YMCA of Greater Houston School Age Enrollment Form

SPECIAL CIRCUMSTANCES/NEEDSThe YMCA believes that each child in our care is unique. Help us provide the best care for your child by providing us with as muchinformation as possible. We strongly encourage you to meet with the director and visit the program prior to enrolling your child.Please give information about special problems and needs including: allergies, existing illness, previous serious illness and injuries,disabilities, hospitalizations in past 12 months, long-term conditions, continuous use medication, etc. In addition, please explain if there arecertain situations that may cause your child difficulty. How can we best work with you and/or your child to help in these situations? Doesyour child have any limitations or require any special provisions? Write in N/A if none apply to your child.Does your child require any special accommodations? Yes NoIf yes, please contact your YMCA’s Youth Development Director.Please read each statement below, check yes or no, then sign and date at the bottom of the page.Yes No I consent for my child to be transported and supervised by the facility’s staff in case of emergency, on fieldtrips, to and from home, and to and from school, if applicableYes No I consent for my child to participate in satisfaction and outcome surveys, including requests for reportcards, for the purposes of program improvementYes No I consent for my child to participate in water activities such as splashing pools, swimming pools, andother bodies of water provided by the facility.Yes No I consent for my child to be photographed and/or videotaped while participating in the program.Yes No I consent to be added to an email list for notifications about upcoming YMCA programs and or events.My child has permission to ride a bus or walk to and from school or home, or to be released to the care of a sibling under18 years of age. (if applicable, an additional form is needed) Yes (additional form needed) Not ApplicableI understand that as a participant in a state licensed child care, my child’s records may be reviewed and/or copied byrepresentatives of the Texas Department of Protective and Regulatory Services.I have received a copy of policies in the Parent Handbook which includes the YMCA operational and parent policies, and I agree tofollow them.I understand the school district is not responsible for incidents/accidents that occur during after school hours. I give my childpermission to play on the school playground which may or may not meet all child care licensing safety standards.I understand that the YMCA staff and volunteers are not allowed, at any time, to babysit or transport children outside of the YMCAprogram. I understand that state law mandates the YMCA to report any suspected cases of child abuse or neglect to theappropriate authorities for investigation; however, I understand that neither the YMCA nor any of its paid or volunteer workers canbe held responsible in the event of accidents or accidental death. The YMCA strives to provide a safe and healthy environment foryour child.I understand that payments are due by the first of each month. An initial payment is due at the time of enrollment and is nonrefundable.When withdrawing from the program a written two week notice, prior to your draft date, must be turned in to the Y. Norefunds will be issued to anyone withdrawing after the first day of the month.My child attends the following school and his/her immunization record is on file at the school and all immunizations, tuberculosis test, visionand hearing screening records are current. They meet the requirements of the Texas Department of Health.Name of School: Grade: School Phone# :School Address:I have read all the above guidelines and by signing I agree to abide by all the YMCA policies:Signature of Parent or Legal GuardianDate

Student’s Name:YMCA of Greater HoustonSchool Age Child Care Conduct PoliciesChildren are entitled to a pleasant and safe environment while participating in this program. Please makecertain that both you and your child are completely familiar with these policies. The director, uponnotification to the parent, may suspend or terminate all participation in the YMCA After School program forthe following acts of misconduct:1. Leaving the YMCA Afterschool program without permission, or going into unauthorized areas.2. Refusing to follow check-in or check-out procedures.3. Refusing to remain with the group.4. Refusing to follow basic rules of safety.5. Intentionally injuring another child or staff.6. Being rude or disrespectful to staff.7. Cursing.8. Stealing or defacing school or YMCA property.9. Stealing or defacing another child's property.10. Bringing or using illegal substances or items.I have read and understood, and agree to comply with these policies. YMCA staff members reserve the right tosuspend or terminate any child’s participation in the program based on the severity of theincident, even if it isthe child’s first infraction.Print Parent’s Name:Parent’s Signature:Date: