YMCA OF SOUTHERN MAINE
2016-2017 School Age Child Care Program
Student Registration Form
Student’s First Name:
Last Name:
Date of Birth:
Gender:
Grade in 2016-2017:
Date to Start Program:
Address:
City:
State:
1. Parent/Guardian First Name:
Zip:
Last Name:
Address:
City:
State:
Zip:
Phone:
Work Phone:
Employer:
Employer Address:
E-Mail:
Relationship to Child:
2. Parent/Guardian First Name:
Last Name:
Address:
City:
State:
Phone:
Work Phone:
Employer:
Employer Address:
Zip:
E-Mail:
Relationship to Child:
With whom does this child live?
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Please list at least TWO emergency contacts that are authorized for pick-up other than the
child’s parents/guardians:
1. Emergency Contact Name:
Emergency Contact Address:
City:
State:
Phone:
Zip:
Work Phone:
Relationship to Student:
2. Emergency Contact Name:
Emergency Contact Address:
City:
State:
Phone:
Zip:
Work Phone:
Relationship to Student:
If you would like our staff to better understand specific family structures/agreements that could affect your child’s
drop-off, daily program, or pick-up; please list here in detail:
Check the Appropriate School, Program and Days of the Week
School
Brown

Dyer Kaler
Skillin

Small


Pineland Branch
Biddeford Primary

Program & Days of the Week (check all that apply)
Morning program only:
☐3-day AM
($47/week)
☐ Mon ☐ Tues ☐ Weds ☐ Thurs ☐ Fri
☐ 5-day AM
($65/week)
Afternoon program only:
☐3-day PM
($72/week)
☐ Mon ☐ Tues ☐ Weds ☐ Thurs ☐Fri
☐ 5-day PM
($100/week)
Combined program:
☐3-day AM/PM
($100/week)
AM: ☐ Mon ☐ Tues ☐Weds ☐Thurs ☐Fri
PM: ☐ Mon ☐ Tues ☐Weds ☐Thurs ☐Fri
☐ 5-day AM/PM
($135/week)
Minimum Due at Registration: $50 per child. First & last week’s deposit is due by Sept. 1, 2016 to secure a spot for the first
day of school.
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PAYMENT METHOD
Please choose your preferred payment method for the $50 Registration Fee:
☐ Check (enclosed)
☐ Cash (enclosed)
☐ Charge (VISA/MasterCard/American Express)
Name on Card:
Card #:
Exp. Date:
Weekly Autodraft: We are able to draw weekly payments from your Visa, MasterCard, American Express or checking
account for School Age Child Care payments. They will be withdrawn each Wednesday for the following week’s care.
☐ I authorize auto payments for the weekly balance due, to begin on the first Wednesday of the program
(both first & last weeks’ payment to be taken at this time) and continue each Wednesday until the end of the
2016-2017 school year.
Charge (VISA/MasterCard/American Express)
Name on Card:
Card #:
Exp. Date:
Bank Account
Name on Account:
Account #:
Routing #:
I have given authority to the YMCA of Southern Maine at 70 Forest Avenue, Portland, Maine to debit my Visa/MasterCard/American
Express/Checking Account. When Visa/MasterCard/American Express/Bank honors the debit by charging my account, such debit
shall constitute my receipt for payment. Should any pre-authorized debit not be honored by Visa/MasterCard/American
Express/Bank when received by them, I will remain liable for such payment. I understand that this draft will remain for as long as I
use the YMCA School Age Enrichment programs. It is my complete understanding that if I wish to terminate or change my school
age child care program services in any way, I must give the YMCA a 14-day written notice. I understand that if I have a draft
payment that does not clear for insufficient funds, I will be subject to a $20.00 NSF charge by the YMCA.
Signature of account/card holder: ___________________________________________________________
Please note: If you are unable to set up weekly auto draft payments you will need to speak directly with
the School Age Child Care supervisor to determine exactly how your weekly payments will be processed.
