Date given: ________________
Returned Date: _____________
Registrations $30.00
Cash/Check/ Card
YMCA Community Preschool
Child’s Legal Name _____________________________________________
Name Child Goes By ______________________
Sex: Male / Female
Address of Child ______________________________________________
Home Phone ______________ Birth Date ____________ Age ________
Mothers Name_________________ Fathers Name __________________
Mothers Date of Birth ____________ Fathers Date of Birth ______________
Address of Parents /Guardians ______________________________
Father’s Employer ____________________
Work Phone _____________
Mother’s Employer ____________________
Work Phone _____________
Parent / Guardians email address __________________________________
Marital Status: Married ___ Single __ Separated __ Divorced __ Other ____
Custody / Visitation Arrangements:_________________________________
Is child adopted? __ If yes: Age of adoption __Is child aware of adoption? __
EMERGENCY INFORMATION
Persons Authorized to Pick Up Your Child other than Parents:
1.Name _______________ Phone ___________
Relationship _____________
2.Name _______________ Phone ___________
Relationship _____________
3.Name _______________ Phone ___________
Relationship _____________
4.Name _______________ Phone ___________
Relationship _____________
Persons To Be Notified In Case Of An Emergency
1.Name_________________
Phone _________
Relationship _____________
2.Name ________________
Phone _________
Relationship _____________
3.Name ________________
Phone _________
Relationship _____________
Child’s Information
Please explain any health problems (allergies, asthma, etc.) your child has
that we should be aware of
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Does your child have any vision or hearing problems?
_____________________________________________________________
_____________________________________________________________
Please explain any medications your child is taking.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Will it be necessary to administer the medications during school hours?
____________________
Is your child allergic to any medications? ____
Please list:__________________________________________
Is your child allergic to any foods? _____
Please list: __________________________________
Please list any concerns about any aspect of your child’s development?
_____________________________________________________________
_____________________________________________________________
Please list any language other than English used in the home:
____________________________
Please list any previous preschool, daycare, or group play
experiences:___________________________________________________
_______________________________________
Please list the names, age and relationship of all people living in your home.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Preschool Medical Consent Form
_________________
__________________
_______________
Child’s Name
Address
Phone #
_________________________________
______________
Father’s Work Address
Work #
_________________________________
______________
Mother’s Work Address
Work #
In the event reasonable attempts to contact me at __________ or___________ at
(phone #)
(other parent/guardian)
__________ have been unsuccessful, I hereby give consent for the
(phone #)
administration of any treatment deemed necessary by Dr. ____________ at
(physicians’ name)
________________. In the event our preferred physician is not available,
(phone#)
the child will be transported to___________________ or a hospital
(preferred hospital)
reasonably accessible. This authorization does not cover major surgery unless the
medical opinions of two other Licensed Physicians concur that it is necessary for
such surgery. These opinions must be obtained prior to the performance of such
surgery.
__________________________________________
________________
(Signature of parent/guardian)
(Date)
I DO NOT give consent for emergency medical treatment of my child in the event of
illness or injury requiring emergency treatment. I wish the YMCA authorities to
take NO ACTIONS or
TO:
__________________________________________________________________
__________________________________________________________________
___________________________________________________
__________________________________________
(Signature of parent/guardian)
________________
(Date)
Permission Form
PERMISSION FOR:
Child: __________________________
Birth date: _________________
Parent/Guardian: ______________________________________________
Address: _____________________________________________________
Phone: _______________________________
In the following permission statements the phrase “my child” refers to the above
child.
Field Trip Permission
I give my permission to the YMCA for my child to participate in the activities away
from the YMCA facility and release the YMCA from all responsibility for injury
resulting from such activities.
_________________
(Initial)
Publicity Permission
I give my permission for pictures to be taken of my child while participating in
activities in the preschool program. Such pictures may be used for instructional
and promotional purposes including newspaper advertisements and the Y website
and Facebook pages.
_________________
(Initial)
Curriculum
I acknowledge that curriculum may include Good Touch / Bad Touch, Education of
guns, Drugs and Strangers.
__________________
(Initial)
I have read, initialed and give permission for the above activities.
_________________________________
(Signature of Parent or Guardian)
__________________
(Date)
YMCA Community Preschool Tuition
Pre-K Class (Mon-Wed-Fri)
Fun Bunch Class (Tue & Thur)
8:30 am – 11:00 am
8:30 am – 11:00am
1st Semester (18 weeks)
Aug
$60
Sept-Dec
$120/month
$540
1st Semester (18 weeks)
Aug
$36
Sept-Dec
$72/month
$324
2nd Semester (20 weeks)
Jan-May
$120/month
$600
2nd Semester (20 weeks)
Jan-May
$72/month
$360
Total Tuition for year
$1,140
Total Tuition for year
$684
Registration Fee: $30 (Due upon enrollment)
Payments may be made by the semester or monthly.
Monthly payments – Should be made by the 5th of each month.
Semester payments – Due to the Y Fiscal year, first semester payment
must be made in two installments.
-August-October tuition is due by August 30th.
-November and December tuition is due by November 15th.
-Second Semester payment is due by January 15th.
Attendance Policies
A student is not given vacation or sick days. Extended absences will not
affect tuition amount. The YMCA Community Preschool is closed when the
Randolph Central School Corporation is closed. Refer to the weather policy
in the parent handbook for further instructions.
Financial Agreement
I have read the Tuition and Attendance Policies for the YMCA Community
Preschool. I agree to pay the fees according to their policy. I understand
that if I do not pay, my child will be put on a waiting list and another child
will be given his/her place. I also understand that is my account becomes
exceedingly delinquent the YMCA may be forced to hand my account over to
a collections agency.
I choose to pay by semester. I understand payments are due in the
following manner: August- October due by August 30th. November –
December are due by November 30th. Second semester payment is due by
January 15th.
_______________
(Initial)
I choose to pay monthly. I understand that payment is to be made by the
5th of each month.
_______________
(Initial)
A $5 late fee will be added to your account if payment is not received when
due.
_________________________
_________________
Signature of Parent or Guardian
Date