Before/after School Registration Form - Ymca Of Metropolitan Chattanooga printable pdf download

Mark Branch of Choice

For Office Use Only-Weekly Fee:

___Downtown

___Cleveland

YMCA Member ______

Case Manager ________

Non-Member ________

Registration _________ __

___Hamilton

___Rhea

Scholarship ________ _ _

Paid/Date ____________

Certificate Fee _______

Staff Initials _______ ____

A P P L I C A T I O N

___Henry

___North Georgia

Child’s Information:

(Please, only one child per registration form.)

Child’s Name_________________________________________________________________ SS# (last 4 digits)______________

School_____________________________________ Grade______ Location________________________________ ____________

Birthday________________________ __________________________ Male __________ Female __________ Age __________

Hair Color ______________ Eye Color ______________ Height ____________ Weight ___________ Build ____________

Parent/Guardian’s Information:

Mother’s Name: _______________________________________ Birth Date: _________ Home Phone: ___________________

Father’s Name: ________________________________________ Birth Date: _________ Home Phone: ___________________

Address: _____________________________________________ _ _____________________________________________________

City: _______________________________________________________________ State: ______ Zip: ______________________

Email address: _______________________________________________________

Mother’s Employer: ___________________________ Work Phone: ___________________ Cell Phone: ___________________

Father’s Employer: ____________________________ Work Phone: ___________________ Cell Phone: ___________________

GIVE NAMES AND PHONE NUMBERS OF TWO PEOPLE TO CALL IF YOU CANNOT BE REACHED:

Emergency #1: ___________________________ Relationship: ________ Work #: ___________ Home #: ___________ Cell #: ___________

Emergency #2: ___________________________ Relationship: ________ Work #: ___________ Home #: ___________ Cell #: ___________

Physician: _______________________________________________________________________Phone: ___________________

Insurance Company: __________________________________________________ Policy # _____________________________

(Please include a copy of insurance card)

LIST NAMES AND PHONE NUMBERS OF PERSONS AUTHORIZED TO PICK UP YOUR CHILD:

Name

: __________________________________ Relationship: ________ Work #: ___________ Home #: ___________ Cell #: ___________

Name

: __________________________________ Relationship: ________ Work #: ___________ Home #: ___________ Cell #: ___________

Name

: __________________________________ Relationship: ________ Work #: ___________ Home #: ___________ Cell #: ___________

LIST ANYONE NOT AUTHORIZED TO PICK UP YOUR CHILD: (Please Explain)

Name: _____________________________________________________________________________________________

(If the person is a legal parent/guardian you must have legal documents from the court stating this person is not allowed to pick up your child.)

DOES YOUR CHILD HAVE ANY PHYSICAL CONDITIONS OR ALLERGIES THAT WE SHOULD KNOW ABOUT?

___________________________________________________________________________________________________________

My signature below indicates that this registration form is correct to the best of my knowledge and the child herein described has permission to engage in all

prescribed activities except those noted by me. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by

the adult leader in charge to hospitalize, secure proper anesthesia, or to order injection or surgery for my child. I have read the rules and policies of the

YMCA Child Care program and understand the YMCA adheres to these rules. I agree to follow the policies of the YMCA. I understand that my failure to do

so may result in our being discharged from the program. I understand that payment is expected in advance and that there will be a late fee assessment

should I neglect to pay on time. I understand that the YMCA is mandated by law to report any suspected child abuse or neglect to the appropriate

authorities for investigation. I hereby consent to the use of my child’s likeness in photographs, film, videotape or

website for use in editorial, illustrated or promotional purposes.

Parent/Guardian Signature: _______________________________________________________________ Date: ___________________

The YMCA considers all registrations without regard to race, color, religion, sex, national origin, or the presence of medical condition or

handicap. However, the YMCA does reserve the right to refuse admission to any child who may require a level of attention beyond that which

the YMCA programs are designed to accommodate or who may require specialized training that may prevent the YMCA staff from adequately

meeting the needs of the child. Limited financial assistance is available.

Before/after School Registration Form - Ymca Of Metropolitan Chattanooga

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