D90 Blended Learning Registration Packet

RIVER FOREST SCHOOL DISTRICT 90 CHILDCARE & BLENDED LEARNING SUPERVISION REGISTRATION PACKET
To begin the registration process for the D90 Blended Learning Supervision Program, you will need to complete the registration packet and provide your child(ren)'s health exam form. You will receive an email notification that the registration packet has been received. A team member from the D90 Childcare Team will follow up to confirm when your registration has been finalized.

This online registration form allows you to register for multiple children (up to 4) residing in the same household.

You will need to provide your child(ren)'s health exam form. You will have an oportunity to upload with your registration packet. The form must be received prior to first day of program attendance. If you are unable to upload the form, you can email the form to D90childcare@westcookymca.org. If your child(ren) was a previous D90 participant and we have your health form on file, you do not need to resubmit.

Parent/Guardian 2 Information
Parent/Guardian 2 Name *

First Name Middle Name Last Name Suffix
Parent/Guardian 2 Email *
example@example.com
Parent/Guardian 2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 2 Primary Phone *

Area Code Phone Number
Type of phone number *

Cell Home Work
Parent/Guardian 2 Other Phone *

Area Code Phone Number
Type of phone number *

Cell Home Work
Parent/Guardian 2 Place of Work
Parent/Guardian 2 Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Family Dynamics: (please share any information you believe can assist our staff in the care of your child) *
If necessary, of the above listed Parent/Guardians, who should we contact we contact first? *

WEST COOK YMCA PICK-UP AUTHORIZATION
All individuals who wish to pick up your child must be listed below. (Excluding parents and guardians listed on the general information sheet.) For the safety of your child, anyone picking up your child must have a picture I.D. Anyone without proper authorization will not be allowed to take your child.

REQUIRED: Emergency contacts (in the case that guardians are not able to be reached during program) These Individuals are also authorized to pick up child:
Emergency Contact 1 *

First Name Last Name
Emergency Contact 1 Relationship to Child(ren) *
Emergency Contact 1 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact 1 Daytime Phone *

Area Code Phone Number
Emergency Contact 1 Evening Phone *

Area Code Phone number
Emergency Contact 1 Cell Phone *

Area Code Phone Number
Emergency Contact 2 Name

First Name Last Name
Emergency Contact Relationship to Child(ren)
Emergency Contact 2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact 2 Daytime Phone

Area Code Phone Number
Emergency Contact 2 Evening Phone

Area Code Phone Number
Emergency Contact 2 Cell Phone

Area Code Phone Number
Optional: Pick-Up Authorization

I authorize the following additional people listed to pick up my child. I do not authorize additional people to pick up my child

Authorized Additonal Pick Ups
Additional Pick-Up 1 Name

First Name Last Name
Additional Pick-Up 1 City Located
Additional Pick-Up 1 Phone Number

Area Code Phone Number
Additonal Pick-Up 1: Conditions for releasing child (if any)
Additional Pick-Up 2 Name

First Name Last Name
Additional Pick-Up 2 City Located
Additional Pick-Up 2 Phone

Area Code Phone Number
Additional Pick-Up 2 Conditions for Releasing Child (if any)
Additional Pick-Up 3 Name

First Name Last Name
Additional Pick-Up 3 City Located
Additional Pick-Up 3 Phone

Area Code Phone Number
Additional Pick-Up 3 Conditions for Releasing for Child (if any)
Additional Pick-Up 4 Name

First Name Last Name
Additional Pick-Up 4 City Located
Additional Pick-Up 4 Phone

Area Code Phone Number
Additional Pick-Up 4 Conditions for Releasing Child (if any)
Additional Pick-Up 5 Name

First Name Last Name
Additional Pick-Up 5 City Located
Additional Pick-Up 5 Phone

Area Code Phone Number
Additional Pick-Up 5 Conditions for Releasing Child (if any)
If anyone other than those listed will be picking up your child, you must contact Youth Development Program Staff via d90childcare@westcookymca.org. Phone authorization will not be sufficient. Reminder that all need photo I.D. needed for pick up authorization.

