School Age Enrollment Packet Form

YMCA of Greater Grand Rapids
School Age Enrollment Packet
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.
Welcome to the YMCA of Greater Grand Rapids School Age Program. We are very excited that you have decided to participate in our program. The YMCA of Greater Grand Rapids offers a variety of out of school time experiences. This enrollment packet is intended for those registering for a school age experience which takes place at our partnering school sites. Please mark the location below. In order to ensure a safe and engaging experience guardians must complete this packet in its entirety. This packet must be completed for each child in the program and is a requirement to have completed at least three business days before programming.
Child Information
Child's First and Last Name*
First NameMiddle NameLast Name
Gender Identificaiton*
MaleFemaleOther
Birth Date*
MonthDayYear
Date
Grade*
Home Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
School Age Locations
Choose an option below
Choose a School Site Location*
Date of Admission *Administration Only
MonthDayYear
Date

1st Parent/Guardian/Authorized Representative
1st Parent/Guardian/Authorized Representative Name*
First NameLast Name
1st Parent Address (if different from child)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
1st Parent Mobile Phone Number*
Area CodePhone Number
1st Parent Home Phone Number (if Different from child)
Area CodePhone Number
1st Parent Email Address*
example@example.com
1st Parent Employer Name & Address*
1st Parent Business Phone Number*
Area CodePhone Number
2nd Parent/Guardian/Authorized Representative
2nd Parent/Guardian/Authorized Representative Name
First NameLast Name
2nd Parent Address (if different from child)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
2nd Parent Mobile Phone Number
Area CodePhone Number
2nd Parent Home Phone Number (if Different from child)
Area CodePhone Number
2nd Parent Email Address
example@example.com
2nd Parent Employer Name & Address
2nd Parent Business Phone Number
Area CodePhone Number

3rd Parent/Guardian/Authorized Representative
3rd Parent/Guardian/Authorized Representative Name
First NameLast Name
3rd Parent Address (if different from child)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
3rd Parent Mobile Phone Number
Area CodePhone Number
3rd Parent Home Phone Number (if Different from child)
Area CodePhone Number
3rd Parent Email Address
example@example.com
3rd Parent Employer Name & Address
3rd Parent Business Phone Number
Area CodePhone Number

4th Parent/Guardian/Authorized Representative
4th Parent/Guardian/Authorized Representative Name
First NameLast Name
4th Parent Address (if different from child)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
4th Parent Mobile Phone Number
Area CodePhone Number
4th Parent Home Phone Number (if Different from child)
Area CodePhone Number
4th Parent Email Address
example@example.com
4th Parent Employer Name & Address
4th Parent Business Phone Number
Area CodePhone Number

Emergency Contacts/Authorized Pick Up
Names of additional persons (not parents, legal guardian, authorized representative) who may be called in an emergency and/or who are authorized to take the child from the site. *The child will not be allowed to leave with any other person without written authorization from parent or authorized representative
Person 1 Name*
First NameMiddle NameLast Name
Person 1 Phone Number*
Area CodePhone Number
Person 1- Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Person 1- Relationship To Child*
When To Contact Person 1 (Choose up to 2)*
Emergency ContactRelease of Child

Person 2- Name*
First NameMiddle NameLast Name
Person 2- Phone Number*
Area CodePhone Number
Person 2- Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Person 2- Relationship To Child*
When To Contact Person 2 (Choose up to 2)*
Emergency ContactRelease of Child

Person 3- Name
First NameMiddle NameLast Name
Person 3- Phone Number
Area CodePhone Number
Person 3- Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Person 3- Relationship To Child
When To Contact Person 3 (Choose up to 2)
Emergency ContactRelease of Child

Person 4- Name
First NameMiddle NameLast Name
Person 4- Phone Number
Area CodePhone Number
Person 4- Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Person 4- Relationship To Child
When To Contact Person 4 (Choose up to 2)
Emergency ContactRelease of Child

Restricted Pick Up
The following individuals are RESTRICTED from signing out my child due to a court-issued restraining order (a certified copy of the official documentation must be kept in the child’s YMCA file)
Restricted Name 1
First NameLast Name
Restricted Name 2
First NameLast Name

Physician & Dentist
Physician & Dentist to be called in Emergency & Medical Insurance Information
Medical Insurance Company and Plan
Policy Number
Policy Expiration
MonthDayYear
Date
Physician's Name
First NameLast Name
Physician's Phone Number
Area CodePhone Number
Dentist's Name
First NameLast Name
Dentist's Phone Number
Area CodePhone Number
If Physician Cannot Be Reached, What Action Should Be Taken?

