After-School Activity

Extended Care Release Form

This form is to be used if your child is in an after school program such as CYO or Scouts and will require the assistance of the Extended Care Program.

This form will be kept in Extended Care's "after school release form" file and will assist us in being better prepared for keeping track of your children and making sure they are where they are supposed to be and whom they are supposed to be with.

If this form is NOT on file with Extended Care your child will NOT be released to attend their activity and you will NOT be called for authorization.

My child, __________________________________________________, will be participating in

________________________________________________ after school. This will happen on

_______day at ___________. He/She will need to be signed out from Extended Care.

He/She will be signed out by ___________________________________________________________

who is the _______________________________________ supervising this activity.

This will be in effect from ________________________ to ________________________.

Please check one of the following:

_____ I will be picking up my child after this activity.

_____ My child will need to be signed back into Extended Care.

_____ My child's activity is right after school and will come to Extended Care after that.

I understand that if any of the above specifications are changed, I will notify

Extended Care.

Parent's signature _____________________________________________________________________

Date _______________________