STUDENT 1 APPROVAL FOR WEST COOK YMCA ACTIVITIES

Please check all the appropriate boxes that you are approving or not approving and sign and date at the bottom of the page.
Photo/Video Permission Authorization *

I give permission for my child to have their picture and/or video taken as part of the West Cook YMCA Program. I understand that the picture or video may be displayed within the facility, in the newspaper, or on other media outlets. I DO NOT give permission for my child to have their picture and/or video takenfor the purpose of using within the facility, newspapers, or other mediaoutlets.
Emergency Medical Authorization: The purpose of this authorization is to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under our supervision when parents or guardians cannot be reached. *

I hereby give my consent for the administration of any medical treatment deemed necessary by our family doctor or another licensed physician at the closest hospital facility. I DO NOT give my consent for the emergency medical treatment beyond basic first aid for my child. In the event of sudden illness or injury requiring emergency medical treatment, I hereby give the YMCA staff authority to do the following:
I approve as checked above and know the responsibility would rely on me for any medical costs that would come up. I give authorization based on the above boxes checked: *

Clear
Date Signed *

Month Day Year
Date

STUDENT 1 HEALTH HISTORY FORM
Pediatrician's Name *

First Name Last Name
Pediatrician's Phone *

Area Code Phone Number
Pediatrician's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dentist's Name *

First Name Last Name
Dentist's Phone *

Area Code Phone Number
Dentist's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medications/Dietary Restrictions *
If your child needs medication administered to him/her during program please complete the medical distribution permission form. Please list ANY additional information about your child’s health history, behavior, and physical, emotional, or mental health about which the YMCA staff should be aware. All information given is confidential and will only be viewed by necessary YMCA staff.
Does your child currently have a 504 plan in place? Please describe: *
Does your child currently have an IEP in place? Please describe: *

WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY
Please list all siblings and their ages and other members of your households *
Developmental and Social Experience
How would you describe your child: *
Does your child respond to being in large and small groups: *
Languages spoken at home: *
Does your child have any fears: *
Swimming and water experience: *
Previous experience with other children: *
Reaction to strangers: *
How do you comfort your child: *
What is the method of behavior management at home: *
What would you like your child to gain from this experience: *
Please give us any other information which would help us to know your child better such as habits, developmental barriers, medical needs, behavioral concerns, fears, or any other factors that would beimportant to know: *
Health History and Eating Habits
Serious illnesses and/or hospitalizations: *
Special physical conditions or disabilities that may require accomodations (please be specific): *
Regular medications and/or allergies i.e. asthma, hay fever, insect bites, medicine, food reactions or intolderances: *
Dietary Restrictions *
Are there any more details or comments about your child we should know? *
Upload your child's health exam form. If your form is not submitted with the registration packet, it will need to be emailed to D90childcare@westcookymca.org prior to the first day of attendance.

Browse Files

Cancel of

STUDENT 1 MEDICAL DISTRIBUTION PERMISSION FORM
(Only for students who will take medication during program or needs medicine, including an inhaler or Epi-pen, to be kept on-site.)

I give the West Cook YMCA permission to administer the following medication to my child.
- Medication must be in its original, labeled container. No medication will be accepted if not the original container.
- The child’s name must be on the medication container.
- The date on the prescription must be current (within 1 month for antibiotics; and within 1 year for other medications).
- The medication’s name, dose and frequency of administration on the label must be consistent with parental instructions.
Reason for Medication
Date to start medication

Month Day Year
Date
Days to be given

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Prescribing Physician's Name:

First Name Last Name
Prescribing Physician's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Prescribtion Number
Directions for administering (dosage, time of day, times per day, etc.)
Other
Parent/Guardian's Signature

Clear
Date Signed

Month Day Year
Date

Would you like to add another student

Yes No

STUDENT 2 APPROVAL FOR WEST COOK YMCA ACTIVITIES

Please check all the appropriate boxes that you are approving or not approving and sign and date at the bottom of the page.
Photo/Video Permission Authorization *

I give permission for my child to have their picture and/or video taken as part of the West Cook YMCA Program. I understand that the picture or video may be displayed within the facility, in the newspaper, or on other media outlets. I DO NOT give permission for my child to have their picture and/or video takenfor the purpose of using within the facility, newspapers, or other mediaoutlets.
Emergency Medical Authorization: The purpose of this authorization is to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under our supervision when parents or guardians cannot be reached. *

