Family Name: _____________________________________________________

Child(ren)’s name(s)__________________ Grade_____ Name _____________________ Grade_____

Name ___________________________ Grade____ Name ________________________Grade ______

Address: ___________________________________________________

City : ____________________ State_______ Zip: _____________

e-mail______________________________________________________________ (needed for correspondences)

H Phone: ____________________ W-Phone:__________________ Emergency Contact: ________________________

Cell Phone:_____________________ Fax #: _________________ Emergency Phone: _________________________

Medical Concerns ______________________________

I hereby release and discharge Pope John Paul II Regional Catholic Elementary School (“JPII”), its, employees, staff members and administration from any claims, responsibilities or liabilities for injuries or harm incurred as a result of my participation and/or my child’s participation at JPII. I authorize JPII, its employees, staff members and administration to take whatever action necessary, in their best judgment, in an emergency and I hereby release and discharge JPII from any responsibility or liability related thereto.

Parent/Guardian Signature: _______________________________

*** Registration will not be accepted without a properly signed waiver ***

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PAYMENT INFORMATION

 Please check all days attending:  Nov 1 ______    Dec 14 ______    Jan 21 _______    Feb 1 _______    Feb 18 ______    March 24 _____

                                                         April 9 ______      April 21 ______    May 1 ______    May 2 _______    May 16 ________

1^st Child - Number of days _______@ $35 ________ = $ ______     2nd Child - Number of days _______@ $30 ________ = $ ______ 

3rd Child - Number of days _______@ $30 ________ = $ ______        4th Child - Number of days _______@ $30 ________ = $ ______ 

TOTAL DUE $ _____________

EXTENDED DAY

AM Extended day  7 - 9 am ( time of drop off) __________

PM extended day   3 - 5:30 ( pick up time) ___________ Number of children _____ Number of days  ____ @ $5 each ________

Lunch includes Pizza, drink, snack : # of 1 slice @ $3.00__________ 2 slices @ $5.00 _______________

Amount Enclosed: $__________

____ Cash ____ Check # ____________________ Credit Card # _________________________________________

Exp. Date: _____________ Print Name on card: _____________________________

Signature of cardholder: _______________________