Ozark Mountain Summer Day Camp Registration 2023

Ozark Mountain Family YMCA Summer Day Camp Registration

Payment of registration fee and first tuition payment are required to complete online registration.
Automatic Payments
At this time, your account is not set up for auto pay. If you would like to sign up for automatic payments, please download the form and return it to your YMCA location, or fax it to 417-896-7002.

Please contact ymcasasbiling@orymca.org for any questions regarding automatic payments, account changes, or any other billing related questions.
Participant Information
Child's Legal Name*

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

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Photo of Child*

Browse Files

Cancelof
Grade entering Fall 2023*

Kindergarten1st2nd3rd4th5th
Shirt Size*

Youth 6/8Youth 10/12Youth 14/16Adult SmallAdult MediumAdult LargeAdult XLAdult XXL
Start Date*

MonthDayYear
Date
Please check week(s) your child will be attending. Changes require a 2 week notification emailed to ymcasasbilling@orymca.org

May 29June 5June 12June 19June 26July 3* (closed July 4th)July 10July 17July 24July 31August 7August 14
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.
Primary Parent/Guardian(person responsible for tuition payments)*

First NameLast Name
Address same as child's*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Work Hours*
Work Phone Number*

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

YesN/A
Second Parent/Guardian Name

First NameLast Name
Address same as child's

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number

Area CodePhone Number
Email
example@example.com
Work Hours
Work Phone Number

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Address*

Street Address

Street Address Line 2

CityState / 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
Authorized to Pick Up
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:
Comments on Child's Development, Special Health or Medical Requirements
List any allergies, habits, 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?*

NoYes, for payment assistanceYes, for a foster childYes, for an adopted child
Will you be applying for YMCA Financial Assistance?*

YesNo
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 give the following DVN to your case worker in order for payments to be authorized.

Ozark Mountain Family YMCA - DVN 001993571
Payment Assistance

Since you have indicated that you would be seeking childcare payment assistance you will need to contact the state offices and provide the following DVN for your chosen location in order to have your payments authorized. Without your state letter of authorization the YMCA is unable to charge the prorated amount.

Ozark Mountain Family YMCA - DVN 001993571
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. Proof of all household income is required before this application can be processed. Please submit the following documents received by anyone in your household to saspaymentassistance@orymca.org:
- Last two paystubs for anyone working in the home
- Unemployment
- Disability
- Social Security
- Food stamps
- Child support
- AFDC/TANF
- Number of children and adults in the household
Please allow up to two weeks to process financial assistance paperwork. During that time you are responsible for program fees until assistance is approved.
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

Acknowledgements
Limited Liability Waiver

Ozarks Regional YMCA
Signature of Parent/Guardian*

Clear
Your Fee Today (Choose One)*
prevnext( X )
MEMBER First Tuition Payment$100.00
Member rate for Summer Day Camp; valid membership verification required

NON-MEMBER First Tuition Payment$130.00
Non-Member rate for Summer Day Camp

Total $0.00
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Ozark Mountain Family YMCA Summer Day Camp Registration

Participant Information

Parent/Guardian Information

Individual Accomodations

Authorization for Medical Care

Acknowledgements

Limited Liability Waiver