Primetime YMCA of Topeka

2018-2019 Before/After School Program

The Y’s before and after school program employs mission Oriented team members who are active, engaging and responsible to work with your children. Based in area elementary schools, students in grades K-6 are nurtured in a comfortable, thought-provoking child care environment. Student’s needs are balanced with learning, physical activities and social skills. Crafts, games, tutoring and one on- one communication give children the opportunity to thrive by helping them learn and grow.

Sites are open before school at 7am and after school until 6pm.

Lowman Hill Stout Berryton SHES AM—$25.00 /week PM—$35.00 /week Diana McGuire—785-435-8635

LIFECHANGING Topeka YMCA | ymcatopeka.org | facebook.com/ymcatopeka

School Age Program

YMCA PRIME TIME-BEFORE & AFTER SCHOOL CARE

2018-2019 Enrollment Forms (Please Print) Account #

SCHOOL (Please Circle One):

Auburn 26501-008 Lowman Hill 35448-007

Berryton 14839-008 Shawnee Heights 487-007 DT Kid’s Club 14688-004

Farley 65756-007 Stout 61482-007 SW Kid’s Club 48554-007

Jay Shideler 712-008 Wanamaker 714-009

Start Date ___/___/___ Attended Prime Time Last Year? ___Yes ___No

__AM 7am to Bell __PM Bell to 6pm

Child’s Name: Date of Birth:__/__/__ Age: Grade in Fall of 2018:

Male or Female

Child’s Address: City/State/Zip:

Ethnicity: __Caucasian __African American __Hispanic __Asian/Pacific Islander __Other:________________

Primary Parent/Guardian Contact Information __Mother __Father __Other:____________________

Primary Parent/Guardian Name: Date of Birth:__/__/__ Cell#

Male or Female Home#

Home Address (if different from child): City/State/Zip: Work#

Custodial Parent: __Yes __No May the Y release to non custodial Parent? __Yes __No

Ethnicity: __Caucasian __African American __Hispanic __Asian/Pacific Islander __Other_________________

Email: Preferred Method of Communication:

__Email __Phone __Text __All

Primary Parent/Guardian Contact Information __Mother __Father __Other:____________________

Primary Parent/Guardian Name: Date of Birth:__/__/__ Cell#

Male or Female Home#

Home Address (if different from child): City/State/Zip: Work#

Custodial Parent: __Yes __No May the Y release to non custodial Parent? __Yes __No

Ethnicity: __Caucasian __African American __Hispanic __Asian/Pacific Islander __Other_________________

Email: Preferred Method of Communication:

__Email __Phone __Text __All

Emergency Contact/Authorized Pick Up (other than parents):

Name: Home Address: City/State/Zip:

Relationship to Child: Phone #: Driver’s License:

Additional Authorized Pick Up (other than parents):

Name: Address: Phone #:

Name: Address: Phone #:

Name: Address: Phone #:

YMCA Prime Time/Kid’s Club

Payment Agreement

.

Accounting Policies:

1. Acceptable payment form is: Electronic Funds Transfer (EFT) or advance payments made in full every

Friday prior to attendance the next week.

2. To secure your child’s spot, a one-time $15, non-refundable, registration fee is due at the time of

registration.

3. Drafts will be made by the close of business on Friday for the following week of prime time. Drafts will

be made each week unless a two-week written notification has been provided for cancellation.

4. The Y does not issue statements for individual tax purposes. Please keep any and all cancelled checks,

payment receipts or bank statements as documentation of childcare payments.

5. No adjustments in the weekly fee will be made for partially attended weeks.

6. If your payment is returned for insufficient funds (NSF), your payment along with an NSF service fee of

$25.00 will be collected electronically. Any change to your bank draft information must be received at

least seven days prior to the date the change is to take effect. A $10 late fee will be assessed on

payments not made by the deadline.

7. If full payment is not received, I understand that my child will be considered unregistered for prime

time and will not be able to attend until the payment is collected in full.

Payment Information:

Parent name_____________________________________ DOB________________

Child’s name ___________________DOB_______ Child’s name

_________________DOB______

__I will make advanced payments in full at the Y Member Service Desk at the time of registration.

__I receive third party payments, i.e. DCF/SRS, KVC, I understand that I am responsible for all

copayment. Fees and payments will not be determined by time sheets.

__I will be paying with electronic funds transfer. Information below is required with a voided check:

Bank name___________________________________ Bank City/State_________________________

Type of Account: __Checking __Savings

Print your name as it appears on the account: _____________________________________________

Bank routing number______________________ Account number _____________________________

__ I will be paying with a credit card: __Visa __ Mastercard __ Discover __ American Express

Card Number ________________________________ Expiration Date __________ 3-Digit Code ____

Print name as it appears on card _________________________________ Zip Code ______________

We have read the Accounting Policies and agree to comply with all payments and policies.

