Preschool Extended Child Care Registration Form (Page 2 of 2) in pdf

STATISTICAL INFORMATION (CONFIDENTIAL) Other funding agencies such as the United Way and the Commission on

Children and Families request the following information for statistical purposes only and is completely voluntary.

Ethnicity:

Monthly Gross Income:

Household Status:

 White/Caucasian

 $0-$500

 Single Parent

 Black/African American

 $501-$1000

 Dual Parent

 Native American/Alaska Native  $1001-$1597

_____# of people in household

 Asian

 $1598-$2000

 Asian Indian

 $2001-$2500

 Hispanic/Latino

 $2501-$4021

 Hawaiian/Pacific Islander

 $4022+

 Other______________

Your signature below acknowledges you have read and agree to these terms and conditions:

MONTHLY PAYMENTS: Full payment is due by the 1

business day of each month. Failure to remit full payment

by the 5

will result in a discontinuation of services (Program Lockout). Refunds and/or credits will not be granted

for days missed due to absences and/or vacations. A $25.00 fee will be assessed for all returned payments.

CHANGES/CANCELLATIONS: In order to assure processing, 14 days notice is required for changes or

cancellations and fees remain the same unless 2 week notice is given in writing to the YMCA. For changes or

cancellations please contact the Child Care Office, 541-772-6295 ext.108.

LATE PICK-UP: Late fees will be charged for each child picked up after the scheduled closing time. Failure to pay

may result in termination of care. Late fees are as follows: 1-15 minutes = $15 per child. Each minute following

the first 15, is $1 per minute per child. Chronically late pick-ups will be grounds for dismissal from the program.

If no one can be reached by 1 hour after closing, the police will be called to escort your children to Protective

Services for child abandonment.

THIRD PARTY PAYMENTS: The YMCA accepts third party payments, (i.e. DHS), once written verification is

received from the third party. Fees accrued prior to the effective date, uncovered portions, and vouchers not

signed in a timely manner, are the responsibility of the parent or guardian.

CONFIRMATION:

I have read the policies, terms and conditions as stated above and agree. I hereby agree

for myself, my child, our respective heirs and legal representatives, to release, indemnify, and hold the YMCA and

its officers, directors, board members, employees, volunteers and agents (“releasees”) harmless from any and all

claims and causes of action of any nature, whether caused by the alleged negligence of the releasees or otherwise,

which I or my child may now or hereafter have against the releasees which may at any time arise as a result of any

act or thing occurring in or arising out of my or my child’s participation.

I have read and understand this waiver.

Print name:

Signature:

Date:

For identification purposes please list one:

Social Security #:

Driver’s License:

____

_____

_______

__________

Office Use Only:

Registration Fee

______________

Monthly Fee

______________

Total Paid at Registration

______________

Staff member taking form:

Date:

______________________________________________

_____________________________

Rogue Valley Family YMCA

522 West Sixth Street ● Medford, OR 97501 ● ● Phone: 541-772-6295 ● Fax: 541-772-8427

Preschool Extended Child Care Registration Form Page 2

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