ST. EPHREM C.A.R.E.S. PROGRAM
5340 HULMEVILLE ROAD
BENSALEM, PA 19020
________________________________________

C.A.R.E.S. "BEFORE SCHOOL" REGISTRATION

CHILD'S NAME: _______________________________ ROOM # _______
______________________________ _______

ADDRESS: ______________________________ PHONE # _________

MOTHER'S NAME: ______________________________WORK # _________

FATHER'S NAME: ______________________________ WORK# _________

MY CHILD/CHILDREN WILL BE DROPPED OFF AT:
6:30 _______ 7:00 _______ OTHER: _______

MY CHILD/CHILDREN WILL BE ATTENDING:
3 DAYS _______ 5 DAYS _______ ON A NEEDS BASIS: _____

IN CASE OF AN EMERGENCY SCHOOL CLOSING, OR SICKNESS,
CONTACT: NAME: __________________________PHONE #________

(Contact person should be someone who has authority to pick-up your child in an emergency situation.)

Registration Cost is $15 per family per school year. $25 if registering for "After" School also.

CHECKS SHOULD BE MADE TO ST. EPHREM CARES.

COSTS ARE PER CHILD.

5 DAY BASIS: $15.00 week. 3 DAY BASIS: $9.00 week

NEEDS BASIS: $3.50 PER CHILD PER DAY.

PARENT'S SIGNATURE: _______________________________DATE: _________