EXTENDED KINDERGARTEN
2015 – 2016 REGISTRATION FORM
The RC Durr YMCA location serves and provides transportation for: Burlington, IHM, Goodridge, Longbranch and
Stephens. We also offer an Extended Kindergarten program on site at Thornwilde and North Pointe Elementary.
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.
(if applicable)
Street Address
Street
Address
City/State/Zip
City/State/Zip
Gender
Male
Female
(Circle)
Age
D.O.B.
Grade

Phone(Home)
Kindergarten
School/Location
Attending
Place a
next to the
best
number to
call while
your child is
in the
program.
Phone(Cell)
Phone(Work)
Which Kindergarten session is
your child attending @ school?
AM K
PM K
Email Address
United Way Reporting: MANDATORY
Registration Fees
Registration Fee: $50 per child
Non-refundable/Non-transferable/Due at the time of registration
Monthly Even Billing
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?
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.
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!
Participant's Race: (Circle one)
White/Caucasian
Black/African-American
American Indian
Native Hawaiian/Pacific Islander
Hispanic
Multi-Racial
Asian
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.
 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:
Extended Kindergarten
Ext. K 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 and Stephens.
All of our Extended Kindergarten programs follow the Boone County Public School District Calendar. 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.
Student's Name:
Automatic Payment (Mandatory):
Parents/Guardians must pay the monthly rate automatically through a credit or debit card. Please fill out the payment information below. Be assured,
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.
Days of Program
YMCA Child Care
Programs
(When applicable, please indicate which
days of the week your child will attend)
Before School Extended K
Circle the 4 to 5 days your child will attend:
Full Time (4 to 5 Day Program)
Before School Extended K
Part Time (1 to 3 Day Program)
After School Extended K
Full Time (4 to 5 Day Program)
After School Extended K
Part Time (1 to 3 Day Program)
Before & After Extended K
Full Time (4 to 5 Day Program)
Before & After Extended K
Part Time (1 to 3 Day Program)
Extended K ONLY
Full Time (4 to 5 Day Program)
Extended K ONLY
Part Time (1 to 3 Day Program)
M
T
W
TH
F
Circle the 1 to 3 days your child will attend:
M
T
W
TH
F
Circle the 4 to 5 days your child will attend:
M
T
W
TH
F
Circle the 1 to 3 days your child will attend:
M
T
W
TH
F
Circle the 4 to 5 days your child will attend:
M
T
W
TH
F
Circle the 1 to 3 days your child will attend:
M
T
W
TH
F
Circle the 4 to 5 days your child will attend:
M
T
W
TH
F
Circle the 1 to 3 days your child will attend:
M
T
W
TH
F
Time of Program
Monthly
Flat Rate
6:30 am – 4:00 pm
$385
6:30 am – 4:00 pm
$255
(Minus school day)
(Minus school day)
9:00 am – 6:00 pm
(Minus school day)
$445
9:00 am – 6:00 pm
$320
6:30 am – 6:00 pm
$510
(Minus school day)
(Minus school day)
6:30 am – 6:00 pm
$385
8:50 am – 3:40 pm
$215
(Minus school day)
(Minus Kindergarten day)
8:50 am – 3:40 pm
(Minus Kindergarten day)
Place an "X" for program
registering for
$120
Please Note that parents are responsible for completing transportation information at their child’s school. The Y does not arrange any bus
services, changes, etc. with the Boone County Transportation Offices. However, we must work closely with the schools so that we ensure your child is
where they need to be, when they need to be there! Please complete the following information:
THORNWILDE & NORTH POINTE EXT. K ONLY: Check ALL that apply!
My child will ride the bus to school on the morning bus/afternoon bus (circle one)
My child will ride the bus home at the end of their school day (3:40pm)
My child will need to attend the Before School program before their Kindergarten day (6:30 am – 8:30 am)
My child will need to attend the After School program after their Kindergarten day (3:40 pm - 6 pm)
Office Use Only:
Processing Initials:
MS/Staff: _________________________
Y Account #: _________________________________________
AS400: ___________________________
ACCESS: _________________________