Authorization & Release for Medical and Dental Treatment
I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the YMCA Program. I hereby grant permission for my child to leave the YMCA Program premises under the supervision of a staff member for neighborhood walks or field trips in authorized vehicles.
The undersigned, as the parent(s) or legal guardian(s) of the above named person (the minor) authorizes the YMCA of Greater Grand Rapids and its Employees, Directors, and Adult Volunteers (collectively “YMCA”) to consent to an x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist/physician licensed under the law of the State or other jurisdiction in which care is sought.
The undersigned understand and agree that the YMCA shall not be legally or financially liable for any bills or medical expenses incurred, or for any cause of action or claim arising from any medical care or dental care provided, or the lack of medical care or dental care. The undersigned hereby agree to this indemnity defined and hold YMCA harmless from any claim made by or on behalf of the minor’s heirs or parents or guardian arising out of any medical care or dental care provided.
NOTE: The YMCA requests that if the minor is in the custody of both of their parents or more than one legal guardian, both or all sign this authorization. The YMCA understands that the minor is in the custody only of the person(s) who have signed this authorization.
If for religious reasons you cannot sign this, you must provide a Written statement from parent(s) or authorized representative exempting child from medical assessment, immunizations, and treatment because of adherence to a religious faith that practices healing by prayer or other spiritual means; or physician's statement that immunization is not indicated and the YMCA branch must be contacted for a legal waiver, which must be signed for attendance.

Child's Health Statement
I, the undersigned, understand that at a YMCA programs, physical activity is a regular part of the daily scheduled activities. To the best of my knowledge, my child is in excellent physical health and has no restrictions (except what is listed in this packet under “special consideration”) from strenuous activity. If I have any questions regarding my child’s health, I understand that it is my obligation to seek professional medical advice and to inform the YMCA of any restrictions on my child’s activities. I understand that the YMCA is a group-centered program with one adult teacher assigned to group of children. The YMCA does not provide any in-house one-to-one assistance services.
Check One
Yes, I agreeNo, I do not agree

Program Agreements
AGREEMENT: I understand agree to and/or acknowledge the following:
Program Agreements
I understand that YMCA School Age programs are regulated by Michigan Department of Licensing and Regulatory Affairs. I understand that this means the program is required to implement program standards and experiences which are in alignment with these regulations. These regulations require,but are not limited to, maintaining a ratio of 1 adult for every 18 children. Additionally, our program design is based in a group care model; it is in the best interest of the program and youth experience to share the details describing the needs of your children to ensure the appropriate experience maybe offered without causing compromise to program required regulations and to ensure reasonable modifications may be made if necessary.
The YMCA School Age Program maintains a licensing notebook of all licensing inspection reports, special investigation reports and all related corrective action plans. The notebook will be available to parents for review during regular business hours. Licensing inspection and special investigation reports from at least the past two years are available on the Bureau of Community and Health Systems website at www.michigan.gov/michildcare.
I acknowledge that I have received a copy of the most current Parent Handbook which may be located on the YMCA of Greater Grand Rapids website and will comply with the policies set forth. I acknowledge that I have read and I understand the YMCA’s policies and procedures related to field trips.

I acknowledge that I have read and I understand the YMCA’s policies and procedures about staff and volunteers not bring permitted to babysit, transport or relate to children anytime outside of the YMCA program, found in the Parent Handbook which may be located of the YMCA of Greater Grand Rapids website.

I understand that I am not allowed to leave my child at the YMCA program site unless a YMCA staff is there to receive and supervise my child. I understand that the YMCA staff  are not permitted to be alone with one single child, this may impact the location for pick up and or  delay drop off as staff must ensure a 2nd staff member is present.

I understand that should a person arrive to pick-up my child who appears to be under the influence of drugs or alcohol, for the child’s safety, staff may have no recourse but to contact the police.

I understand that all YMCA staff are mandated by state law to report any suspected child abuse or neglect to the appropriate authorities for investigation.

I understand that Law Enforcement personnel may request the information listed in your file and may interview your child, if necessary. I understand that, per Michigan Department of Licensing and Regulatory Affairs, my child’s file is available for review and representatives from these agencies may interview my child without prior parental/guardian permission. This is a process connected program self –reporting, in the case this is necessary the state representatives will involve the guardians as appropriate.

I acknowledge that I have read and I understand the YMCA’s Positive Discipline policies and child suspension/ removal procedures, including pick-up time limits and penalties, found on in this packet and in the Parent Handbook which may be located of the YMCA of Greater Grand Rapids website.

