2002 YMCA SUMMER DAY CAMP REGISTRATION FORM

							School Name: ______________________________________________________                                                                   Grade: __________________
 5-Day Program               4-Day Program                       3-Day Program                    2-Day Program                   Starting Date: ____________
         *4, 3, and 2-Day Programs must also submit a calendar with the days they will attend for each session. Days must be consistent (i.e. Mondays and Wednesdays for all 4-Weeks).

Student’s Name           _____________________________                          ____________________________                          Nickname ___________________
                         First Name                                             Last Name

    DOB_____/_____/_____                      Age_______                         Male OR  Female                                    SSN# ______-______-_________
    Who does child live with? __________________________________                                              Relationship? _____________________________
    Who is responsible for payment of childcare? ___________________________________________________________________
Father/Guardian _____________________________                                   _____________________________                         SSN# ______-______-_________
                         First Name                                             Last Name

    DOB_____/_____/_____                      E-mail Address __________________________________________________________________
    Address _____________________________________                                     City_________________________                         State_______ Zip_________
    Please Check the Phone Number best to reach you at:
    Home Phone (____) _______-________                           Cell/Pager (____) _______-_________                         Work Phone (____) ______-________

Mother/Guardian              ____________________________                          ___________________________                        SSN# ______-______-_________
                             First Name                                            Last Name

    DOB_____/_____/_____                      E-mail Address __________________________________________________________________
    Address _____________________________________                                     City_________________________                         State_______ Zip_________
    Please Check the Phone Number best to reach you at:
    Home Phone (____) _______-________                           Cell/Pager (____) _______-_________                         Work Phone (____) ______-________
Emergency Contact Other than Parent/Guardian
    (Must have parent’s permission to make appropriate decisions for child in case parent can’t be immediately reached)

    Name _______________________________________________________                                                     Relationship to Child__________________________
    Daytime/Work Phone(s) ________________________________________                                                   Other Phone(s) ______________________________

Authorized persons to pick-up child (other than the above guardians and emergency contact):
* Anyone picking up a child must be listed on child’s registration form and needs to carry a photo ID and YMCA Program Card on them for identification.

    Name________________________________________________                                               Phone(s) _______________________________________
    Name________________________________________________                                               Phone(s) _______________________________________
    Name________________________________________________                                               Phone(s) _______________________________________

    *Persons NOT allowed to pick-up child: __________________________________________________________
         *Appropriate paperwork such as custody papers is needed immediately if a parent is not allowed to pick up a child

Medical Information (Parent’s Insurance is Primary):
    Child’s Physician________________________________________________________                                                  Phone (______) _________-____________
    Child’s Dentist__________________________________________________________                                                  Phone (______) _________-____________
    Family Medical / Hospital Insurance Carrier___________________________________                                             Policy Number ______________________
Background Information
    Does your child have any special problems or needs? If so, please list and explain. ____________________________________________
         __________________________________________________________________________________________________________
    Does your child have any allergies? _________________________________________________________________________________
    Does your child take any kind of medication? _________________________________________________________________________
    Any other information we should know about your child? _______________________________________________________________
         __________________________________________________________________________________________________________
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                                 2009-10 YMCA AFTERSCHOOL REGISTRATION FORM
                                                                              PAGE 2

Afterschool Authorizations (Check if Yes or No):
 Authorization for Swim and Activity Participation & Transport
 I understand that my child is responsible for his/her belongings and his/her behavior. I authorize and give my permission for my child
 to participate in all program activities, unless notified in writing. This includes water activities and YMCA transportation while staffed
                                                                                                                                                   
 by the YMCA or other related personnel. Some field trips require an additional fee or I may be asked to contribute items for special         Yes   No
 activities.


 Authorization for First-Aid / Emergency Medical Care
 I hereby grant my permission to YMCA staff and /or medical personnel to give my child first-aid. In the event of an emergency, I give
                                                                                                                                                   
 my permission to medical staff selected by YMCA staff to secure and administer treatment (including hospitalization) and provide
 necessary transportation for my child as named above. I understand that the YMCA will notify me as soon as possible in the event of          Yes   No
 illness, injury, or emergency. If requested or required, I agree to pick up my child.


 Agreement of Fees and Attendance
 Fees are to be made payable to the Bristol Family YMCA and paid at the Business Desk of the YMCA over the counter, by draft or
 mail to: 400 MLK JR. Blvd., Bristol TN 37620. I agree to accept full responsibility for my child(ren)’s fees, payable in advance
 monthly. Any fees not paid in advance are subject to a $15.00 late fee charge. I understand that since payment is due in advance,
 unless previous arrangements have been made, more than two weeks of non-payment will result in automatic suspension from the
 program. If I default on fees I understand that I will be responsible for the costs of collection. There are no refunds or credits for
 absences, sickness, mishaps, or holidays. Registration fee is non-refundable and non-transferable. Refunds will only be considered by
 the Program Director in extreme circumstances. I am to receive a receipt for all payments, which I need to keep in my files.
                                                                                                                                                   
 I understand there is a late fee of $1.00 for the first 5 minutes and $1.00 for each additional minute per child for any pick-up after       Yes   No
 5:45pm.

 The 5-Day Afterschool Program includes all half days and in-service days. Spring Breaks are a part of the session fees. Christmas
 Break is at an additional fee and I will need to notify the YMCA of my child’s attendance prior to the break.

 I understand that the YMCA must receive a written, two-week’s notice if I want to terminate enrollment or be subject to pay
 for that two weeks.

 Suspension Information
 I will be notified if the inclusion of my child is not in the best interest of the Program or the child (endangerment, discipline, and            
 disrespect). If the situation can not be resolved, the YMCA reserves the right to suspend or remove any child from the program at my         Yes   No
 cost.


 Photo Release                                                                                                                                     
 My child may be photographed. The YMCA reserves the right to use this photo for YMCA promotions only.                                        Yes   No

 Insurance                                                                                                                                         
 The parent and/or guardian is responsible for all medical coverage in the event of an accident/emergency.                                    Yes   No

 Scheduled Early Dismissal and School Out Days
 I understand that on scheduled early dismissal days, my child will be staying at his regular extended day site & will need a nutritious           
 lunch & drink sent with him if the school isn’t providing it (no soda-100% juice, milk.) On School Out days, I will need to transport my     Yes   No
 child to and from the YMCA on M L King Jr Blvd.


 Snow (Bad Weather) Dismissals and Transportation:
                                                                                                                                                   
 I understand that I am responsible for transporting my child to and from the YMCA site in case schools close for bad weather such as
 snow (unless the Y is closed-listen to the news on TV or radio.) I am also responsible for my child’s lunch on these days (no soda.)         Yes   No

 Parental Agreement
  I will communicate with YMCA Staff if I have concerns. I will keep the staff informed of any communicable diseases that my child                 
 and/or family contract. I have received a parent handbook. I have read and understand all policies & agree to abide by the policies of       Yes   No
 the Bristol Family YMCA.


The Bristol Family YMCA reserves the right to remove any participant from our program if it is deemed that the inclusion of that child is not in
the best interest of the child or the program (child is not able to function consistently and safely in a 1:15 group setting).

Please Print Parent/Guardian’s Name              ___________________________________________________________

Parent/Guardian’s Signature _________________________________ Date: ____________________

                            Every blank must be filled in to make this registration valid