Extended Day Registration Form Use the form below to register your child for the Extended Day Enrichment Program. Student/Family Information Parent/Guardian* Family Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Family Email Address* For weekly home/school communications Family Primary Phone* Mother Cell Phone Father Cell Phone Number of Students* 1234 First Student Full Name* Grade (2020-2021)* Montessori 3 year old (half day)Montessori 3 year old (full day)Montessori 4 year old (half day)Montessori 4 year old (full day)KindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEight Grade Number of Days* Select the number of days each week your child will be attending the Extended Day Essential Care Program. 5 Days3 Days Select Days* Check the box beside each day your child will be attending each week. Monday Tuesday Wednesday Thursday Friday Different Address This child has a different address. Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Second Student Full Name* Grade (2020-2021)* Montessori 3 year old (half day)Montessori 3 year old (full day)Montessori 4 year old (half day)Montessori 4 year old (full day)KindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEight Grade Number of Days* Select the number of days each week your child will be attending the Extended Day Enrichment Program. 5 Days3 Days Select Days* Check the box beside each day your child will be attending each week. Monday Tuesday Wednesday Thursday Friday Different Address This child has a different address. Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Third Student Full Name* Grade (2020-21)* Montessori 3 year old (half day)Montessori 3 year old (full day)Montessori 4 year old (half day)Montessori 4 year old (full day)KindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEight Grade Number of Days* Select the number of days each week your child will be attending the Extended Day Enrichment Program. 5 Days3 Days Select Days* Check the box beside each day your child will be attending each week. Monday Tuesday Wednesday Thursday Friday Different Address This child has a different address. Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Fourth Student Full Name* Grade (2020-21)* Montessori 3 year old (half day)Montessori 3 year old (full day)Montessori 4 year old (half day)Montessori 4 year old (full day)KindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEight Grade Number of Days* Select the number of days each week your child will be attending the Extended Day Enrichment Program. 5 Days3 Days Select Days* Check the box beside each day your child will be attending each week. Monday Tuesday Wednesday Thursday Friday Different Address This child has a different address. Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Payment and Terms EDECP Payment Optons* Monthly paymentBiannual paymentAnnual payment Terms* I understand that Extended Day Essential Care Program will keep on file the St. Agatha Academy Health History Form and the Student Release Form provided at parent orientation. These forms will provide EDECP staff with medical information, emergency contact information and student release information. Signature Comments This field is for validation purposes and should be left unchanged.