Name of Child / D.O.B. (Child)
Child's Nickname (if applicable) / Height (Child)
Name of Parent / Weight (Child)
21st Century ONLY Does your child speak another language? If yes, state what language. / No
Yes Secondary language spoken is:
Program Location
SACC @ Arnett 21st Century @ Arnett Addon Friday @ Arnett (21st Century)
SACC @ Howell 21st Century @ Howell Addon Friday @ Howell (21st Century)
SACC @ Miles SACC @ Lindeman
Emergency Contact Information
Child lives with: Both Parents Mother Only Father Only Other
Marital Status: Married Divorced Separated Single Other
Additional Siblings Enrolled in YMCA Childcare: Yes No (If answered yes, please list below)
If applicable, please print the name and age of any sibling(s) who would also be enrolled.Name: Age: Name: Age:
Name: Age: Name: Age:
In the event of an illness/emergency, the following individuals will be contacted in the order listed. These individuals also have authorization to pick up the above named child. A minimum of two contacts must be listed! A person authorized to pick up a child must be at least 18 years of age.
1st Called / This person will be called first in the event of an illness/emergency. This must be a parent/guardian. / 2nd Called / If the main parent/guardian cannot be reached, this person will be the second to be called.
Parent/Guardian Name / Parent/Guardian Name
Address
(Including City, State, Zip) / Address
(Including City, State, Zip)
Home Phone / Home Phone
Cell Phone / Cell Phone
Employer / Employer
Employer’s Phone / Employer’s Phone
3rd Called / In the event that a parent/guardian cannot be reached, this person would be the next to call. / 4th Called / This person will be the fourth person to be contacted in the event of an illness/emergency.
Contact Person / Contact Person
Relationship to Child / Relationship to Child
Address
(Including City, State, Zip) / Address
(Including City, State, Zip)
Home Phone / Home Phone
Cell Phone / Cell Phone
In the event reasonable attempts to contact me or a second individual at the numbers listed in my Emergency Contact information from page one of this packet have been unsuccessful, I hereby give my consent for: (1) the administration of any treatment of physician or dentist listed below, or in the event the designated preference is not available, by another licensed physician or dentist; or (2) the transfer of the child to the designated preferred hospital listed or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity of such action, are obtained prior to the performance of the surgery.
Parent/Guardian Signature Date
Medical Preferences and Health History
This section allows you to indicate preferences in doctors/medical facilities and also allows an opportunity to communicate any health history information that can help us ensure a safe and happy experience for your child. Please list any information regarding special medical issues, special dietary needs, allergies, etc. for your child. In order to avoid a delay in your child's enrollment, please fill out all requested information.
An Administration of Medication form is available upon request if your child is to take medications during program hours, has an epi pen, needs access to an inhaler, etc. / DesignatedPreferred
Physician / Name:
Address:
Phone:
Designated Preferred
Hospital / Name: / Designated
Preferred
Dentist / Name:
Address: / Address:
Phone: / Phone:
Current Diagnoses / Dietary Modifications
Current Medications / Allergies (Foods, Meds, Insects, etc.)
Disabilities/Operations/ Injuries/Chronic Illnesses / Behavioral/Sensory Considerations
If you feel we already have an Immunization Certificate on file for your child, please indicate below from which program and we will try to access it!
My child was in CAMP this past summer!
My child was/is in this year’s CHILDCARE program!
Kentucky Immunization Certificate
A copy of your child's immunization record must be received prior to your child's attendance!
If the immunization document expires during your child's enrollment in the program, you will be responsible for providing a new one.
Student History/Information:
Are there any special circumstances in the family, which may be a factor in your child’s behavior?In what ways would you like your child to develop during his/her participation in our program?
Please add any additional comments that you feel might help us understand your child better.
Pick Up Authorization
During pickup we utilize a code word system. You may also choose to be identified through “ID only.” Please review the information below and fill out all required information.
● It is imperative that your codes be confidential, and only told to adults who pick up your child. To help ensure this, please do not tell your child their code words! If your code words are compromised, please see the Site Administrator to change them.
● Adults picking up a child must know and use the code words or provide an ID. This includes parents/guardians. Anyone picking up a child must be at least 18 years of age.
● Parent/Guardian must provide legal documents upon any custody agreements/arrangements made within the court system, etc. regarding who can and/or cannot pick up children.
● ONLY Participants of the 21st Century program have the option to walk home and ONLY if over the age of 8!
Option 1: Check to the left if you wish to establish Code Words for your pickup service. List TWO Code Words below:Code #1 / Code #2
Option 2: Check to the left if you wish your child to be “ID Only” at pickup. Person picking up child must show a valid ID, matching the authorized information listed on page one of this packet.
Option 3: Check to the left if your child is in the 21st Century program, is over the age of 8, and you give your permission for them to sign themselves out and walk home.
Permission to Participate
Please indicate by checking one box below as to what activities that you will provide permission for your child during programming.
Yes / No / I give my permission for my child to use all of the equipment and participate in all activities in the program.Yes / No / I give my permission to the YMCA to use photographs, film footage, audio or video tape recordings, etc. which may include my child’s image or voice for purposes of promoting and interpreting YMCA programs and services to the general public.
