School Aged Child Care Registration Form - Michiana Family Ymca (Page 3 of 4) in pdf

CHILD CARE PROGRAM CONTRACT

I/We understand and agree to the following:

I am an adult over 18 years of age and my children or dependants wish to participate in the Michiana Family YMCA program activities. I, my

spouse, agree to hold free from any and all liability the YMCA of Michiana, Inc. and its respective officers, employees, and members and do

hereby for myself, my heirs, executers, and administrators, waive, release, and forever discharge any and all legal rights to claims for

damages which I or my family to us arising out of, or connected with our participation in any of the activities of the Michiana Family YMCA.

I, my spouse, children and dependents, do declare ourselves to be physically sound, to participate in the activities of the Michiana Family

YMCA.

I/We understand that a staff member must be aware of my child’s arrival and departure and that my child must be signed in and out of the

program by an adult for be released to those authorized on the pick-up list. A photo i.d. is required for all.

I/We understand that early drop-off and late pick-up is not acceptable. $1 per min. fee will be charged.

I/We understand that YMCA Staff Code of Conduct prohibits YMCA Staff from being alone with children they meet in YMCA programs outside

of the YMCA. This includes sleepovers and inviting children anywhere off-site. Staff is not to transport program children in their personal

vehicles. I/We will report suspicious behavior to the Director of Youth Development.

Authorization:

I hereby give permission for my child to participate in scheduled field trips, walking trips and other special events held outside of the YMCA or school

home sites.

I/We do hereby grant permission for photos of my/our child to be used by the YMCA for promotional and educational purposes.

I authorize the release of any behavior or academic information from the contracted schools or appropriate agencies to the YMCA of Michiana Youth

Development Coordinator for behavior plan and/or funding purposes.

I have read, understand, and agree to abide by all policies. I acknowledge this to be a legal and binding contract.

____________________________________________________________

_________________

Parent Signature

Date

Parent/Guardian Signature ___________________________________________________________________

Date ______ / ______ / _______

MICHIANA FAMILY YMCA

1201 Northside Boulevard, South Bend

(P) 574 287 9622 (F) 574 282 3752

(W)

School Aged Child Care Registration Form - Michiana Family Ymca Page 3

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