Secondary 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*
1. Select PM Plan #*
Plan Selection (Student 2)
2. Student Name
First Last
2. Student Grade
2. Select PM Plan #
Plan Selection (Student 3)
3. Student Name
First Last
3. Student Grade
3. Select PM Plan #
Plan Selection (Student 4)
4. Student Name
First Last
4. Student Grade
4. Select PM Plan #
Payment
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.

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