Child's Name

First Name

Last Name

Gender

Male

Female

Age

Date of Birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Primary Care Giver

First Name

Last Name

Secondary Care Giver

First Name

Last Name

Primary Cell Number

(###)

###

####

Secondary Cell Number

(###)

###

####

Child's Legal Guardians

The Child May Only Be Released To The Person Signing This Agreement Or To The Following:

First Name

Last Name

Address of Alternate Pick-up Person

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number for Alternate Pick-up Person

(###)

###

####

Persons To Contact In The Event Of An Emergency When Parents Cannot Be Reached:

This person must be local and able to pick of child when parent is unavailable

First Name

Last Name

Alternate Emergency Contact

(###)

###

####

Does Child Have Allergies (Insects, Medication, Foods, Etc.)?

Yes

If yes, please explain:

Is Child on any Regular Medication?

Yes

If yes, please explain

Child's Known Medical Conditions(6. i.e. diabetic, asthmatic, drug allergies):

Medical Authorization:

PARENTAL AGREEMENT WITH BEFORE/AFTER SCHOOL CARE PROGRAM AND MEDICAL AUTHORIZATION 1. Should my child, suffer an injury or illness while in the care of Shoal Creek Adventist School After Care, and administration is unable to contact me immediately, SCAS shall be authorized to secure such medical attention and care for my child as may be necessary including the utilization of 911 services. I shall assume responsibility for payment of services. 2. I agree to keep the facility informed of changes in telephone numbers, etc. where I can be reached. I acknowledge it is my responsibility to keep my child’s records current. 3. No medication will be dispensed to my child. 4. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medication, etc., that involves my child. 5. Parents are requested to wait until their child is checked in at the door before leaving in the morning. Students must be signed out by a parent/guardian before being dismissed in the evening. 6. I have read the Before/After School Care Policy and hereby agree to comply with the rules and regulations of the Shoal Creek Adventist School Before/After School Care program regarding, but not limited to fees, attendance policy, health, discipline, snacks and other items specified in the Policies and Procedures.

Primary Guardian

First Name

Last Name

Secondary Guardian

First Name

Last Name

Before & After Care Policies

Before/After Care Program Fees 2024-2025

Payment for students enrolled in the Shoal Creek Before/After Care Program is made through FACTS (link to resource page). It is the parent/guardian’s responsibility to direct FACTS to withdraw funds to maintain an adequate available balance to pay for Before and/or After Care as needed.

Before School Care Fees:
$6.00 per family per day

After School Care Fees:
$6.00 hourly per family per day

Drop-in Fees:
$6.00 drop-in charge per family (first 15 min.)
$18.00 Drop-in flat rate charge (per day)

Late Fees
*** After 6:00 p.m. Monday-Thursday, and 5:00 p.m. on Friday, there will be a late fee of $1.00 per minute fee ****, unless prior arrangements have been made. If fees are not paid timely, the student will be dropped from the Before/After Care program. Students are subject to late fees 15 minutes after dismissal on days when aftercare is not provided.

Peachtree Hills Seventh-day Adventist Church

Atlanta Adventist Academy High school Grades 9-12

Before & After Care

Before/After Care Program Fees 2024-2025

Shoal Creek Adventist School

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