YMCA OF WESTERN NORTH CAROLINA
Child Care Services YMCA
Afterschool Registration Forms, 2013-2014
REGISTRATION CHECKLIST
Early registration is recommended. There is a one week waiting period from the date the completed application is received until the
date the child is able to start the program. Incomplete forms will delay a childs start date.
CHILDS NAME:__________________________SCHOOL LOCATION:________________________START DATE: ___________
FORMS
Youth Information Form
You are required to complete a new Youth Information Form annually.
Individualized Care Plan
Please complete if you have noted on the Youth Information Form your child will be taking prescription medication at afterschool
care, or has any special need and/or disability. A youth development director will review every ICP and will meet with parents if
necessary to determine how to best meet the childs needs.
Mobile Alerts Form
Please complete the required Mobile Alerts Form.
2013-2014 Summer Day Camp and Afterschool Policy Signature Form
Please read our policies and procedures. Parent signature required.
Please check if submitting multiple registrations and list the names of the children: ________________________________________________________
Current Copy of Immunization Record
We can use the immunization record on file if the information is the same and there are no updates.
Current Color Photo of Child
Please place on the Youth Information Form in the spot labeled photo
Bank Draft Option Form
Please complete the Bank Draft Option form if you would like the weekly bank draft option.
SEEK (Excluding Beaverdam)
Please note that by checking this box, you are notifying this office that you will be utilizing Child Care Subsidy Vouchers to assist
with your weekly child care fee. You hereby agree to fulfill all requirements while enrolled in this program, including the
proper usage of SEEK machines. Failure to adhere to all requirements may result in removal from the YMCA program.
Child Care Subsidy Vouchers (Excluding Beaverdam)
Three (3) original copies
Recipients of Child Care Vouchers (Excluding Beaverdam)
Please present SEEK card at time of registration.
YMCA Financial Assistance Application
Applications are accepted throughout the summer camp season early submission is recommended by July 3, 2013.
Registration Fee and Deposit and/or Weekly Payment
The Registration Fee and first weeks payment is due in full at time of registration.
Registration Fee: $50 per child
$75 per family
***EARLY REGISTRATION DISCOUNT*** All completed registrations received and processed in the Child Care
Services YMCA office through June 28, 2013 will receive one half off the $50/$75 registration fee.
Weekly Payment Plan:
Full-time - 5 Days/wk.: $75
Part-time - 3 Days/wk.: $65 (You must choose the 3 days attending each week). Circle:
Th
Payment Method: Check # _______ Cash Money Order Credit Card* Other *Balances under $10 paid by credit/debit
card will be assessed a $5.00 convenience fee.
Parent/Guardian Signature _____________________________________________________Total Payment Amount Enclosed $ ________________________
2013 Child Care Services Branch Youth Information Form
This youth information is effective for the 2013-2014 Summer Camp and Afterschool Programs.
Childs Information
Childs name___________________________________________________________________________
Address _____________________________________________________ City ____________________ Zip ___________
___ Male ___Female Birth date _________________
Age (as of June 2013) _____ Ethnicity ______________________
School child attends during school year _________________________________Grade (as of Aug. 2013) ______________
(If school closes due to inclement weather, you will be notified via Text Alert or through WLOS IF the
Afterschool program will operate.)
Allergies (please be specific and note level of severity, etc.): ________________________________________________________________________________
Current Medications (please note all medications AND complete the Individualized Care Plan if medications will need to be administered at the Y program):
__________________________________________________________________________________________________________________________________
Special Needs/Concerns/Differernces ___ YES ( If yes, please complete the attached Individualized Care Plan Form): ____ No
What activities your child would enjoy while at Afterschool/Summer Camp:____________________________________________________________________
What are your expectations for the Afterschool/Summer Camp Program?______________________________________________________________________
Names and Ages of Siblings: __________________________________________________________________________________________________________
Swimming Ability (check one): ___ Non-Swimmer ___ Beginner ___ Intermediate ___Advanced
Family Information (List both parents/guardians AND check the one parent/guardian completing this form to contact for payments and questions.
