Fremont Newark Ymca Summer Child Care Registration Form
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1
2FREMONT/NEWARK YMCA
SUMMER CHILD CARE
REGISTRATION FORM
Child’s Name: First _______________________________________ Last ___________________________________________ Birthdate: _____ /_____ /_______ Age ________
Home Address: __________________________________________________________________ City: _________________________ Zip: __________________
Grade (Fall 15): _____________ Home Phone: _________________________________________ Currently Enrolled in a Y-
No
Name of current Y-Kids Program: __________________________________
(First time enrollees must fill out a Licensing Packet prior to starting.)
Parent/Guardian Name: _________________________________________________________________________________________________ Birthdate: _____ /_____ /_______
Cell #: _________________________ Work #: _________________________ Emergency #: _________________________ E-mail: _______________________________________
Employer: _____________________________________________________________________ Occupation: ________________________________________________________________
Parent/Guardian Name: _________________________________________________________________________________________________ Birthdate: _____ /_____ /_______
Cell #: _________________________ Work #: _________________________ Emergency #: _________________________ E-mail: _______________________________________
Employer: _____________________________________________________________________ Occupation: ________________________________________________________________
Membership, Child Care Payments, and Cancellation/Transfer Policy
• DEPOSITS: I understand that deposits are $25 per week and are
• By signing up for the programs indicated below, I understand and
nonrefundable. Payments in full are due 2 weeks before program start.
accept the above policies and I am responsible for payment:
• I understand my registration will be cancelled if the balance is not
_______________________________________________________________________________________
paid two weeks before the start of each session.
(Parent/Guardian’s Signature)
• PROGRAM MEMBERSHIP: I understand that my child needs to have a
program membership to participate. Program memberships are $40 and
Credit Card Withdrawal Authorization
are an annual fee. All new families are required to pay this in addition
to the $40 registration fee.
(Please check only one) _____ Deposits only ______ Balances as due
I authorize the YMCA to draft the credit card listed below for the
• CANCELLATIONS: may be made in writing up to 2 weeks prior to the
payments indicated above. I understand that fees will be charged
start of the session to receive a refund less deposit. Otherwise,
2 weeks before the start of each session and that I must notify the
payments made will not be refunded.
office in writing before that time if plans have changed and my
• TRANSFERS: may be made in writing up to 2 weeks prior to the start
child(ren) will not attend one or more camps.
of the session. Transfers are granted only if there is room in the
Visa/MC# __________________________________________ Exp. Date _______/_______
program you want to transfer in to. Changes will not be accepted after
Signature _____________________________________ Today’s Date_____/_____/_____
the 2 week deadline.
Session
School Age Child Care Location
Fees
Payment Made
Balance Due
Final Payment
(Durham OR Forest Park)
Due By
June 15-19
$199
June 1
June 22-26
$199
June 8
June 29- July 2*
$189
June 15
July 6-10
$199
June 22
July 13-17
$199
June 29
July 20-24
$199
July 6
July 27-31
$199
July 13
August 3-7
$199
July 20
August 10-14
$199
July 27
August 17-21
$199
August 3
June Bundle (June 15-26)
$350
June 1
July Bundle (June 29- July 31)
$875
June 15
August Bundle (Aug 3- 21)
$525
July 20
June 22- July 17 (Session 1)
Blacow Kinder Readiness Camp
$300
June 8
July 20- August 14 (Session 2)
Blacow Kinder Readiness Camp
$300
July 6
* No Program on July 3
rd
in observance of Independence Day
*Additional $40 membership fee required for new members
Office Use Only:
REGISTRATION FEE
$40
Participant is enrolling in these programs with subsidy funds paid for by:
TOTAL DUE
____ YMCA Financial Assistance ____ Other 3
Party Agency (Agency Name ______________________)
rd
TOTAL PAYMENT
(A YMCA FA approval letter or agency contract must be included at the time of registration.)
____ ALL Licensing Paperwork Completed
Staff Signature: _________________________________________
BALANCE DUE
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