YMCA’s Positive Discipline policies and child suspension/ removal procedures, including pick-up time limits and penalties. YMCA may terminate my child’s enrollment for any of the following reasons:
·      Emergency names and phone numbers are incorrect.
·      Parent is late picking up child after program closes on a consistent basis.
·      Non-payment, late payment or ATS reject of fees.
·      Failure to adhere to the sign in and out policy.
·      Failure to notify the YMCA that the child is absent.
·      Child leaving the program site without authorized permission.
·      Behavior that is continually disruptive or dangerous to others and/or self.
·      Behavior that is disruptive to property and/or refusal to replace said property.
·      Any single incident that is deemed by the program director to be dangerous, harmful or disruptive.
·      Harassment, violent behavior or threat of such behaviors against a staff person or other member by parent/guardian or persons associated to the child (family member, family friend, etc.).

I understand that the YMCA and the staff employed by the YMCA will not become involved in custodial disputes between parent/guardian. All documents request must come from the courts and be signed by a judge. The staff’s responsibility is to provide a safe environment for children.

I understand I am required to give 14 day notice when terminating my child from YMCA day camp program or when making changes to my program option or plan. Without a proper 14 day notice I will still be billed as regularly scheduled. Registration Tuition/Fees are non-refundable.

I understand and agree that in the event my child is not picked-up by closing, the Program site will immediately make every attempt to contact me, or other persons authorized by me to take my child from the program site.  If I or my authorized individuals cannot be located, or if satisfactory arrangements for picking-up the child cannot be made, the YMCA staff will continue to try to locate me or another designed person; but if those efforts are unsuccessful within a reasonable period of time, the appropriate law enforcement and welfare authorities will be contacted. I hereby release the YMCA, its employees and agents, from all liability for any damage sustained by my child or by me which results directly or indirectly from the procedure outline above.  I further agree that I will indemnify and hold the YMCA and YMCA Program harmless for any damage sustained by my child, if this procedure must be utilized because I fail to pick-up my child on time from the program site or because any person designated by me fails to pick up my child on time from the program site. I hereby release the YMCA, its employees and agents from all liability and responsibility for any damages sustained by my child after closing time. I understand and agree that if my child is not picked-up at the designated time on a consistent basis, my child and I may be dropped from the program.

I agree to allow, and grant permission for, my child to participate in all activities which are a part of the YMCA Program.  These activities include water play, use of the playground and apparatus (at sites where permissible), woodworking, cooking, animal care, messy arts and crafts, sports, fitness, outdoor games, adult supervised walks in the immediate neighborhood/community of the YMCA program site, field trips and other active play experiences typical in a before and after school, full-day program and day camp program.   I hereby release and discharge the YMCA, officers, employees, agents and servants (herein, collectively referred to as the YMCA) from all liability associated with camp activities.  For the purpose of this agreement, liability means all claims, demands, losses, courses of action, suits or judgments of any kind that I, my heir, executors, administrators or assignees may have against the YMCA because of any loss or damage to property that results from any cause other than the gross negligence of the YMCA.  I understand that college students may make observations at the YMCA as a part of class assignments and that any observation will be done only under the supervision of the director; photography will not be permitted by student observers.
All of our Out-of-School-Time curriculums are research based to foster and develop your child (ren) in the four key areas of; literacy, wellness, family, and character. As a part of evaluating the effectiveness of these curriculums we will be surveying all students third grade and older with a pre-assessment at the beginning of programming and a post-assessment at the end of programming. This brief survey will take no more than 10 minutes for them to complete and asks questions like; have you made a friend during programming and do you feel safe at the program? All information gathered will be kept confidential and no personal information will ever be shared. Results will only be shared aggregated and de-identified. By agreeing you give permission for your child to participate in these surveys. Should you or your child chose to not to participate in the surveys, your child will simply continue in their regular day camp programming with no repercussions.

