Public School Operated School-Age Child Care Program - REGISTRATION FORM

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BASIC PROGRAM INFORMATION

*Please include the school at which the program takes place; and also any schools that send students to this program.

STUDENTS SERVED

Please indicate the estimated number of students served at each applicable grade-level.
STUDENTS SERVED Please indicate the estimated number of students served at each applicable grade-level.PKK123456789101112
School-Year
Summer

SCHEDULE OF OPERATION

Please provide the requested information for all that apply:
SCHEDULE OF OPERATION Please provide the requested information for all that apply:# hours/ day# days/ week# of weeksTotal # of hours
School-Year (before school)
School-Year (after school)
School Vacation Weeks
Summer

PROGRAM FEATURES

Services/Activities: Which of the following are components of the program? (check all that apply)
Transportation: Please indicate how students travel to/from the program. (check all that apply)
Program Funding/Fees*: How is your program funded? (check all that apply)
*If parents/families pay fees, does your program offer a sliding scale and/or scholarships for families that cannot afford the program?
If available, you may upload a copy of your program flyer/handbook. (This is not required for registration.) Click Browse to find your file, click on the file, and then click Upload to begin upload process.
     Superintendent (Signature)*: _________________________________________________      
    
     Date*: _________________________
    

*Upon receipt of the PDF version of this submitted form, please print and return with the original signature of the Superintendent.