I hereby give my consent for the administration of any medical treatment deemed necessary by our family doctor or another licensed physician at the closest hospital facility. I DO NOT give my consent for the emergency medical treatment beyond basic first aid for my child. In the event of sudden illness or injury requiring emergency medical treatment, I hereby give the YMCA staff authority to do the following:
I approve as checked above and know the responsibility would rely on me for any medical costs that would come up. I give authorization based on the above boxes checked: *

Clear
Date Signed *

Month Day Year
Date

STUDENT 2 HEALTH HISTORY FORM
Pediatrician's Name *

First Name Last Name
Pediatrician's Phone *

Area Code Phone Number
Pediatrician's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dentist's Name *

First Name Last Name
Dentist's Phone *

Area Code Phone Number
Dentist's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medications/Dietary Restrictions *
If your child needs medication administered to him/her during program please complete the medical distribution permission form. Please list ANY additional information about your child’s health history, behavior, and physical, emotional, or mental health about which the YMCA staff should be aware. All information given is confidential and will only be viewed by necessary YMCA staff.
Does your child currently have a 504 plan in place? Please describe: *
Does your child currently have an IEP in place? Please describe: *

STUDENT 2 WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY
Please list all siblings and their ages and other members of your households *
Developmental and Social Experience
How would you describe your child: *
Does your child respond to being in large and small groups: *
Languages spoken at home: *
Does your child have any fears: *
Swimming and water experience: *
Previous experience with other children: *
Reaction to strangers: *
How do you comfort your child: *
What is the method of behavior management at home: *
What would you like your child to gain from this experience: *
Please give us any other information which would help us to know your child better such as habits, developmental barriers, medical needs, behavioral concerns, fears, or any other factors that would beimportant to know: *
Health History and Eating Habits
Serious illnesses and/or hospitalizations: *
Special physical conditions or disabilities that may require accomodations (please be specific): *
Regular medications and/or allergies i.e. asthma, hay fever, insect bites, medicine, food reactions or intolderances: *
Dietary Restrictions *
Are there any more details or comments about your child we should know? *
Upload your child's health exam form. If your form is not submitted with the registration packet, it will need to be emailed to D90childcare@westcookymca.org prior to the first day of attendance.

Browse Files

Cancel of

STUDENT 2 MEDICAL DISTRIBUTION PERMISSION FORM
(Only for students who will take medication during program or needs medicine, including an inhaler or Epi-pen, to be kept on-site.)

I give the West Cook YMCA permission to administer the following medication to my child.
- Medication must be in its original, labeled container. No medication will be accepted if not the original container.
- The child’s name must be on the medication container.
- The date on the prescription must be current (within 1 month for antibiotics; and within 1 year for other medications).
- The medication’s name, dose and frequency of administration on the label must be consistent with parental instructions.
Reason for Medication
Date to start medication

Month Day Year
Date
Days to be given

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Prescribing Physician's Name:

First Name Last Name
Prescribing Physician's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Prescribtion Number
Directions for administering (dosage, time of day, times per day, etc.)
Other
Parent/Guardian's Signature

Clear
Date Signed

Month Day Year
Date

Would you like to add another student

Yes No

STUDENT 3 APPROVAL FOR WEST COOK YMCA ACTIVITIES

Please check all the appropriate boxes that you are approving or not approving and sign and date at the bottom of the page.
Photo/Video Permission Authorization *

I give permission for my child to have their picture and/or video taken as part of the West Cook YMCA Program. I understand that the picture or video may be displayed within the facility, in the newspaper, or on other media outlets. I DO NOT give permission for my child to have their picture and/or video takenfor the purpose of using within the facility, newspapers, or other mediaoutlets.
Emergency Medical Authorization: The purpose of this authorization is to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under our supervision when parents or guardians cannot be reached. *

