Registration Form

                                                                                       Weekly Cost: under 18 months  $170.00  Over 18 months:  $130.00
                                                                                                                         Site ID #:  1710 388 600 
                                                                                             BERNICE’S EDUCATIONAL SCHOOL AGE CENTER, INC.
                                                                                                               2516 W. 4TH Street, Wilm., DE 19805
[email protected]

                                                                              302-651-0286 (Office) * 302-983-7983 (Cell)* 302-981-2451 (Cell) *302-656-2098 (Fax)

I agree to pay BERNICE’S EDUCATIONAL SCHOOL AGE CENTER, INC., for Purchase of Care Plus in addition to my Division of Social Services parent’s fee.  I understand that both fees from Division of Social Services and my co-pay must add up to the total weekly fee charged by BESAC.  It is does not total the weekly fee, I understand that I promise to pay the differences. My worker will be notified if I leave BESAC owing a balance and fail to provide a mandatory two week prior notice to remove my child(ren).  My child care will be terminated for attendance at a different child care facility if I do not pay my balance and provide a two.  The weekly fee will be due if I fail to provide a prior two week notice.


________________________Age_________Sex______Date___________DOB_____________  /   /  2011

Street                                                                               City                                                         State                                       Zip

Parent Name/Address
Street                                                                               City                                                         State                                       Zip

Parent’s Employer


Soc. Sec. # :                           Street  Address                           City                                      State                                       Zip

EMERGENCY CONTACT other than parent


Street                                                                     City                                                         State                                       Zip

Below please list all pe5rsons and their relationship to the above participant to whom the participant may be released:

Photo Identification is mandatory for release to anyone other than noted herein, or no release of child

1.       ________________________                                        Relationship: ________________________

2.       ________________________                                        Relationship: ________________________

3.       ______________________                                            Relationship: ________________________


Photo Release / Field Trips/Sexual Abstinence


While participating in this School Center, lots of pictures and field trips will be taken to display on our bulletin board,  or in other public places, including the newspaper, television, public displays, and going on field trips.  Therefore, I give permission for my child to be photographed, participate in field trips, and Sexual Abstinence program while attending our School Center.  Also, these pictures may be use for publicity at the discretion of the School Center.  My permission is also granted for participation of my 12 year old and up to participates in the sexual abstinence. Lastly, I give permission for my child to sleep on a cot.

________________________                                                                        ________________________

Parent’s/Guardian’s Signature                                                                          Date