Before & After Explore Registration 2020

Before & After Explore Registration

Payment of registration fee and first tuition payment are required to complete online registration.
Participant Information
Child's Legal Name *

First Name Last Name
Is this child included on a YMCA Family Membership? *

Yes No
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
Gender *

Male Female
Photo of Child *

Browse Files

Cancel of
What location will your child be attending? *

Disney Field Gray Hickory Hills- after school only (includes middle school) Jeffries Mann Pittman Rountree Twain Wilder
Start Date (must be at least two business days after registration)

Month Day Year
Date
Discharge Date

Month Day Year
Date
Before or After School *

Before After
Pick your Session(s)

July 6-10 (Session 2) July 13-17 (Session 2) July 20-24 (Session 2) July 27-31 (Session 2)
Grade entering Fall 2020 *

Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th
Parent/Guardian Information

Please note: In order to have authority to enforce restraining orders or limited custody arrangements, a copy of a divorce decree or restraining order must be on file with the School Age Services Program.
Parent/Guardian Name *

First Name Last Name
Address same as child's *

Yes No
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Employer or School Name
Employer or School Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Hours *
Work Phone Number *

Area Code Phone Number
Do you want to add a Second Parent/Guardian's information? *

Yes N/A
Second Parent/Guardian Name

First Name Last Name
Address same as child's

Yes No
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number

Area Code Phone Number
Email
example@example.com
Employer or School Name
Employer or School Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Hours
Work Phone Number

Area Code Phone Number
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Emergency Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

People authorized to pick up child other than Parents/Guardians and Emergency Contacts listed above:

Name

Relationship to Child

Primary Phone Number

Authorized to Pick Up

Individual Accomodations

Any individual accommodations must be approved by the Program Director before the child can attend. A special need is considered to be any condition, disease or circumstance that would require our YMCA staff to provide special care, or take special precautions or considerations to properly care for your child. This may include, but is not limited to: food allergies, asthma, behavioral disorders, etc.
Comments on Child's Development
Note Allergies, Habits, Special Language, etc.
*

My child is in good health, is able to participate in group care and has no special health or medical requirements. My child is able to participate in group care, BUT has special health or medical requirements as listed below:
School Age Child's Special Health or Medical Requirements
List any special medical conditions, including chronic health problems, behavior disorders, special needs, etc.
We would like to schedule a phone interview with our Program Director to discuss any accommodations needed in order to set your child up for success. We will get in touch using the contact information you have provided.

Your child will not be registered until you have been contacted by one of our Program Directors and your registration fees have been paid.
Will you be applying for State Childcare Assistance? *

No Yes, for payment assistance Yes, for a foster child Yes, for an adopted child
Will you be applying for YMCA Financial Assistance? *

Yes No
Since you have indicated your child is adopted or part of the foster care system, your registration fee and first tuition payment have been waived, per our agreement with the state. Please contat Business Manager Amanda Black at ablack@orymca.org to get your DVN number to report to your case worker.
Financial Assistance

Thanks to our generous donors, we are able to offer financial assistance to qualifying families that may not otherwise be able to participate in YMCA childcare programs. Please allow two weeks to process financial assistance paperwork. During that time you are responsible for program fees until assistance is approved.
How many adults in household?
How many children in household?
For each adult in the household, please upload copies of the two most recent pay stubs showing 32+ hours per week, including the rate of pay.

Upload a File

Cancel of
Are any of the household adults full-time college students?

Yes No
Please upload the school schedule

Browse Files

Cancel of
Authorization for Medical Care

I understand that I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice.

If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I authorize Ozarks Regional YMCA to contact the following *

Name of Physician/Clinic/Hospital

Phone Number

Physician or Clinic

Hospital

Release and Waiver of Liability
Your Fee Today
prev next ( X )
Registration Fee $ 10.00

NonMember Before Explore Session 2 $ 35.00
NonMember rate for Before Explore Session 2

Member Before Explore Session 2 $ 30.00
Member rate for Before Explore Session 2; valid membership verification required

NonMember After Explore Session 2 $ 40.00
NonMember rate for After Explore Session 2

Member After Explore Session 2 $ 35.00
Member rate for After Explore Session 2; valid membership verification required

Total $ 0.00
Signature of Parent/Guardian *
Should be Empty:

Before & After Explore Registration

Participant Information

Parent/Guardian Information

Individual Accomodations

Financial Assistance

Authorization for Medical Care

Release and Waiver of Liability