2026-27 Upper School Extended Day Registration

Required

PARENT/GUARDIAN INFORMATION:

Parent 1 Namerequired

Parent 1 Email Addressrequired

Parent 1 Cell Phone Numberrequired

Parent 2 Name (Optional)

Parent 2 Email Address

Parent 2 Cell Phone Number

STUDENT INFORMATION:

How many students are registering for extended day? There is a non-refundable $20 fee per student.required

Student 1 Namerequired

Student 1 Graderequired

Student 1 resides withrequired

Student 1: Monthly Afternoon Care: 3:30pm - 6pm required

Student 2 Namerequired

Student 2 Graderequired

Student 2 resides withrequired

Student 2: Monthly Afternoon Care: 3:30pm - 6pm required

Student 3 Namerequired

Student 3 Graderequired

Student 3 resides withrequired

Student 3: Monthly Afternoon Care: 3:30pm - 6pm required

Student 4 Namerequired

Student 4 Graderequired

Student 4 resides withrequired

Student 4: Monthly Afternoon Care: 3:30pm - 6pm required

ALTERNATE EMERGENCY CONTACTS:

If parents cannot be reached.

Namerequired

Cell Phone Numberrequired

Relationshiprequired

Namerequired

Cell Phone Numberrequired

Relationshiprequired

MEDICAL WAIVER

Should my child become ill or suffer an injury of any nature during the time that he/she is in the care of Hebron Christian Academy Extended Day Program, EDP personnel will attempt to contact me immediately. In the case of severe illness or injury, 911 will be called and my child will be transported by ambulance to the closest medical facility able to treat my child, which will be authorized to provide necessary medical treatment for life threatening injuries/illness. I (the parent or guardian) shall assume responsibility for payment.

Insurance Companyrequired

Policy Numberrequired

If you do not grant permission or authorization for consent to medical treatment, what procedures should be followed?required

RELEASE PERMISSIONS

Persons authorized to pick up my child.

The student is not allowed to enter or leave the facility without being escorted by his/her parents, persons authorized by the parents, or EDP staff. The student may be released only to the person(s) completing this agreement and the person(s) listed below.

Any changes must be submitted in writing by the parents/guardians to the Upper School Extended Day Coordinator, Anne Marie Jacobs, anne.jacobs@hebronlions.org.

Namerequired

Phone Numberrequired

Relationshiprequired

Name

Phone Number

Relationship

Name

Phone Number

Relationship

By completing this form and paying the appropriate fees, I understand and accept the Hebron Christian Academy Extended Day Program regulations as stated on this form and the fee schedule located on the website. I also agree to each statement below.

• Billing for extended day will be paid on the 20th of each month through Blackbaud Billing Management.

• Charges for extended day will be discontinued after a withdrawal request has been submitted and approved by the Upper School Coordinator, Anne Marie Jacobs, anne.jacobs@hebronlions.org.

• Negative balances over 60 days will result in services ended until the balance is paid in full.

• It is my responsibility to keep my child's records current. When and if any significant changes occur, I will notify extended day coordinator.

• I have read and understand the HCA Hold Harmless Policy.

Payment Information

Please select a payment typerequired

Card

Billing Addressrequired

Address

City

State/Province

Country

Zip/Postal Code

Cardholder Namerequired

First

Last

Expirationrequired

Month

Year

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In This Section

2026-27 Upper School Extended Day Registration

PARENT/GUARDIAN INFORMATION:

STUDENT INFORMATION:

ALTERNATE EMERGENCY CONTACTS:

If parents cannot be reached.

MEDICAL WAIVER

RELEASE PERMISSIONS

Persons authorized to pick up my child.

Payment Information