Ymca Loudoun County Form (Page 2 of 4) in pdf

YMCA Children’s Program

: _____________

Program Year

(√) the program registering for:

Payment per month

_____ AM YMCA Kindergarten Enrichment at Buffalo Trail Elementary School

$350

_____ PM YMCA Kindergarten Enrichment at Buffalo Trail Elementary School

$350

_____ AM YMCA Kindergarten Enrichment at Buffalo Trail ES + My Place After School Program

$658.75

(Full time, 5 days a week)

_____ PM YMCA Kindergarten Enrichment at Buffalo Trail ES + My Place After School Program

$658.75

(Full time, 5 days a week)

_____ AM YMCA Kindergarten Enrichment at Buffalo Trail ES + My Place After School Program

$568.50

(Part time, 3 or fewer days a week)

Mon

Tue

Wed

Thu

Fri

_____ PM YMCA Kindergarten Enrichment at Buffalo Trail ES + My Place After School Program

$568.50

(Part time, 3 or fewer days a week)

Mon

Tue

Wed

Thu

Fri

_____ My Place after School Program at Elementary School (Full time, 5 days a week)

$325

_____ My Place after School Program at Elementary School (Part time, 3 or fewer days a week)

$230

Mon

Tue

Wed

Thu

Fri

_____ My Place after School Program at Lunsford or Sterling Middle School

$250

REGISTRATION AGREEMENT

1. Completed registrations are accepted on a first-come, first-served basis.

2. Part time days are nontransferable. A $35 penalty will be assessed if a child attends a day they are not enrolled for. To change child’s

enrollment status to/from part time, a written notice is required two weeks in advance.

3. There is a non-refundable $35 registration fee ($35 for one child or $60 for more than one). This fee is good for one calendar year and maybe

used for participation in other programs at the YMCA Loudoun County such as Summer Day Camp.

4. Payments must be made through EFT (Electronic Fund Transfer) by Credit Card, Bank Account or Check Card. Payment can be drafted only from

one account per month. Payments will be withdrawn on or about the 10

of the month. Payments are made one month in advance.

5. Withdrawal from the program will require a 30 day written notice (no exceptions) and must be made between the 1

and 5

of the month. Any

notice received after the 5

of the month will result in an additional payment. If fees have been paid out but the cancelation is made with less

than 30 days notice, no fees will be returned.

6. Fees are due on the 10th of the month, unless this day falls on a weekend or business holiday. Then fees will be due the following

business day. Late payments will incur a $20 charge. If fees are not paid within two weeks of the due date, the child/children will be removed

from the program and must be reregistered before returning.

7. YMCA child care programs follows the Loudoun County Public Schools calendar. If school is not in session for any reason there will be no

afterschool care. There are no refunds of tuition for snow days, early release due to weather, teacher work days, holidays, or extended school

breaks. There are no refunds for absence caused by illness or vacation.

8. If a child is withdrawn/removed, they may re-register, if space is available.

9. All returned checks will incur a $20 processing fee. Any bank draft payments returned with insufficient funds will incur a $20 processing fee.

10. There is a late pick-up charge of $2 per minute after 6 PM for after school at elementary school and 6:15 PM at middle school

11. Field trips may be part of program activities and parents/guardians will be notified in advance of dates, destinations, times, and pick up

locations.

12. Students attending certain schools may be transported by YMCA vehicle to MY Place afterschool program sites.

13. Electronic version of parent handbook is issued to every family. You are expected to read and abide by the information in the handbook. A

Participant may be removed from the program if the rules, regulations, and guidelines in the Parent Handbook are not followed by either the

parents/guardians or the child.

I have read and understand the registration agreement and agree to abide by these rules and those of the YMCA. I also

acknowledge that I received the YMCA of Metropolitan Washington’s MY Place Parent Handbook. I agree to observe the

Association’s policies and procedures as outlined in the Parent Handbook and understand that these policies may be amended

periodically. I understand that explanations of these policies will be provided upon request. I also understand that I assume

responsibility for reading notices that may be sent to my attention or posted in the YMCA’s facilities.

______________________________________________

Parent/ Guardian Signature

Parent/ Guardian Printed Name

Date

FOR YMCA Use Only:

Proof of Age and Identity

______________________

_____________________________

_______________

Form Type

Place of Birth

Certificate #

Date Issued

) _______________

___________

VA Commonwealth School Entrance Health Form (3 pages – physical and immunization records

Forms Reviewed by

Date received

Ymca Loudoun County Form Page 2

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