Enrollment/emergency Information Form - Safe 'N Sound

SAFE ‘N SOUND

A before- and after-school program

2016/2017

ENROLLMENT/EMERGENCY INFORMATION FORM

I am registering for:  5 Days  3 Days - Please indicate days:  M  T  W  TH  F

I am registering for:  Safe ‘n Sound AM Only  Safe ‘n Sound PM Only  Safe ‘n Sound AM & PM

(Please Print)

Start Date: __________

School: __________________________

Grade ‘16-’17: _____

Birthdate: ____________

Child’s Name: _________________________________________________________________________________________________________________________________________________________________

Gender (circle one): M

Race/Ethnicity: ___Asian ___Hispanic ___Black ___White ___ Other _________________

Home Address: _________________________________________________________________________________________________________________________________________________________________

City: ___________________________ Zip: _____________ Parent e-mail address: ________________________________________________________________________________________________

This e-mail address will be used to send receipts and other important program information.

Home Phone: __________________________________

Child lives with:  Both Parents  Mother  Father  Other ______________________________

Mother/Guardian: ______________________________________________________________________________________________________________________________________________________________

Business Name & Address: __________________________________________________________________________________________________________________________________________________

Work Hours: ______________________________________________________________

Work Phone: _____________________________________________________________ ext. ___________

Cell Phone: ________________________________________________________________

Other: _______________________________________________________________________________________

Father/Guardian: _______________________________________________________________________________________________________________________________________________________________

Business Name & Address: __________________________________________________________________________________________________________________________________________________

Work Hours: ______________________________________________________________

Work Phone: _____________________________________________________________ ext. ___________

Cell Phone: ________________________________________________________________

Other: ________________________________________________________________________________________

Siblings:

name _____________________________________________ age ______

Emergency Contacts (Other Than Parent/Guardian) and Persons Authorized to Pick Up My Child

I, ____________________________, authorize the YMCA to release my child to the following persons when I am unavailable. I understand that I must

inform the Safe ‘n Sound program office of any changes to this list. They must show valid photo I.D.

Name

City

Phone

Relationship

1. __________________________________________________ _______________________ ________________________________________________ ________________________

2. __________________________________________________ _______________________ ________________________________________________ ________________________

3. __________________________________________________ _______________________ ________________________________________________ ________________________

4. __________________________________________________ _______________________ ________________________________________________ ________________________

Monthly Payments – I understand that monthly payments are due on the 1st of each month by automatic draft payment. Payments must

be made on time in order for my child to attend the Safe ‘n Sound program.

2-Weeks Notice – I understand that if I remove my child from the program or make changes to my care option without giving two weeks

notice, I will be responsible for payment until changes are processed.

Signature of Parent/Guardian __________________________________________________________________________________________________________________________________________

Enrollment/emergency Information Form - Safe 'N Sound - 2016/2017

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