Parent Contact #1

Parent #1 Daytime Phone

Parent #1 Email

Parent Contact #2 (optional)

Parent #2 Daytime Phone

Parent #2 Email

Home Address

Emergency Contact Name

Emergency Contact Phone

Doctor Name

Doctor Phone

Student #1 Name

Student #1 Grade Fall 2020 Student #1 Grade Fall 2020PKK12345678

Student #2 Name

Student #2 Grade Fall 2020 Student #2 Grade Fall 2020PKK12345678

Student #3 Name

Student #3 Grade Fall 2020 Student #3 Grade Fall 2020PKK12345678

Please check all weeks you plan to attend (Totus Tuus included at no charge) Please check all weeks you plan to attend (Totus Tuus included at no charge) June 1-5 June 8-12 June 15-19 June 22-26 Totus Tuus June 29- July 3 July 6-10 July 13-17 July 20-24 July 27-31

How do you plan to pay for childcare? How do you plan to pay for childcare?Weekly by CheckOnline via FACTS ($35 setup fee for non-St. Patrick students

Regular care ends at 4 pm. Will you require extended care from the hours of 4:00-5:30 pm? Regular care ends at 4 pm. Will you require extended care from the hours of 4:00-5:30 pm? Yes No