School Age Child Care (SACC)
2015 – 2016 REGISTRATION FORM
Proudly serving the following schools:
Burlington, Camp Ernst, Conner, IHM,
Goodridge, Longbranch, Stephens, Thornwilde, North Pointe
Registration is a quick method of “holding a spot” for your child. To register your child, you will need to complete this two-sided
registration form in full for each child and also pay the registration fee. Only one student per form! Registration is only step
one of the enrollment process. You will also need to return a completed Enrollment Packet with an attached copy of a valid
KY Immunization Certificate prior to your child starting in the program. Monthly Payment will be charged prior to the start of
each new month.
Effective Start Date:
This is the date your child is officially registered to start
the program and fees will begin to be applied! Opening day for
this program is August 13, 2015
Today's Date:
Student Information
Parent/Guardian Information
Name
Nickname
Name
D.O.B.
Street
Address
Street
Address
City/State/Zip
City/State/Zip
(if applicable)
School
Attending
Gender
Phone
Male
(Circle)
Female
Age
Place a
(Home)
D.O.B.
Phone
Grade
Phone
next to
the best
number to
call while
your child is
in the
program.
(Cell)
(Work)
Email Address
Registration Fees
Registration Fee: $30 per child or $50 per family
Non-refundable/Non-transferable/Due at the time of registration
Monthly Even Billing
Tuition must be paid the last Friday of the
month prior to the month attending.
Fees are charged to a credit/debit card on file.
United Way Reporting: MANDATORY
To help us in our required reporting, we request the following
information. It will be kept confidential. This information is for United
Way Reporting purposes ONLY!
Total number of people in your household?
Participant's Race: (Circle one)
Discounts:
Receive 10% off by paying for the school year in full!
We also offer a multiple child discount!
Receive 10% off each additional child!
White/Caucasian
Black/African-American
American Indian
Native Hawaiian/Pacific Islander
Asian
Hispanic
Multi-Racial
Other
Household Income: (Check one)
$0 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 +
Parent Acknowledgements:
 I understand that program fees are a flat monthly rate. Payment is due in advance of the month attending. (To discuss
special payment arrangements, contact the Child Care Billing Department.)
 I understand that if I withdraw my child from the program, I must complete a Change of Program form two weeks in
advance; If I am only changing/updating my child's program registration, I must submit the Change of Program form with
one week notice. I further understand that I will be held financially responsible for all tuition fees accrued, following the above
outlined notice requirements.
 I understand that registration is only Step #1 in the enrollment process. I will need to complete all of the remaining steps of the
registration and enrollment process before my child will officially be enrolled in any Child Care Program.
Parent Signature:
Date:
SACC
SACC services are available on site at RC Durr YMCA, Thornwilde Elementary and North
Pointe Elementary. The RC Durr YMCA location serves and provides transportation for: Burlington, Immaculate Heart of
Mary, Goodridge, Longbranch, Stephens, Camp Ernst Middle, and Conner Middle Schools.
All programs are based on an even billing system, which is calculated by the average cost for the entire school year. Full payment is
due for each month, even if students do not attend the program due to absences, vacations, school breaks, holidays, etc. All Y
Before & After SACC programming follow the Boone County School schedule.
Parent Note:Name:
Before and After School programs are available for Burlington Elementary, Goodridge, Longbranch, Stephens,
Student's
Thornwilde and North Pointe. We only offer After School programs for IHM, Camp Ernst and Conner Middle Schools. All
Automatic
(Mandatory):
programs are Payment
held at the RC
Durr YMCA with the exception of the Thornwilde and North Pointe programs, which are held on
Parents/Guardians must pay the monthly rate automatically through a credit or debit card. Please fill out the payment information below. Be assured,
site
at the schools!
this
information
is kept on file in a secure location. If you have questions or wish to discuss special payment circumstances, contact Jennifer Walker in
the Billing Department at: jwalker@myy.org or call 859-334-6513
WE DO NOT KEEP CREDIT CARD INFORMATION ON FILE FROM PAST PROGRAMS! YOU MUST FILL OUT THE BELOW INFORMATION!
Select type of card:
Visa
MasterCard
Expiration Date:
American Express
Account number:
Name as appears on card:
Billing Address:
Check here if you wish to have your Registration Fee charged to your credit/debit card listed above. Please note, your
credit/debit card will be charged for the Registration Fee if no check/money order is attached.
Check here if you wish to be contacted about Paying in Full to receive a 10% discount.
SACC
Programs
Before School
Full Time
(4 to 5 Day Program)
Before School
Part Time
(1 to 3 Day Program)
After School
Full Time
(4 to 5 Day Program)
After School
Part Time
(1 to 3 Day Program)
Before & After School
Full Time
(4 to 5 Day Program)
Before & After School
Part Time
(1 to 3 Day Program)
Conner, IHM, CEM
After School
Full Time
Days of Program
(Please indicate which days of the week
your child will attend)
Circle the 4 to 5 days your child will attend:
M
T
W
TH
F
Varies
Circle the 1 to 3 days your child will attend:
M
T
W
TH
F
Varies
Circle the 4 to 5 days your child will attend:
M
T
W
TH
F
Varies
Circle the 1 to 3 days your child will attend:
M
T
W
TH
F
Varies
Circle the 4 to 5 days your child will attend:
M
T
W
TH
F
Varies
Circle the 1 to 3 days your child will attend:
M
T
W
TH
F
Varies
Circle the 4 to 5 days your child will attend:
M
T
W
TH
F
Varies
Time of
Program
Monthly
Flat Rate
6:30 – 8:50 am
$170
6:30 – 8:50 am
$110
3:45 – 6:00 pm
$235
3:45 – 6:00 pm
$170
Before: 6:30 – 8:50 am
After: 3:45 – 6:00 pm
$300
Before: 6:30 – 8:50 am
After: 3:45 – 6:00 pm
$215
2:15 – 6:00 pm
$255
2:15 – 6:00 pm
$195
√ Program
Registering
for
(4 to 5 Day Program)
Conner, IHM &CEM
After School
Part Time
(1 to 3 Day Program)
Circle the 1 to 3 days your child will attend:
M
T
W
TH
Office Use Only:
F
Varies
Processing Initials:
MS/Staff: _________________________
Y Account #: _________________________________________
AS400: ___________________________
ACCESS: _________________________