School Aged Child Care Registration Form - Michiana Family Ymca
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4SCHOOL
GRADE
School Aged Child Care Registration Form
2015-2016 School Year Programs
* Incomplete forms will not be accepted. Please be as detailed as possible.
PARTICIPANT INFORMATION
_______________________________________________
Birthdate _______ / ______ / _______
Age ________
Male
Female
Child’s Name (First, Middle Initial, Last)
_______________________________________________
__________________________________________
_______________________
Street Address (Child’s residence)
City
State
Zip
Home Phone Number
PARENT/GUARDIAN INFORMATION
_______________________________________________
____________________________________________________________________
Primary Care Parent/Guardian
Street Address (if different than child’s)
City/State Zip
___________________________
________________________
________________________
_______________________
Best Contact Phone Number
Alternate Phone Number
Employer
Employer Phone Number
_______________________________________________
____________________________________________________________________
Secondary Care Parent/Guardian
Street Address (if different than child’s)
City/State Zip
___________________________
________________________
________________________
_______________________
Best Contact Phone Number
Alternate Phone Number
Employer
Employer Phone Number
___________________________
______________________________________________________________________________________
Marital Status/Custody Arrangement
E-Mail Address (Providing your e-mail allows us to communicate with you through e-mail for updates on our
program)
EMERGENCY/PICK UP INFORMATION
Please provide complete information for anyone with your
permission to pick up your child other than yourself or the above
named parent/guardian.
Name
Relationship to child
Address
Phone Number
_____________________________
___________________________
__________________________
_______________________
_____________________________
___________________________
__________________________
_______________________
_____________________________
___________________________
__________________________
_______________________
PROGRAM REGISTRATION
REGISTRATION FEE $30/$50,
Waived for Full/Program/AWAY Members
BASE
SOYI
HOLIDAY DAY CAMPS
These weekly fees include SOYI Days:
YMCA Afterschool $50/$60
-In $40
-$150
Dec. 21, 2015 – Dec. 31st , 2016
avier Before and After School $50/$60
$22-$150
Spring Brk. Day Camp
th
th
-In $12
April 4
– 8th
, 2016
School Drop-In $5
Drop-In Wed. Only $17/$27
-In (Ex. Wed) $12
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