Young Preschool Registration Packet - YMCA of Metro Atlanta

Andrew and Walter Young Family YMCA
2220 Campbellton Road
Atlanta, GA 30311
(404) 581-4963 FAX (404) 756-0959
__________________
Entrance Date
CHILDREN’S ENROLLMENT FORM
No child shall be admitted for care to the center without enrollment records having been completed on the child in accordance with
the requirements set forth in the Department of Human Resources guidelines. (Authority O.C.G.A. 20-1A-1)
Please do not leave BLANK spaces. This may delay the application process.
___________________________________________________________________________/____/___
Child’s Name Gender Age Birth Date
___________________________________________________________________________________
Home Address City State Zip
________________________
Home Telephone Number
_____________________
Ethnicity
__________________________________
Mother’s Name
_________________________________________
Home Address (if different from the child’s)
Place of Employment: ______________________________
__________________________
Business Phone Number
__________________________________________________ __________________
Business Address City Zip Cell Phone Number
Email Address____________________________________________________________
_____________________________
Father’s Name
__________________________________
Place of Employment
_____________________________________________
Home Address (if different from the child’s)
______________________________
Business Phone Number
_________________________________________________ ______ ______________________
Business Address City Zip Cell Phone Number
Email Address____________________________________________________________
____________________________________________________________________________________
Child’s Living Arrangements: □ Both Parents □ Mother □ Father □ Other
Child’s Legal Guardian: □ Both Parents □Mother □ Father □ Other
The child may be released to the person(s) signing this agreement or to the following:
___________________________________________________________________________________
Name Address Telephone
____________________________________________________________________

Parental Financial Agreement
1. Payments are due Friday before services are rendered. A $5.00 late fee will be
added, per day, if the tuition is unpaid after 6:30 P.M. on Monday. Child/ren will
not be admitted if payment is not received by Wednesday at 6:30 P.M.
BE SURE TO GET A RECEIPT FOR ALL PAYMENTS.
2. There is no adjustment of fees when a child is absent from school, including
holidays or school cancellations.
3. There is a $37 charge for each returned check. Two returned checks will result
in your account being placed on a “certified check or money order” status.
4. If your HEAD START and/or GEORGIA PRE-K child cannot be picked up by
3:00 P.M. every day, they should be enrolled in the after care program. If you
are late picking your child up your child will be placed in after care and you will be
charged $20 for the day. If you have prior knowledge that your child will be in
after care please notify us.
5. A late fee charge of $1 per minute is due if your child is not picked up by
6:30 P.M. If a child remains on the premises longer than 30 (thirty) minutes after
closing, DFCS will be notified of the neglect.
6. A 2 (two) week’s written notice must be provided before withdrawing a child. All
parents will receive an exit interview to determine if their child’s needs were met.
I, the undersigned, understand and agree to abide by all policies of the Andrew and Walter Young Family
YMCA Early Learning Academy.
__________________________________
Parent/Guardian Signature
___________________________
Date
__________________________________
Parent/Guardian Print
____________________________________
Child’s Name
________________________________________________
Director’s Signature
Note: A copy of this agreement will be kept on file.

Parental Agreement
The Andrew and Walter Young Family YMCA Early Learning Academy agrees to provide care for my
child:
_____________________________________________________________________
Child’s Name
1. Children who must take prescribed medicine are required to have a medication form filled out
and signed at the time the medication and instructions are brought to the front desk. Medications
must be labeled with the child’s name, date, name of the licensed health care provider, expiration
date, and original prescription label. Authorization to dispense medication shall be limited to two
weeks, unless otherwise prescribed. Children are not to have any form of medication on
their person or in their cubbies, book bags, diaper bags, etc.
2. My child will not be allowed to enter or leave the facility without being escorted by the parent(s),
person authorized by parent(s), or facility personnel.
3. I acknowledge it is my responsibility to keep my child’s records current to reflect any significant
changes as they occur, e.g. telephone numbers, work location, emergency contacts, child’s
health status, etc.
4. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse
reactions to medications, and exposure to communicable diseases which include my child.
5. The Andrew and Walter Young Family YMCA Early Learning Academy agrees to obtain written
authorization from me before my child participates in routine transportation, field trips, special
activities away from the facility, and water related activities occurring in water that is more than
two (2) feet deep.
I have received a copy and agree to abide by the policies and procedures for the Andrew and Walter
Young Family YMCA Early Learning Academy.
__________________________________________
Parent/Guardian Signature
_______________________
Date
__________________________________________
Parent/Guardian Print
__________________________________________
Facility Administrator Signature
_______________________
Date

