PARENT/GUARDIAN AGREEMENT FOR AFTER -SCHOOL CARE

I AUTHORIZE THE FOLLOWING PERSON(S) TO SIGN OUT MY CHILD/CHILDREN:

Child/Children Name(s)______________________________________________________________________________________________________________

1.________________________________________________________________________
       Name Relationship                             Phone # Home & Cell

2.________________________________________________________________________
        Name Relationship               Phone # Home & Cell

3.________________________________________________________________________
        Name                                   Relationship                                   Phone # Home & Cell

4.________________________________________________________________________
        Name                                   Relationship                                   Phone # Home & Cell

(FOR ANY EXCEPTIONS TO THE ABOVE, THE PARENT/GUARDIAN MUST PHONE THE
      SCHOOL OFFICE BEFORE NOON ON THE DAY OF THE TEMPORARY CHANGE)

RE:  FINANCIAL OBLIGATION

Because the after-school care program is primarily a service to those parents/guardians who need additional supervision for their children. 
I know that the school cannot afford to track late day-care accounts.
I am also aware that my child/children will not be eligible for after-school care if my bill has become delinquent and that I must, in that case, pick up my child/children within fifteen minutes after the school dismissal.

Therefore,


I AGREE TO PAY AFTER-SCHOOL CHARGES WITHIN ONE WEEK AFTER BILLING

SIGNATURE OF PARENT/GUARDIAN ______________________________________