REASONABLE ACCOMMODATIONS CLAUSE:
Children with special needs or challenges will be accepted provided that “reasonable accommodations” can be made for their participation in the program and/or child’s participation does not require an inordinate amount of staff time that would not allow for the safety and welfare of the other children in the program. I understand that if my child/ren requires a one on one attention, whether due to special needs or behavior, my child may be removed from the program. You are solely responsible for determining if your child/ren are physically fit for the activities contemplated in these programs. It is always advisable, especially if your child/ren have an illness, injury or impairment, to consult a physician before undertaking any active recreational program.
By signing below, I acknowledge that I have read and agree to all the statements of this Program Agreement document:
Date*
MonthDayYear
Date
Electronic signature*

PLAYGROUND AND TRANSPORTATION RELEASE
FIELD TRIP/TRANSPORTATION AUTHORIZATION: My child, has my permission to be transported in the YMCA of Greater Grand Rapids' bus or contracted transportation service to his/her elementary school or the YMCA of Greater Grand Rapids site from his/her school as well as to and from any additional field trips scheduled. I understand that a notice will be sent home in advance of any field trip. If the YMCA is providing transportation, record of each child riding in the bus will be on site. All buses are checked annually by the Michigan State Police, and carry a first aid kit for emergencies.
Yes, I agreeNo, I do not agree
PLAYGROUND AUTHORIZATION: I understand that my child is actively playing on equipment at a program school site playground. The playground equipment may not meet safety guidelines set forth by the Playground Safety Act of 1997.This equipment has not been certified through the State of Michigan Child Care licensing division.
Yes, I agreeNo, I do not agree
Release and Waiver of Liability and Indemnity Agreement
IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as “the undersigned”) hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities and/or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1.    THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, volunteers and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or demands on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA.

2.    THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA.

3.    THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence, active or passive, of releasees or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Michigan and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.
By signing below, I acknowledge that I have read and agree to all the statements of this Release and Waiver of Liability and Indemnity Agreement:
Date*
MonthDayYear
Date
Electronic signature*

PHOTO & VIDEO/AUDIO RECORDING RELEASE
I
First NameLast Name
am eighteen years of age or older, and if not, then my Mother/Father/Legal Guardian has also signed below under my signature.

With regard to my participation in activities sponsored by or related to any activity in which I participate in any way sponsored by the National Council of Young Men’s Christian Associations of the United States of America, and to any YMCA of the USA Association, including the Young Men’s Christian Association of Greater Grand Rapids (collectively, “YMCA”), I hereby give my permission and consent, now and for all time (without any further compensation, claim or demand by me) to the YMCA, and to advertising agencies, agents, entities and third parties collaborating with the YMCA and their representatives, if any, (the “Organizations”) to make, reproduce, edit, broadcast or rebroadcast any video, film, or digital footage and other sound track recordings, or photo reproductions of my image or voice in any form, and my narrative account of my experience with YMCA activities (“Materials”) for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any further compensation to me. I may or may not be identified by name in such reproductions. However, I shall not be stated by name to have endorsed any particular commercial products or commercial services without my express written permission.

I further agree to the following:
•  Any Materials created subject to this Release shall belong to the YMCA as its property, with full right of disposition of them without my oral or written permission.
•  The Materials will not be subject to any obligation of confidentiality and may be shared with and used by the Organizations, as well as with any third parties as the YMCA may elect.
•  The YMCA shall not be liable for any claim arising from the use or disclosure to a third party of any of the Materials.
•  The YMCA shall exclusively own all known or later existing rights to the Materials worldwide and shall be entitled to the unrestricted use of the Materials for any purpose without compensation to me or the provider of the Materials.

AGREEMENT AND CONSENT
I have read and understood the contents of this Release. I agree that my consent to this Release is irrevocable. I hereby voluntarily release and discharge the YMCA and the Organizations and their representatives from any and all claims arising out of or relating to or in connection with the uses and reproductions of my image and voice and my narrative account as described herein. I understand that the term “YMCA” in this Release specifically includes the YMCA of Greater Grand Rapids.
Choose One:*
Yes, I AgreeNo, I do not agree
Date*
MonthDayYear
Date
Electronic signature*

PAYMENT PLAN & HOW IT WORKS FINANCIAL POLICIES AGREEMENT
The YMCA of Greater Grand Rapids Financial Agreement is a continuous payment plan. I understand this payment plan will remain in effect for as long as I have my child enrolled in the YMCA School Age program, or until ACH/credit card is cancelled or the authorization granted to the YMCA has been revoked.
Agree
I have read and I understand the payment due dates will be shared at the time of enrollment to be detailed on the tuition agreement form. Schedule changes are allowed (pending availability) as long as they are communicated 14 calendar days prior to the start of each week.*
Agree
I understand that program participation requires that my account is in good standing with all balances up to current. This includes program fees and membership dues (if applicable). Non-payment of program fees and/or membership dues, will result in my child not being allowed to participate in the program and could result in legal referral with the additional costs to myself, until the balance is paid and current. I further understand that there is an administrative processing fee for any payment returned by my bank or credit account and for late payments.
Agree
I understand that cancellations must be made by May 15, 2020. Cancellations made after May 15, 2020 will incur a $40.00 cancellation fee per family, each week that is cancelled. There are no credits or refunds for missed days.*
Agree
Your account will accrue at $1.00 late fee per minute after the program closes and your child is still with us.
Agree
I understand this completed enrollment packet is a requirement of program participation and must be provided three business prior to the intended start week. Failure to complete this form and submit will result in the non-completion of the enrollment packet and therefore cancel enrollment (less the $40 cancellation fee).*
Agree
By signing below, I acknowledge that I have read and agree to all the statements on Payment Plan and How it Works.
Date*
MonthDayYear
Date
Electronic signature*