Persons to contact in the case of an emergency when parents cannot be reached:
Name Address Telephone
1.
2..
3.
4.
___________________________________________________________________________
Child’s Physician or Clinic’s Name (Child’s Primary Health Source) Telephone
My child has the following special need(s):
_________________________________________________________________
The following special accommodation(s) may be required to most effective
meet my child’s needs while at this center:_______________________________
_________________________________________________________________
_________________________________________________________________
My child is currently on medication(s) prescribed for long-term continuous
use and/or has the following preexisting illness, allergies or health concerns:
(Place N/A if none exist)
________________________________________________________________
________________________________________________________________
________________________________________________________________
___________________________________________________
Signature (Parent/Guardian)
___________________
Date

Andrew and Walter Young Family YMCA Preschool
HEALTH ALERT FORM
Dear Parent/Caregiver:
In our ongoing efforts to better care for your child/ren, please list any medical
conditions (i.e., asthma, nose bleeds, etc.): any food restrictions (i.e., vegetarian,
no milk, no pork, etc.) and/or any allergies (i.e., peanuts, tomatoes, eggs, etc.) that
he/she may have. In addition, please list any physical problems, mental health
disorders, mental retardation or developmental disabilities which would limit the
child’s participation in the center’s program and activities. (591-1-1-.08, BFTS)
This information will be kept on file and a copy will be given to your child’s teacher.
Child’s Name: ______________________Teacher:________________
Medical Conditions:
Food Restrictions:______________________________________________
_____________________________________________________________
_____________________________________________________________
Other:________________________________________________________
For each child with special health care needs or food allergies or special nutrition needs, the preschool protects children with food
allergies from contact with the problem food. The preschool asks families of a child with food allergies to give consent for
posting information in the food preparation area and in the areas of the facility the child uses so it is a visual reminder to all those
who interact with the child during the program day.
Parent/Guardian Signature:__________________________ Date:_____

Medical Care and Emergency Contact Information
Child’s Name:__________________________________________ Birth date:________
Address_________________________________________________________________
Mother’s Name_____________________________ Phone_______________________
Father’s Name______________________________ Phone_______________________
Alternate Emergency Contact 1)______________________________________________
Alternate Emergency Contact 2)______________________________________________
Child’s Physician:_________________________________________________________
Family Physician__________________________________________________________
Known Allergies of Child (medicine, food, etc.)_________________________________
________________________________________________________________________
Describe past serious illnesses or hospitalization, with dates________________________
________________________________________________________________________
________________________________________________________________________
Health Insurance: Company______________________ Policy#___________________
________________________________________________________________________
NOTARIZED EMERGENCY MEDICAL TREATMENT CONSENT
I hereby give the Andrew and Walter Young Family YMCA Preschool permission to
provide first aid care for my child. In the event I cannot be reached, I hereby authorize the
Andrew and Walter Young Family YMCA Preschool to transport my child to the
emergency room of the hospital/s listed below. And I hereby grant my consent for the
hospital and its medical staff to provide my child with emergency medical treatment which
a physician deems necessary ( including anesthesia). If I have not specified any hospital/s
below, my child may be taken to and cared for at the nearest hospital. I agree to accept
financial responsibility for all medical expenses incurred.
Hospital//s:_____________________________________________________________
________________________ _________
_________________________ _______
Parent/Guardian Date Parent/Guardian Date
State of Georgia
County of_________________________________
The foregoing CONSENT was acknowledged before me this _________ day of _________________, 20____.
Notary_________________________________
(Notary Seal)
My commission expires_________________

Andrew & Walter Young Family YMCA
Vehicle Emergency Medical Information

Andrew & Walter Young Family YMCA
Parent Policies and Procedures
1. The program operates Monday – Friday, from 6:30 AM – 6:30 PM, January through December.
2. The center provides care for ages 3 months – 5 years of age
3. The holidays for the program are outlined in the center calendar and parent handbook.
4. I acknowledge that it is my responsibility to keep my child’s records current to reflect any significant
changes as they may occur, (telephone numbers, work locations, emergency contacts, child’s health
status, immunization records, etc.)
5. The center must have an updated Immunization Certificate on file for each child; this is a state requirement.
The first certificate must be provided before the first day of attendance and updated thereafter. The
Georgia Pre-K program and Head Start require the certificate to be on file within 30 days of the first day of
school. The Ear, Eye and Dental should be on file within 90 days.

