Parent/Guardian Name *

First Name

Last Name

Phone *

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Student 1 *

First Name

Last Name

Student 2

First Name

Last Name

Student 3

First Name

Last Name

Which Days Will Your Child(ren) Be Attending After-Care? *

Monday

Tuesday

Wednesday

Thursday

Friday

I acknowledge that I will let Horizons know if an individual other than someone listed on the authorized pickup list will be picking up my child . I understand that Horizons reserves the right to not release my child to an unknown person not listed on the child's authorized pick up list.* *

I understand and agree.

I do not agree. I understand that my child will not be able to receive after-care.

I acknowledge that all children must be picked up by 5:30pm. If families arrive late for pick-up from after-care more than 3 TIMES, they will no longer be able to use extended day after-care services. Parents will be charged a $5 per 5 minutes late fee. I agree to pick up my child(ren) in the designated window of time.* *

I understand and agree.

I do not agree. I understand that my child will not be able to receive after-care.

I acknowledge that there is a $10 a week cost per student for the extended care services. If the fee is not paid for that week, your child(ren) may be asked to leave the after-care program.* *

I understand and agree.

I do not agree. I understand that my child will not be able to receive after-care.