Platte County School District Y Club Before And After School Program Enrollment - 2015-2016 Page 3
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4PLATTE COUNTY SCHOOL DISTRICT
Y CLUB BEFORE AND AFTER SCHOOL
PROGRAM ENROLLMENT
2015-2016
For Office Use Only:
Customer ID
Program Director
Signature
Date Processed
Please print neatly and complete all sections. Incomplete or illegible registration forms will not be processed.
Participant Information
Child’s Name
Date of Birth
Grade in School-Fall 2015
Male
Female
Address
City
State
Zip
Primary Guardian Name
Employer
Primary Phone
Mobile Phone
Email
Phone Carrier
I would like to receive text alerts regarding Y Club.
Secondary Guardian Name
Employer
Primary Phone
Mobile Phone
Email
Phone Carrier
I would like to receive text alerts regarding Y Club.
Enrollment Information
School Name
Program:
Full-Time Before AND After School $64.00
Full-Time Before School Only $41.00
Full-Time After School Only $47.00
Part-Time Before School Only $34.85
Part-Time After School Only $39.95
Part-Time Before AND After School $54.40
Pirate Perks After School Only $40.00*
Pirate Perks Before School Only $20.00*
No School Day/Drop-In Only
If Part-Time:
Monday
Tuesday
Wednesday
Thursday
Friday
• Part-Time: care is 1 to 3 set days per week. Part-time care is offered on a limited basis.
• Full-Time: care is 4 to 5 set days per week.
* Pirate Perks available to Platte County RIII School District employees.
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