionally assist faculty/staff during EDC.

I Do NOT ALLOW my child to occasionally assist faculty/staff during EDC.

PARENTS / GUARDIAN AGREEMENTS

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.
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.
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.) *

clear

Date: * +

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

Kindergarten	1st Grade
2nd Grade	3rd Grade
4th Grade	5th Grade
6th Grade	7th Grade
8th Grade

TBD	KA	KB
1A	1B	2A
2B	3A	3B
4A	4B	5A
5B	6A	6B
7B	7A	8A
8B