Tri-County Ymca Afterschool Program Registration Form

TALENT RELEASE FOR PHOTOGRAPHY, VIDEOTAPE, AND AUDIO PRODUCTIONS

I hereby release the Tri-County YMCA from any forms of remuneration involving the current or future use of

photographs, videotapes, or audio recordings for which I have performed.

This statement is hereby acknowledged and agreed upon by me with the full understanding that any photographs,

video, or audio tapes will be freely used by the Tri-County YMCA for public display in either printed or electronic

material for the purpose of furthering the business of the Tri-County YMCA.

Signature______________________ Date_______________

PAYMENT POLICY

Please read and initial the following:

______ I, ___________________________________, (Parent(s) responsible for payment) hereby agree

to accept full responsibility for all fees required for my child(ren) to attend the Tri-County YMCA

Afterschool Program.

______ Payment is due the Friday of the week your child(ren) attends the afterschool program.

______ If the payment is not received within 7 calendar days, an invoice will be sent to the parent(s).

______ If the payment is not received within 14 calendar days, this will result in suspension from the

program. A child can be reinstated after the payment is received and approved by the Afterschool

Coordinator.

______ Parents arriving after 6:00 pm to pick up their child(ren) will be charged a late fee of $1.00 per

minute per child. This fee will automatically be charged to the account.

*If there are extenuating circumstances, please discuss this with the Afterschool Coordinator to see if

alternative arrangements can be made.

* Credit card payment is available upon request. Please contact the Afterschool Coordinator for

paperwork.

Signature:_______________________________

Date:_____________

AFTERSCHOOL FEES

With the generous support of local donors during our Annual, Campaign, the Tri-County YMCA is able to provide a

pricing structure based on financial need. This structure will follow the free/reduced school lunch program. Please

indicate which category applies to you:

Regular Lunch at School:_______

Reduced Lunch at School: _______Free Lunch at School:______

I, _______________________, hereby give the Tri-County YMCA authorization to contact my

child’s school to verify the type of financial assistance I receive. I also give permission to the

school corporation to release the information to the Tri-County YMCA.

Signature:_______________________________

Date:_____________

Please return completed registration form and registration fee to:

Staff use:

Tri-County YMCA

Attn: Afterschool Program

Please contact Jami Ferguson

____ Entered in Trinexum

131 E 16

with any questions.

Ferdinand, IN 47532

Amount Paid: ______

_____ File Copied

Tri-County Ymca Afterschool Program Registration Form - 2016-2017 Page 2

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