2025-26 Cape Care Application - Cape Elizabeth Community Services

Child's Last Name *

Child's First Name *

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Child's Birth Date *

Gender *

Grade in Fall 2025 *

Child's Primary Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian 1 Name *

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Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Cell Phone Carrier *

Parent/Guardian 1 Other Phone *

Parent/Guardian 1 Email *

Parent/Guardian 1 Employment *

Please enter place of employment and work phone number.

Parent/Guardian 2 Name *

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Parent/Guardian 2 Cell Phone *

Parent/Guardian 2 Cell Phone Carrier *

Parent/Guardian 2 Other Phone *

Parent/Guardian 2 Email *

Parent/Guardian 2 Employment *

Please enter place of employment and work phone number.

Emergency Contact 1 (name and phone number) *

Grandparent, neighbor, or friend who can assume care for your child in the event you cannot be reached.

Emergency Contact 2 (name and phone number) *

Grandparent, neighbor, or friend who can assume care for your child in the event you cannot be reached.

Child's Information

Does your child qualify for Maine's low income Child Care Subsidy? *

Does your child speak and/or hear another language at home? If so, which language? *

Does your child have an IEP (Individual Education Plan) as determined by CDS (Child Development Services)? *

Does your child have any allergies, chronic health or medical conditions? *

An individual health care plan may be required.

Does your child have an inhaler, epi-pen, or other medication needed at school? *

If yes, an Authorization to Administer Medication form may be required.

Physician's Name & Phone Number *

Dentist's Name & Phone Number *

Preferred Hospital *

In case of an emergency where would you like your child transported via ambulance/rescue?

Authorizations and Permissions

Do you give Cape Care Staff the following authorizations/permissions?

Use images of your child for publications, social media, promotional materials, etc. *

Show G/PG movies on special occasions/rainy days *

Apply sunscreen *

Provide emergency medical treatment/transportation *

Transportation to on/off campus activities and events *

Parents will be notified in advance unless emergency protocols are in effect.

Participate in activites including but not limited to swimming *

Swim lessons are part of the Preschool and Pre-K curriculum. Free swim for K - 4 students on special care days.

Who is authorized to pick up your child?

Who is NOT authorized to pick up your child?

Cape Care Program Choices

Waiver of Liability

I hereby permit my minor child to participate in Cape Care administered by Cape Elizabeth Community Services located at the Community Center during the 2025-26 school year. In consideration of my minor child being allowed to participate in Cape Care, I, for myself and my minor child, hereby agree to release, discharge, indemnify and hold the Town of Cape Elizabeth, Community Services, and their agents and employees harmless from any liability claims, demands, costs or damages arising out of program activities, and transportation, by negligence or otherwise, which I or my minor child might have. I, the undersigned, further authorize anyone working for Community Services to call for such medical care for my child or to transport my child to the appropriate medical clinic or hospital, if in the opinion of anyone working at Community Services, medical attention is needed for my child. The undersigned agrees that upon transporting the child to any medical facility, clinic, or hospital, the responsibility of Community Services shall be fulfilled and Community Services shall not have any further responsibility for the child. We further authorize the attending physician to administer any necessary medical attention in the event we cannot be reached at the provided telephone numbers. I understand that participation may include transportation by buses/vans owned and operated by the Cape Elizabeth School Department. The release is binding, and I so understand, not only upon my heirs, administrators, executors, and assigns, and I herewith again reaffirm my free and willing intent to execute it, acknowledging a complete understanding of terms and conditions and the totality of its effect, and the totality of the waiver of rights that I would otherwise have had, had this agreement not been executed. I certify that the above-named minor child is in excellent health and that there are no limits to my child’s participation except as stated in writing. I further certify that the Town of Cape Elizabeth / Community Services has on file all current immunization records.

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A non-refundable Registration fee of $100.00 is required (Except for Pre-Kindertgarten).

A non-refundable registration fee will be charged if your child is accepted into the Cape Care Before Care, After Care or Preschool program. You will only be charged $100.00 per child, to secure their spot in Cape Care.

Would you like to use this card to pay for Cape Care 2025-26?

Yes, please charge this card monthly
Yes, please charge this card weekly
No, I will provide another form of payment

Signature *

Date *

Name on the card *

Card Number

Expiration Date *

CVC Code *

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For Office Use Only

Start Date