OTHER FINANCIAL INFORMATION:
☐ I have applied for Financial Assistance (the completed application is enclosed with this registration form).
☐ (Circle one) ASPIRE / TANF / DHHS Voucher will be covering the cost of my child to attend YMCA School
Age Child Care programs. The contact person at the agency for my file is ______________________________
and his/her phone number is ____________________________________.
Please note: Any weeks of care not covered by a third party becomes the responsibility of the parent.
Parent/Guardian Signature:
Date:
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Student Health History Form & Child Concern Form
Child’s Name:
Date of Birth:
Physician Name:
Phone:
Physician Address:
Dentist Name:
Phone:
Dentist Address:
Hospital Preference:
MEDICAL HISTORY
Does your child have any allergies? ☐ Yes ☐ No
If yes, please explain:
Does your child have asthma? ☐ Yes ☐ No
If yes, please explain:
Does your child take any medications? ☐ Yes ☐ No
If yes, please explain: (Please note: ANY medication administered during program hours must be documented on an
Authorization to Dispense Medication Form )
Does your child carry an epi-pen?
☐ Yes ☐ No
If yes, please explain:
We provide reasonable accommodations to qualified individuals with disabilities. All participants must be able to
participate safely in programs. We do not provide one-on-one supervision and retain the discretion not to enroll or
to remove a participant from our program if that participant is not able to participate safely in the program.
This Medical History form is correct to the best of my knowledge, and my child herein described has permission to
engage in all prescribed school age child care program activities except as noted. I hereby give permission to the
medical personnel selected by the YMCA Director/Coordinator to order x-rays, routine tests, treatment, to release
any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my
child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the
YMCA to secure and administer treatment, including hospitalization for my child named above.
Parent/Guardian Signature:
Date:
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YMCA OF SOUTHERN MAINE
2016-2017 School Age Child Care Program
Child Concern Form
Child’s Last Name:
First Name:
This form is used to assist us in providing the best possible experience for your child while she/he attends School
Age Child Care. Your signature on this form gives us permission to share this information with the School Age
staff who will be working with your child.
Does your child have any behavioral or health concern which you want us to be aware of?
What is your recommendation for the best way for us to help your child?
Are there any specific situations that trigger this concern in your child?
What is typical and/or atypical behavior from your child?
While your child attends school, has there been any plan of action designed to address this concern which has
been effective? If yes, please explain in detail:
Signature of Parent/Guardian: __________________________________________________ Date: ____________________________________
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WAIVERS
General Waiver (Required): I hereby, for myself, heirs, and executors waive and release all claims against the
YMCA of Southern Maine for any danger my child may suffer or acquire during the YMCA School Age Child Care
Program.
Parent/Guardian Signature
Date
Field Trip Transportation Liability Agreement: I give permission for the YMCA to take my child on field trips
(bus or walking). I give my permission for my child to be transported by the appropriate YMCA of Southern Main
staff in a YMCA approved vehicle. I assume any and all liability for damages to or caused by my child in connection
with the transportation services offered by the YMCA, except those caused by gross negligence or intentional act of
the YMCA. I also understand that the YMCA will not be responsible for my child between the YMCA and his/her
residence and vice versa.
Parent/Guardian Signature
Date
Walk Home Liability Agreement (complete only if your child will be walking to/from program without an adult
present): I give permission to have my child picked up and dropped off at the YMCA School Age Child Care program
without a parent/guardian being present. I assume any and all responsibility for my child before he/she arrives and
after the YMCA dismissed my child for the day, and understand that the YMCA will not be responsible for my child
between the YMCA and his/her residence and vice versa.
My child will arrive unaccompanied at: __________________ am each day.
Please dismiss my child from program at: ________________ pm each day.