____________________________ ___________________________ _____________

Print Name of Authorized Signature Authorized Signature Date

Participant Health History and Information

Hospital preference (circle one): St. Francis Stormont Vail Other ____________________

Child’s Doctor:___________________________Address:_______________________________Phone#:______________

Is your child covered by insurance? __Yes __ No If yes please complete the following:

Health Insurance/Medical Assistance Name______________________________ Policy/Card number _________________

Military Medical Care I.D. Number_____________________________________

Check any conditions that your child has experienced:

__Asthma __Autism __Diabetes __Heart/Lung Conditions __ADD/ADHD __Cerebral Palsy/Other Motor Disorder

__Cognitive or Learning Disabilities __Status of Vision, Hearing, Speech to Note__________________________________

__Non-Food Allergies (list)_____________________________________________________________________________

__Food/Milk Allergies (list)_____________________________________________________________________________

If your child has food allergies or dietary restrictions, attach a statement from a medical professional. (REQUIRED)

__My child carries an epi-pen, inhaler or other medication. (additional medication form is required)

__Other conditions to note:____________________________________________________________________________

Please provide symptoms and/or special instructions for any condition marked above. (Additional form is required and notes

may be attached)____________________________________________________________________________________

Check any of the following that relate to your child:

__Fears we should be aware of: ________________________________________________________________________

__An event in your child’s life that may have been particularly upsetting: _______________________________________

__Social or emotional characteristic you would like to note: __________________________________________________

Other conditions requiring special care or additional information you feel would be helpful. (additional pages or notes may be

attached)___________________________________________________________________________________________

Please answer yes/no to each of the following:

___My child attended a public/accredited non-public school in Kansas, Missouri, or Oklahoma the previous year.

____I have provided a copy of immunization records for my kindergarten child along with this form.

____My child is current on his/her immunizations.

Is your child currently taking any medication during prime time? __Yes __No If yes, what kind and why (unless confidential

by law)? _____________________________________________________________________________________If any

medication (prescription or over the counter) is required during Y program time, a medication form MUST be completed.

The YMCA of Topeka has my permission to: (initial each line)

____ Involve my child in swimming

____ Involve my child in field trips

____ Involve my child in photographs or video taken for Y publicity purposes

____ Transport my child, provided that the Y and the driver have the legally required insurance in force, the driver has a

valid Kansas driver’s license and there is a current Kansas tag on the vehicle.

Statement of understanding: (your signature confirms your agreement with the following terms)

I will notify the staff of any changes in the registration information.

I understand it is my responsibility to sign my child in upon arrival to the program and out before leaving each day.

I understand there is $1/minute late pick up fee charged for each child picked up after 6pm. If the child is not picked up by 7:00pm

911 will be called.

I understand that the Y has a no outside contact policy between Staff and Children. This includes but is not limited to: babysitting,

sleepovers, transportation or other non-Y events.

I understand that state law mandates the Y to report any suspected cases of child abuse or neglect to the appropriate authorities for

investigation.

In the event that I cannot be reached to make arrangements for emergency medical attention at the time of illness or

accident, I hereby authorize the Y to take my child to the nearest facility for medical attention.

I consent to my child’s participation in the Y program and assume the risks involved. I attest and verify that I have knowledge of the

risks involved in program activities and I give my child authorization to participate in such activities.

By signature and of free will I do hereby agree to indemnify and hold harmless the Y for any and all claims or demands, cost of

expense arising out of any injury or damage sustained by me or any party I am responsible for.

I understand that even when every reasonable precaution is taken, accidents can sometimes happen. Therefore, in exchange for

allowing my child to participate in Y programs, I understand and expressly acknowledge that I, for myself and for anyone entitled to act

on my behalf, waive and release the Y, sponsors, representatives and successors from all claims or liabilities of any kind arising out of

my child’s participation in activities at or sponsored by the Y. I further agree to indemnify and save harmless the Y from any claims or

demands arising out of such injuries or losses. I understand that this release includes any claims based on negligence, action or

inaction of the YMCA of Topeka, its staff, directors, members and guests.

______________________________ _______________ _________________________ _____________

Print Name Relationship to child Sign Name Date

__________________________________________________________________ _____________________________

If the health history form was completed by a person other than a Parent/Guardian What is that person’s relationship to

Who provided you with this information? the child?