___ Parent/guardians name _________________________________________________________________ Employer ________________________________
E-mail address ____________________________________________________________(please provide the email address that we may use for contacting you)
Home address _________________________________________________________________ City ________________________________ Zip _____________
Home # _______________________ Work # _______________________ ext. _______ Mobile # _______________________ Pager # ____________________
___ Parent/guardians name _________________________________________________________________ Employer ________________________________
E-mail address ____________________________________________________________(please provide the email address that we may use for contacting you)
Home address _________________________________________________________________ City ________________________________ Zip _____________
Home # _______________________ Work # _______________________ ext. _______ Mobile # _______________________ Pager # ____________________
Emergency Information(If you do not have a doctor/dentist, please list Buncombe County Health Department or another provider of your choice. All
information is REQUIRED, including hospital name.)
In case of emergency, please contact the following first: ____Mother/Guardian ___Father/Guardian
Childs doctor ________________________________________________________________________Doctors phone # _______________________________
Childs dentist ________________________________________________________________________Dentists phone # ______________________________
Hospital preference ________________________________________________________________________________________________________________
Insurance company ________________________________________________________________________ Policy # _________________________________
Emergency Contact Information
When a parent/guardian is not available, I authorize these individuals to pick-up my child:
1.
Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________
2.
Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________
3.
Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________
4.
Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________ Pager # ____________
YMCA of Western North Carolina
Child Care Services Branch Individualized Care Plan Form
This form will be utilized when a parent/guardian has indicated on the Youth Information Form that their child will be
taking a prescription medication, requires special attention, has a special need or disability while participating in the
YMCA program.
_______________________________________________________________________________________________________
MEDICATION INFORMATION:
CHILDS NAME: ________________________________________________ CHILDS DATE OF BIRTH ___________________
Name of Prescription Medication to be taken at the YMCA:_____________________________________________________
Expiration Date: _____________ Time to Be Taken and Frequency: ______________________________________________
Dosage Amount: ____________Beginning Date: _______________________ Ending Date: ___________________________
Special Instructions:______________________________________________________________________________________
______________________________________________________________________________________________________
Possible Reactions: ____________________________________________________________________________________
_____________________________________________________________________________________________________
Prescribing Provider: ____________________________________________ Phone: ________________________________
Pharmacy: ____________________________________________________ Phone: ________________________________
I give the YMCA staff authorization to give medicine noted above and to call the health care provider if needed.
Parent/Guardian Signature: _________________________________________________________ Date: __________
TELL US MORE ABOUT YOUR CHILD:
If you listed a medication on the previous sheet or checked yes to a special need, concern or difference, please explain
so that our staff are familiar prior to your child attending program:
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
If the YMCA staff and/or the parents/guardians feel it is necessary, a meeting will be scheduled in advance to discuss
specific information. The YMCA program welcomes all children to the extent that it is reasonably able to do so. A child
who requires measures that constitute a fundamental alteration to the program or other undue hardship, or a child that
poses a direct threat to the health and safety of others, will not be able to participate in the program. All children,
regardless of their circumstances, are subject to YMCA disciplinary procedures.
_______________________________________________________________________________________________________
Office Use Only: ____YMCA is to contact family regarding admission into camp
____ Parent requests contact with YMCA staff prior to camp
CHILD CARE SERVICES YMCA ~ MOBILE ALERTS
As part of the registration process, we now require you to complete this form with updated information to ensure
proper receipt of texts.
___
I am new to the Ys mobile text alerts.
___
I am already signed up for mobile alerts, however, I need to update my information. (Please complete only
the sections you want to update.)
___
I am already signed up for mobile alerts and do not need to update my information.