I hereby give my consent for the administration of any medical treatment deemed necessary by our family doctor or another licensed physician at the closest hospital facility. I DO NOT give my consent for the emergency medical treatment beyond basic first aid for my child. In the event of sudden illness or injury requiring emergency medical treatment, I hereby give the YMCA staff authority to do the following:
I approve as checked above and know the responsibility would rely on me for any medical costs that would come up. I give authorization based on the above boxes checked: *

Clear
Date Signed *

Month Day Year
Date

STUDENT 3 HEALTH HISTORY FORM
Pediatrician's Name *

First Name Last Name
Pediatrician's Phone *

Area Code Phone Number
Pediatrician's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dentist's Name *

First Name Last Name
Dentist's Phone *

Area Code Phone Number
Dentist's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medications/Dietary Restrictions *
If your child needs medication administered to him/her during program please complete the medical distribution permission form. Please list ANY additional information about your child’s health history, behavior, and physical, emotional, or mental health about which the YMCA staff should be aware. All information given is confidential and will only be viewed by necessary YMCA staff.
Does your child currently have a 504 plan in place? Please describe: *
Does your child currently have an IEP in place? Please describe: *

STUDENT 3 WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY
Please list all siblings and their ages and other members of your households *
Developmental and Social Experience
How would you describe your child: *
Does your child respond to being in large and small groups: *
Languages spoken at home: *
Does your child have any fears: *
Swimming and water experience: *
Previous experience with other children: *
Reaction to strangers: *
How do you comfort your child: *
What is the method of behavior management at home: *
What would you like your child to gain from this experience: *
Please give us any other information which would help us to know your child better such as habits, developmental barriers, medical needs, behavioral concerns, fears, or any other factors that would beimportant to know: *
Health History and Eating Habits
Serious illnesses and/or hospitalizations: *
Special physical conditions or disabilities that may require accomodations (please be specific): *
Regular medications and/or allergies i.e. asthma, hay fever, insect bites, medicine, food reactions or intolderances: *
Dietary Restrictions *
Are there any more details or comments about your child we should know? *
Upload your child's health exam form. If your form is not submitted with the registration packet, it will need to be emailed to D90childcare@westcookymca.org prior to the first day of attendance.

Browse Files

Cancel of

STUDENT 3 MEDICAL DISTRIBUTION PERMISSION FORM
(Only for students who will take medication during program or needs medicine, including an inhaler or Epi-pen, to be kept on-site.)

I give the West Cook YMCA permission to administer the following medication to my child.
- Medication must be in its original, labeled container. No medication will be accepted if not the original container.
- The child’s name must be on the medication container.
- The date on the prescription must be current (within 1 month for antibiotics; and within 1 year for other medications).
- The medication’s name, dose and frequency of administration on the label must be consistent with parental instructions.
Reason for Medication
Date to start medication

Month Day Year
Date
Days to be given

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Prescribing Physician's Name:

First Name Last Name
Prescribing Physician's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Prescribtion Number
Directions for administering (dosage, time of day, times per day, etc.)
Other
Parent/Guardian's Signature

Clear
Date Signed

Month Day Year
Date

Would you like to add another student

Yes No

STUDENT 4 APPROVAL FOR WEST COOK YMCA ACTIVITIES

Please check all the appropriate boxes that you are approving or not approving and sign and date at the bottom of the page.
Photo/Video Permission Authorization *

I give permission for my child to have their picture and/or video taken as part of the West Cook YMCA Program. I understand that the picture or video may be displayed within the facility, in the newspaper, or on other media outlets. I DO NOT give permission for my child to have their picture and/or video takenfor the purpose of using within the facility, newspapers, or other mediaoutlets.
Emergency Medical Authorization: The purpose of this authorization is to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under our supervision when parents or guardians cannot be reached. *

I hereby give my consent for the administration of any medical treatment deemed necessary by our family doctor or another licensed physician at the closest hospital facility. I DO NOT give my consent for the emergency medical treatment beyond basic first aid for my child. In the event of sudden illness or injury requiring emergency medical treatment, I hereby give the YMCA staff authority to do the following:
I approve as checked above and know the responsibility would rely on me for any medical costs that would come up. I give authorization based on the above boxes checked: *