6. Children should not bring food into the center. Adequate balanced meals are served daily, which include
Breakfast, Lunch and afternoon Snack. Food and menu exceptions cannot be made for individual children,
unless there is a documented medical reason that must be supported by a doctor’s statement. Food that
comes from home for sharing must be either whole fruit or commercially packaged foods in factory sealed
containers. (5.B.02)
7. The center staff will administer only DATED, LABELED, PRESCRIBED medications or age appropriate
over-the-counter medication. Parents must sign an authorization form before any medication can be
administered. Parents will be notified of any adverse reactions to the medication.
8. Parents are required by the state to ESCORT their child(ren) into the center each day. ALL children must
be signed IN and OUT daily.
9. Every child must have an afternoon rest/nap. This allows the children an opportunity to have a break from
the day’s activities and this is also a state requirement.
10. Each child must have a complete change of clothes in case of accidents. ALL belongings must be labeled
with your child’s name. We are not responsible for lost or stolen items.
11. The facility agrees to keep me informed of any incidents, including illnesses, injuries and exposure to
communicable diseases.
12. The center agrees to obtain written authorization from me before my child participates in routine
transportation, field trips, special activities away from the facility, and water-related activities occurring in
water that is more than 2 feet deep.
13. Discipline and guidance at the center is important. We have a policy in place where the teachers use
behavior modification techniques to improve the behavior. Physical punishment is never permitted. If it is
determined that the behavior is not improving, we will request a parent meeting with the teacher and
director to discuss other possible solutions. At times it may be necessary to terminate a child’s enrollment
if it is determined that the center cannot meet the needs of the child.
14. The center makes no arrangements for transportation to or from the center.
15. Children will not be accepted at the center if they are ill, this includes, but is not limited to temperatures of
101 degrees or higher oral temperature and any contagious symptoms, rashes, sore throat, vomiting, etc.
Should the child become ill during the day, the parent or designated emergency contact person will be
notified to pick the child up.
16. We will notify parents when a communicable disease has been introduced into the center. Children with a
communicable disease cannot attend the center and must be free of the illness before re-entering the
program.
17. A copy of the State Rules & Regulations which apply to the operation of the center is available for your
review. A copy of the most recent licensing review is also available for your review upon request.
18. We have an agreement with Dr. Melba Johnson that in case of an emergency, and we are unable to reach
you, your child will be able to receive emergency medical treatment. The center must have current
evidence of healthcare coverage in case of emergencies. (5A.01)
19. In case of violent weather, please do not call the center, we will be busy providing the best possible care for
our children. In the event of a fire, gas leak, or bomb threat, the children will be evacuated immediately
from the center. Emergency plans are posted for your review. In case of inclement weather that may
require the closing of the center, we will make such announcements on the recorded voicemail system here
at the center.

20. Parents are always WELCOME and encouraged to visit your child at the center. However, it is required
that you make your presence known by signing in at the front desk. Children should not be removed from
the center without proper notification to the staff.
21. Parents are asked, for SAFETY reasons, to park only in designated marked parking areas. PLEASE DO
PARK IN THE FIRE LANES IN FRONT OF THE PRESCHOOL DOORS!
22. It is the YMCA mission to serve all kids in need of quality childcare. We will make every effort possible
to serve all families requesting services. All kids enrolling in our program must be able to function within
the student/teacher ratios set by the State.
I have read the Andrew and Walter Young Family YMCA Preschool “Policies & Procedures” and will abide by all
policies to insure compliance.
Parent/Guardian Signature:________________________________
Director’s Signature:_____________________________________
Date:__________
Date:_________
Pick-up/Release Form
______________________
_
I authorize the student(s) listed below to be released to the following
individuals. These individuals have been advised they will be required to
show identification. My child will not be released to any other person
unless prior written notification is submitted.
__________________________
Student’s Name
__________________________
________________
Teacher
________________

Student’s Name
__________________________
Student’s Name
Teacher
________________
Teacher
__________________________
Parent/Guardian’s Signature
________________
Date
Name: Emergency Contact # Relationship:
_______________ ______________ ______________
_______________ ______________ ______________
_______________ ______________ ______________
_______________ ______________ ______________
_______________ ______________ ______________
Authorization to Dispense External Preparations
Except for first aid, personnel shall not hand out prescription or non prescription medications to a child without
specific written authorization from the child’s physician or parent. All medications shall be stored in accordance
with the prescription or label instructions and kept in places that are inaccessible to children. Each dose of
medication given to a child shall be documented showing the child’s name, name of medication, date and time
given, and the name of the person giving the medication.
Child’s name_________________________________
Date_____________________
I hereby give the Andrew & Walter Young Family YMCA Preschool staff permission to apply
one or more of the following products, in accordance with directions on the container.
(Check all that apply)

Baby Wipes
Band-aids
Neosporin, Bactrian or similar ointment
Bactine or similar first aid spray
Sunscreen
Insect Repellent
Non-prescription ointment (A&D, Desitin, Vaseline, etc.)
Other (please specify):
Other (please specify):
I hereby request that the Andrew & Walter Young Family YMCA Preschool staff administer the
checked products in accordance with the directions on the container.
__________________________________________
Parent/Guardian
_____________________
Date
__________________________________________
Parent/Guardian
_____________________
Date
PHOTOGRAPH/VIDEOTAPE RELEASE

_____
_______________________
Date