Getting To Know You Quesionnaire
The YMCA of Greater Grand Rapids makes safety a high priority in our programs. In order to best serve our participants we are requesting additional information to ensure we are equipped to provide the best possible experience. Detailing the information below will help ensure we are the right program model to best serve your child’s needs and that your child has the greatest opportunity for success while in our care. You are also welcome to submit this form directly to the Program Director at your chosen location. Once the information has been submitted the program lead will review these details, if there is any information requiring a follow up conversation for further details, the program lead will connect with you directly.
Thank you for helping us best serve the youth!
Tell us about your child’s school experience/environment, any supports offered throughout the day or additional services provided?
What types of things does your child enjoy? Hobbies, Heroes, Interests
What things frustrate or overwhelm your child? Sounds, interactions with others
How do they handle frustrations? What are techniques are used for soothing and calming?
Any assistance needed in the restroom? Are they completely independent while using the restroom?
Any assistance needed during meal times?
What goals or experiences do you and your child have for their time in our program?

Are You Ready?
We are very excited that you have decided to participate in our School Age program. Before you finalize your enrollment, it is important that you complete this SELF-CHECKLIST to ensure that you and your child are ready for the Day Camp. Your signature is required at the bottom of this checklist.
Emergency Information: I understand that I must submit the Emergency Contact Information (included in this packet) to ensure a safe and supportive program experience for my child.*
Agree
I understand that YMCA school age programs are regulated by Michigan Department of Licensing and Regulatory Affairs. I understand that this means the program is required to implement program standards and experiences which are in alignment with these regulations. These regulations require,but are not limited to, maintaining a ratio of 1 adult for every 18 children. Additionally, our program design is based in a group care model; it is in the best interest of the program and youth experience to share the details describing the needs of your children to ensure the appropriate experience maybe offered without causing compromise to program required regulations and to ensure reasonable modifications may be made if necessary. I acknowledge The YMCA School Age Program maintains a licensing notebook of all licensing inspection reports, special investigation reports and all related corrective action plans. The notebook will be available to parents for review during regular business hours. Licensing inspection and special investigation reports from at least the past two years are available on the Bureau of Community and Health Systems website at www.michigan.gov/michildcare.*
Agree
I have read and I understand the Program Agreements (included in this packet). Children requiring one-to-one services must contact the branch Program Department before enrolling.*
Agree
I have read and I understand the YMCA’s Positive Discipline Policies (included in this packet) and understand the behavior expectations necessary to facilitate the most engaging experience for all.*
Agree
I have read and I understand the Payment Plan & How It Works. I agree to the Financial Policies Agreement detailed in this packet.*
Agree
Getting To Know Your Child: I understand that it is HIGHLY RECOMMENDED that I complete a Getting To Know You Questionnaire, to assist the Y staff in understanding my child’s individual needs. I can submit this with my enrollment package or directly to the YMCA Director at least three business days before the start of the program.*
Agree
Signature*
Clear
Date*
MonthDayYear
Date

Submit Packet
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YMCA of Greater Grand Rapids

Child Information

School Age Locations

1st Parent/Guardian/Authorized Representative

2nd Parent/Guardian/Authorized Representative

3rd Parent/Guardian/Authorized Representative

4th Parent/Guardian/Authorized Representative

Emergency Contacts/Authorized Pick Up

Restricted Pick Up

Physician & Dentist

CONFIDENTIAL HEALTH HISTORY STATEMENT

Authorization & Release for Medical and Dental Treatment

Child's Health Statement

Program Agreements

PLAYGROUND AND TRANSPORTATION RELEASE

Release and Waiver of Liability and Indemnity Agreement

PHOTO & VIDEO/AUDIO RECORDING RELEASE

PAYMENT PLAN & HOW IT WORKS FINANCIAL POLICIES AGREEMENT

Getting To Know You Quesionnaire

Are You Ready?

Submit Packet