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Wraparound Care Enrollment
Section 1: Student Details
Parent/Guardian Name
*
Preferred Wraparound Care Option (select A,B, or C and/or D,E, or F):
*
Preferred Wraparound Care Option (select A,B, or C and/or D,E, or F):
A
Before School Care
B
After School Care
C
Before/After School Care
D
Day 1 Virtual Care
E
Day 2 Virtual Care
F
Both Day Virtual Care
Desired start date:
*
Any known schedule conflicts (optional):
*
Section 3: Payment Terms (total amount/week - determined by preferred wraparound care option)
*
Section 3: Payment Terms (total amount/week - determined by preferred wraparound care option)
A
$60/week
B
$60/week
C
$120/week
D
$65/week
E
$65/week
F
$130/week
G
$125/week
H
$250/week
Section 4: Signature
Full Name (typed)
*
Date
*
Signature
*
Submit
