Platte County School District Y Club Before And After School Program Enrollment - 2015-2016 Page 4
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2
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4Child’s Name
Last Name
First Name
Payment Information
PAYER INFORMATION: A person, other than the primary guardian may pay for the weekly payments. If the person who will be
responsible for payments is different than the primary guardian please complete this section. Each account may have one payer.
Splitting balances between multiple parties is not available.
Payer Name
Payer Phone Number
Address
City
State
Zip
Y CLUB WEEKLY PAYMENT OPTIONS
Pay by check/money order at site weekly on Monday
Draft by credit card/checking account weekly on Sunday
For automatic drafts please select one of the following account options
Please draft from my card information below
Please draft from my attached VOIDED checking account information
Registration fee and first week's tuition amount $
(Registration WILL NOT be processed without payment)
Check #
Visa
MasterCard
Discover
American Express
Card Account #
/
/
/
Expiration Date
month/year
I understand that the registration fee is non-refundable and non-transferable, except for medical reasons, in which case a doctor's note
must accompany a refund or transfer request. I understand that my child may not attend the Y program until the Emergency Information
Packet, which includes Enrollment Form, KDHE Health History Form and notarized authorization for emergency medical care, is completed
and provided to the Y Club at the school they will be attending.
I acknowledge that I have read the Y Club Before and After School Program information sheet.
Parent Signature
Date
FINANCIAL ASSISTANCE
Based on the available contributed resources through the Y's Annual Campaign, the Y provides financial assistance to those in
need that wish to participate.
Because we are committed to your privacy, we do not accept registration forms or payments via email.
WALK-IN
MAIL-IN
FAX
Youth Development Services
YMCA of Greater Kansas City
816.931.1847
8205 W 108th Terrace, Suite 120
3100 Broadway, Suite 1020
Overland Park, KS 66210
Kansas City, MO 64111
Phone: 913.345.9622
Revised 05.05.15
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