NLR Elementary Extended Care Contract Date* MM slash DD slash YYYY Parent/Guardian Name* First Last Email Plan Selection (Student 1)1. Student Name* First Last 1. Student Grade*Choose OnePreK3PreK4Kindergarten1st2nd3rd4th5th1. Select AM Plan #*Select OneNot ApplicableBS51BS41BS31BS21BS111. Select PM Plan #*Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS131. (Optional) Select Additional PM Plan #*Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS13Plan Selection (Student 2)2. Student Name First Last 2. Student GradeChoose OnePreK3PreK4Kindergarten1st2nd3rd4th5th2. Select AM Plan #Select OneNot ApplicableBS51BS41BS31BS21BS112. Select PM Plan #Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS132. (Optional) Select Additional PM Plan #Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS13Plan Selection (Student 3)3. Student Name First Last 3. Student GradeChoose OnePreK3PreK4Kindergarten1st2nd3rd4th5th3. Select AM Plan #Select OneNot ApplicableBS51BS41BS31BS21BS113. Select PM Plan #Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS133. (Optional) Select Additional PM Plan #Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS13Plan Selection (Student 4)4. Student Name First Last 4. Student GradeChoose OnePreK3PreK4Kindergarten1st2nd3rd4th5th4. Select AM Plan #Select OneNot ApplicableBS51BS41BS31BS21BS114. Select PM Plan #Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS134. (Optional) Select Additional PM Plan #Select OneNot ApplicableAS51AS52AS53AS41AS42AS43AS31AS32AS33AS21AS22AS23AS11AS12AS13PaymentI would like to*pay monthly.pay in full.pay by semester.I understand that my FACTS account with be drafted for the amount corresponding to the Plan # I have chosen.* I understand and give my permission. Δ