First Name: _________________________________________
Last Name: _________________________________________
Address: _______________________________________________________ City: _____________________________________________
State: __________ Zip Code: ____________________ Email: __________________________________________________________
Mobile Phone #: (
) _________ - ___________________ Mobile Phone Carrier: ______________________________
Parents DOB (Month, Day, Year): __________________________
Member of YMCA?: (Please circle)
YES
NO
_______________________________________________________________________________________________________________________
PLEASE SELECT AS MANY BOXES AS YOU NEED TO STAY INFORMED.
REMEMBER, YOU MUST SIGN UP FOR THE AFTERSCHOOL & CAMP ALERTS.
Facility Alerts:
_____
Asheville
_____
Child Care Services
_____
Corpening
_____
Hendersonville
_____
Reuter
_____
Woodfin
_____
Adventure Camp
_____
Specialty Camps
Afterschool & Camp Alerts:
_____
Explorer Camp
_____
Discovery Camp (Buncombe)
_____
Afterschool Site (Please fill-in): _____________________________________________________
_____
Schools Out Site (Please fill-in): ____________________________________________________
_____
Discovery Camp (Hendersonville)
By signing below, I certify that I am over the age of 13 (Childrens Online Protection Act) and that I understand that
by signing up for these alerts, standard message rates may apply depending on my wireless plan.
Signature: ___________________________________________________
Date: ______________________________________
2013 YMCA Child Care Services Branch
Summer Day Camp/Afterschool Policy Signature Form
Parents/Guardians, please read each area below carefully. Your signature on this document indicates your acknowledgement,
understanding, and agreement with all policies of the YMCA of Western North Carolina.
Policies/Procedures I have been informed of the Camp/Afterschool Handbook located online at [Link]/camp-information
and agree to all policies.
Weekly Deposit A non-refundable and non-transferable deposit of $20 is required to register campers for each weekly camp
session.
Registration Fees A one-time nonrefundable and non-transferable CCS registration fee of $50 per child, $75 per family is due at
the time of Summer Camp AND Afterschool Registration. Payment of a separate registration fee is required for both programs.
Refunds and Cancellations Any deposits and other fees paid are non-transferable and will not be refunded due to cancellation.
Insufficient Funds If drafts or checks are not honored you are still responsible for the payment plus a $30 service charge applied
by Federal Automated Recovery System. Child(ren) will be unable to attend any YMCA program until the account is paid in full.
Subsidy Voucher Participation I agree to notify the YMCA of any changes in my subsidy voucher status and to abide by the rules
set forth by the issuing agency. All subsidy voucher participants are responsible for paying the rate discrepancy between what the
YMCA charges and what the voucher will reimburse. The parent/guardian is responsible for any payment for child care not covered by
the voucher.
Emergency Treatment/Emergency Transportation I agree that the operator, YMCA of Western North Carolina, may authorize the
physician of their choice to provide emergency care in the event that I cannot be contacted immediately. I authorize for my child to
be transported in the case of an emergency when medical attention by a physician is necessary. I understand that the YMCA will not
transport children in their personal vehicles at any time and a hospital or fire/emergency department will always be contacted.
I, as the operator YMCA of Western North Carolina, do agree to secure transportation to an appropriate medical resource in the
event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not
administer any drug or any medication without specific instructions from the physician or the childs parent, guardian, or full-time
custodian. Provisions will be made for adequate and appropriate rest and outdoor play.
Signature of Operator/YMCA Representative: James Spearin and Paul Vest Date: June 2013-June 2014
Field Trips/Transportation I permit my child to leave the YMCA on authorized trips under the supervision of the YMCA staff. A
written schedule of all activities to be conducted off the YMCA Camp premises will be posted for parents to review. By signing this
form, you give your child permission to be transported in YMCA vehicles. I understand that field trips occur weekly in Summer Camp
and that some field trips have an additional cost to attend. Field trips are on an infrequent basis during Afterschool.