Parent/Guardian Signature
Date
Aquatic Permission Slip and Liability Agreement I give permission for the YMCA of Southern Maine (“YMCA”) to
provide scheduled, aquatic opportunities to my child. This permission covers any instructional and recreational
activities conducted by the appropriate YMCA staff. I assume any and all liability for damages to or caused by my
child in connection with the aquatic services provided by the YMCA, and unconditionally release the YMCA from any
and all liability therefor or relating thereto, except those caused by the gross negligence or intentional wrongful act
of the YMCA.
Child’s Name: ______________________________________________________________________________
Parent/Guardian Name: _______________________________________
Date: ___________
Parent/Guardian Signature: _______________________________________
Date: ___________
____ I decline. Signature: ______________________________________
Date: ___________
(Check here, sign and date if you do not wish to grant permission).
Media waiver on next page…
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YMCA OF SOUTHERN MAINE
PHOTO AND VIDEO/AUDIO RECORDING RELEASE
I am 18 years of age or older and, if not, my Mother/Father/Legal Guardian has also signed below.
For my participation in activities to be conducted by the YMCA of Southern Maine, I hereby give my permission and
consent, now and for all time, to the YMCA of Southern Maine, the National Council of Young Men’s Christian
Associations of the United States of America (YMCA of the USA) and third parties collaborating with the YMCA of
Southern Maine and/or YMCA of the USA to make, reproduce, edit, broadcast or rebroadcast any video film, footage,
sound track recordings and photo reproductions of me and/or my narrative account of my experience at the YMCA of
Southern Maine, for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business
uses without any compensation to, and/or claim, by me. I may, or may not be, identified in such reproductions;
however, I shall not be stated by name to have endorsed any particular commercial products or commercial services.
I further agree to the following:
- Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative
account of my experience at the YMCA of Southern Maine, I authorize, according to this Release, shall
belong to the YMCA of Southern Maine, YMCA of the USA and third parties collaborating with the YMCA of
Southern Maine and/or YMCA of the USA. Therefore, they will have full right of disposition of any video film,
footage, sound track recordings and photo reproductions of me and/or my narrative account of my
experience at the YMCA of Southern Maine;
- Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account
of my experience at the YMCA of Southern Maine will not be subject to any obligation of confidentiality and
may be shared with and used by the YMCA of Southern Maine, YMCA of the USA and third parties
collaborating with the YMCA of Southern Maine and/or YMCA of the USA;
- The YMCA of Southern Maine, YMCA of the USA and third parties collaborating with the YMCA of Southern
Maine and/or YMCA of the USA shall not be liable for any use or disclosure to a third party of any video film,
footage, sound track recordings and photo reproductions of me and/or my narrative account of my
experience at the YMCA of Southern Maine; and
- The YMCA of Southern Maine, YMCA of the USA and third parties collaborating with the YMCA of Southern
Maine and/or YMCA of the USA shall exclusively own all known or later existing rights to worldwide and shall
be entitled to the unrestricted use any video film, footage, sound track recordings and photo reproductions
of me and/or my narrative account of my experience at the YMCA of Southern Maine for any purpose
without compensation to me.
I agree that my consent and this release are irrevocable. I hereby release and discharge the YMCA of Southern Maine,
YMCA of the USA and third parties collaborating with the YMCA of Southern Maine and/or YMCA of the USA from any
and all claims in connection with the uses and reproductions of any video film, footage, sound track recordings and
photo reproductions of me and/or my narrative account of my experience with the YMCA of Southern Maine as
described herein.
Signature:
Age: _________________
Printed Name: ________________________________________
Address: _______________________________________________________
I am the Mother/Father/Legal Guardian of
_____________________________(child’s name). For the
consideration contained herein, I hereby consent to the foregoing on behalf of my minor child.
Signature of Mother/Father/Legal Guardian:
________________________________Date: ___________________
I decline.
Signature: ____________________
Date:
(Check here, sign and date if you do not wish to grant permission).
___________
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