Clear
Date Signed *

Month Day Year
Date

STUDENT 4 HEALTH HISTORY FORM
Pediatrician's Name *

First Name Last Name
Pediatrician's Phone *

Area Code Phone Number
Pediatrician's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Dentist's Name *

First Name Last Name
Dentist's Phone *

Area Code Phone Number
Dentist's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medications/Dietary Restrictions *
If your child needs medication administered to him/her during program please complete the medical distribution permission form. Please list ANY additional information about your child’s health history, behavior, and physical, emotional, or mental health about which the YMCA staff should be aware. All information given is confidential and will only be viewed by necessary YMCA staff.
Does your child currently have a 504 plan in place? Please describe: *
Does your child currently have an IEP in place? Please describe: *

STUDENT 4 WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY
Please list all siblings and their ages and other members of your households *
Developmental and Social Experience
How would you describe your child: *
Does your child respond to being in large and small groups: *
Languages spoken at home: *
Does your child have any fears: *
Swimming and water experience: *
Previous experience with other children: *
Reaction to strangers: *
How do you comfort your child: *
What is the method of behavior management at home: *
What would you like your child to gain from this experience: *
Please give us any other information which would help us to know your child better such as habits, developmental barriers, medical needs, behavioral concerns, fears, or any other factors that would beimportant to know: *
Health History and Eating Habits
Serious illnesses and/or hospitalizations: *
Special physical conditions or disabilities that may require accomodations (please be specific): *
Regular medications and/or allergies i.e. asthma, hay fever, insect bites, medicine, food reactions or intolderances: *
Dietary Restrictions *
Are there any more details or comments about your child we should know? *
Upload your child's health exam form. If your form is not submitted with the registration packet, it will need to be emailed to D90childcare@westcookymca.org prior to the first day of attendance.

Browse Files

Cancel of

STUDENT 4 MEDICAL DISTRIBUTION PERMISSION FORM
(Only for students who will take medication during program or needs medicine, including an inhaler or Epi-pen, to be kept on-site.)

I give the West Cook YMCA permission to administer the following medication to my child.
- Medication must be in its original, labeled container. No medication will be accepted if not the original container.
- The child’s name must be on the medication container.
- The date on the prescription must be current (within 1 month for antibiotics; and within 1 year for other medications).
- The medication’s name, dose and frequency of administration on the label must be consistent with parental instructions.
Reason for Medication
Date to start medication

Month Day Year
Date
Days to be given

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Prescribing Physician's Name:

First Name Last Name
Prescribing Physician's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Prescribtion Number
Directions for administering (dosage, time of day, times per day, etc.)
Other
Parent/Guardian's Signature

Clear
Date Signed

Month Day Year
Date

Should be Empty:

RIVER FOREST SCHOOL DISTRICT 90 CHILDCARE & BLENDED LEARNING SUPERVISION REGISTRATION PACKET

Parent/Guardian 1 Information

Parent/Guardian 2 Information

WEST COOK YMCA PICK-UP AUTHORIZATION

Authorized Additonal Pick Ups

Student # 1 Information

STUDENT 1 APPROVAL FOR WEST COOK YMCA ACTIVITIES

STUDENT 1 HEALTH HISTORY FORM

WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY

STUDENT 1 MEDICAL DISTRIBUTION PERMISSION FORM

Student # 2 Information

STUDENT 2 APPROVAL FOR WEST COOK YMCA ACTIVITIES

STUDENT 2 HEALTH HISTORY FORM

STUDENT 2 WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY

STUDENT 2 MEDICAL DISTRIBUTION PERMISSION FORM

Student # 3 Information

STUDENT 3 APPROVAL FOR WEST COOK YMCA ACTIVITIES

STUDENT 3 HEALTH HISTORY FORM

STUDENT 3 WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY

STUDENT 3 MEDICAL DISTRIBUTION PERMISSION FORM

Student # 4 Information

STUDENT 4 APPROVAL FOR WEST COOK YMCA ACTIVITIES

STUDENT 4 HEALTH HISTORY FORM

STUDENT 4 WEST COOK YMCA SCHOOL AGE DEVELOPMENTAL HISTORY

STUDENT 4 MEDICAL DISTRIBUTION PERMISSION FORM