Activities Outside the Fenced Playground I hereby give permission to the YMCA of WNC for my child to participate in
developmentally-appropriate supervised activities outside the fenced playground at Buncombe County School locations. I understand
this statement is required to be signed for licensing and that this space is still on the school property.
North Carolina Child Care Law and Rules I have received a copy of the North Carolina Child Care Law and Rules from the YMCA.
Registration Paperwork Signature on this document indicates responsibility for payments and is the only one who can alter the
forms.
Sunscreen: (initial the appropriate statement)
______ I allow YMCA staff to provide NO-AD 45 sunscreen for my child (sunscreen product information available by request).
______ I will provide sunscreen for my child (in an individual bottle labeled with their name and date stored in a zip lock bag)
School Success I understand that the YMCA works with the Buncombe County and Asheville City Schools to develop and deliver
activities that engage and impact children. I give permission for YMCA staff to talk with school staff in regards to my childs grades,
behavior and other information.
Behavior Management Policy: I have read this policy in the Handbook and agree with all policies as outlined.
YMCA Statement I hereby, for myself, my family, heirs, executors, and administrators, waive and release any and all claims and
damages I may have against the YMCA of Western North Carolina and their respective agents, representatives, successors, and
assigns, for any and all injuries which may be suffered by me or my family in connection with participation in YMCA activities and
programs. I agree to adhere to all policies as outlined on this policy/signature page. I also grant full permission to the YMCA to use
any photographs or video recording taken of me or my family. I agree to comply with YMCA policies and procedures and understand
that my participation can be terminated without refund for exhibiting inappropriate behavior or abuse toward the YMCA staff and/or
facilities.
Parent/Guardian Name:__________________________________________ Parent/Guardian Signature:_________________________
(please print)
Childs Name:_____________________________________________________________________ Date:________________________
CHILDS NAME
_________________________________________________________________
YMCA OF WESTERN NORTH CAROLINA
CHILD CARE SERVICES YMCA
Draft Agreement
SCHOOL LOCATION
PARENT INFORMATION
Title (Mr., Ms., Dr.)
First Name
MI
Street
City
Preferred Phone # for us to reach you
Email Address
Last Name
State
Zip Code
BANK DRAFT ENROLLMENT
Please initial:
_____ Drafts for child care payments will be deducted from your account on the WEDNESDAY PRIOR the week of child care. The first
draft date will be August 28, 2013 for the week of September 2nd, 2013.
_____ Any failed draft will be subject to a $20 Late Fee and a $25 Insufficient Funds Fee.
_____ You are required to give a 30-day written notice prior to your draft date of any cancellation/change.
_____ This draft agreement will expire on the Thursday prior your childs last day of school/camp or 30 days from written notice prior
to your draft date of any cancellation/change.
_____ I understand there are NO refunds given. It is my responsibility to check my bank statements and report any corrections.
_____ I understand that I will not receive a statement or billing from the YMCA.
Please check:
_____ Draft from my checking account (please attach a voided check.).
_____ Draft from my savings account. Routing #:________________________________________ Acct #:___________________________ ____________
_____ Draft from my credit/debit card. Please bring your card with you to Child Care Services when registering, or a YMCA Staff
member will call to collect your account information.
Healthier Communities Campaign donation: This is a tax-deductible donation.
______Healthier Communities Campaign one time gift of $______
OR: **Draft Date is the 10th of Every Month**
Campaign donation drafted monthly from my account
____$5
Healthier Communities Total Contribution
Beginning Draft Date ___/___/___ End Draft Date ____/___/___
$_________
____$10 ______Other
Recognition Name: __________________________________________________________
In making this pledge, I agree to honor its payment regardless of continued participation in child care or YMCA membership.
Signature:________________________________________________________________________________________________________________ Date _____/_____/_____
OFFICE USE ONLY
Registration Fee Amount $__________ Draft Amount $_______________ Beginning Draft Date _____/_____/_____
Staff Signature:_________________________________________________________________________________________________________
Date_____/_____/_____