Yes / No / I give my permission for qualified staff to provide routine health care, necessary first aid, etc.
Program Policy & Procedure Acknowledgments
● I understand that my child must be potty-trained before the start date of any Y Child Care program.
● I understand that the Y’s Child Care programs will follow the Erlanger/Elsmere Public School schedule. All SDO & Snow Day programs are held at Arnett Elementary only!
o If students are scheduled to be off from school but I still need child care, I am aware that I must purchase/register in advance for the SDO (School’s Day Out) program for an additional charge.
o If schools are closed due to inclement weather, I am aware that I can bring my child to the Snow Day program and purchase registration for the day – IF SPACE IS AVAILABLE! To guarantee a spot in the program, I can also pre-purchase Snow Day Insurance so that I may not be turned away!
● I understand that under no circumstances will my child bring their own toys or electronic devices, which include but are not limited to: electronic devices/games, video watches, cell phones, card games, or other personal items such as nail polish, makeup, etc. If my child does so, the staff will confiscate the item and return it to the parent at the end of the day.
● I understand that a detailed record of my child(ren)’s arrival and departure will be documented. Child(ren) must be signed in and out of the program they are registered with the time noted of their arrival and departure. This is a state law and must be done every day. I understand that the YMCA is not responsible for my child until the parent/guardian or staff member signs them into the program.
● I understand that if my child will be absent from the program I need to contact or leave a message for the Site Administrator prior to the start of the program. Contact information is outlined in the Parent Handbook and Parent Hot Tips page.
● I understand that all Y programs have a “nit free” lice policy, which is different from the public school system. It is our policy that if your child is found with lice or nits/eggs, the child may not attend the program. Your child may not return until they have been checked and cleared by the Site Administrator or Senior Program Director.
● I understand that I must review and FULLY complete and submit all requested paperwork, prior to the start of the program. This includes providing a Kentucky certified copy of my child’s Immunization Certificate. (A copy of shot records or out of state records will not be accepted. An expiration date must be listed on the form.)
● I further understand that I am responsible for reading and adhering to all policies, procedures, and guidelines referenced in the Parent Handbook and signed off on this Enrollment Packet Document. A hard copy of the Parent Handbook is available on request or can be accessed by parents on our website at: www.myy.org
● I understand that the program will often enlist special programming from outside resources and that non Y individuals may engage in activities with my child. At no time, under any circumstances will a child be engaged in that said activity without a Y staff member. (i.e.: Library bus visits, special event visits, off-site field trips, tutoring sessions, etc.)
Acknowledgment of YMCA Policies
Your child's safety and security is our number one priority! Our staff goes through extensive training to help ensure the wellbeing of your child. However, through no negligence on anyone's part, accidents may happen. Parents must agree to the following:
• I understand that the YMCA is not responsible for personal property lost, stolen or broken, while participating in the program.
• My child and I will adhere to the YMCA Code of Conduct. I understand that the Y will hold us both accountable for the Code and may restrict my access to any Y programming upon breach of this code. (Code of Conduct is outlined in the Parent Handbook.
• I understand that the Y assumes no responsibility for injuries or illness which my child may sustain as a result of their physical condition or resulting from their participation in any program activities, use of equipment, exercise, or any other activity during the program.
• I expressly acknowledge on behalf of myself and my heirs that I assume the risk of any and all injuries and illness, which may result from my child’s participation in program activities. I hereby release and discharge the Y, its agent’s servants, and employees from any and all claims for injury, death, lose or damage, which my child may suffer as a result of their participation in program activities.
• I understand to meet mandatory reporting responsibilities (i.e.: United Way requirements, state reporting mandates, Y Passport programming, program evaluations, etc.) information is shared with internal and external identities as part of the process of interpreting YMCA programs.
Financial Policy & Procedure Acknowledgments
● I am responsible for all fees for programs that I register my child for. I also understand that to avoid billing, to change my registration in any way I must follow the below policies:
● If I need to WITHDRAW my child from a program, I must provide the Site Administrator with a Change of Program form at least 2 weeks prior to my child's last day. You will be contacted within 3 business days after the form is received to discuss your account and how payment/credit will need to be secured.
● CHANGES to my child’s program attendance must be made using the Change of Program form at least 1 week prior to the needed change. You will be contacted within 3 business days after the form is received to discuss how the change impacts your account and how payment/credit will need to be secured.
● I understand that there is a late fee of $1.00 per minute/per child after the designated pickup time. The person picking up the child will sign the late fee slip to acknowledge charges and the parent's credit/debit card on file will be charged.
● I understand that there is a $25 penalty fee for returned checks. After one returned check, ONLY money orders will be accepted, made payable to the YMCA.
● I understand that the R.C. Durr YMCA will provide a tax statement that will be mailed out by January 31st for child care payments during the previous year.
● Registration will be denied to any individuals who have any outstanding Y balances from last year's Child Care program, camp or from any other additional YMCA programming. All outstanding balances must be paid in full prior to registration.
Financial Policy & Procedure Acknowledgments – SACC PROGRAM ONLY