Stepping Stones Drop In

This form is for approved use only. The Stepping Stones program is not a drop in care service, however in case of an emergency, this form provides the information we need to keep your child safe. Please complete this form only after speaking with the preschool staff.

Payment for this service will be billed separately from tuition. Your FACTS account can be used for payment or you can pay by check or cash.

Student Name *


First	Last

Birthdate *

	/		/
day		month		year

Gender *

Female

Male

Preschool Class: *

Mothers Name: *


First	Last

Mothers Phone: *

-
Area Code	Phone Number

Fathers Name: *


First	Last

Fathers Phone: *

-
Area Code	Phone Number

Primary Email: *

Allergies: *

Yes

If Yes, Please List:

Emergency Contact Name and Phone Number(other than parents): *

I give permission for my child to be picked up by: (list name, relation, and phone number) *

Please read the following statement and acknowledge receipt by checking the box.

Please acknowledge the following statements and agree by checking the box. *

This service is $10 per hour. I will arrive promptly to pick up my child at the end of the PM Stepping Stones Program in which we have enrolled. I further understand that a late fee of $10.00 per every 5 minutes will be charged to my FACTS account if I am late picking up my child.

Closing and Cancellations: If school is delayed to inclement weather, AM Stepping Stones will be closed. If school is dismissed early due to inclement weather, PM Stepping Stones will be closed. If preschool is closed or releases early due to inclement weather, holidays, vacations or teacher training, there will be no Stepping Stones Program.

Date Needed: *

	/		/
day		month		year

Select the slots you are requesting (call for availability) *

Morning 8-9

Afternoon 1-2

Late Afternoon 2-230

Comments or Special Instructions:

Word Verification:

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