School Year Registration Form

Southside Youth Senter

School Year Registration Form
Student Information
Student #1 Name*

First NameLast Name
Student #1 Date of Birth*

MonthDayYear
Date
Hispanic/ LatinXNon-Hispanic/ LatinX
White/CaucasianBlack/ African AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific Islander
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
After-SchoolSchool Breaks/Holidays
Full timePart Time
Monday, Wednesday, Friday OnlyTuesday, Thursday Only
School *
Current Grade Level *
Allergies (Food, Environmental, Medicinal, etc.), If none, please answer "N/A"*
Medical Conditions/ Diagnosed Special Needs (Autism, ADHD, Asthma, etc.) If none, please answer "N/A":*
YesNoNo Medical Conditions/ Diagnosed Special Needs listed
If you answered yes, please provide us with as much detail as you can.
If your child's medical condition/ diagnosed special needs require special care, please list the instructions here.
Please list any Accommodations or Modifications and/or adaptive equipment you wish to provide for your child, with instructions on how to properly use the equipment.
YesNo
YesNo
Medications*
PCP (Primary Care Provider: Doctor, Nurse Practitioner, Physician's Assistant) Name*
PCP Clinic Name*
PCP Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student #2 Name

First NameLast Name
Student #2 Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hispanic/ LatinXNon-Hispanic/ LatinX
White/CaucasianBlack/ African AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific Islander
After-SchoolSchool Breaks/Holidays
Full timePart Time
Monday, Wednesday, Friday OnlyTuesday, Thursday Only
School
Current Grade Level
Allergies (Food, Environmental, Medicinal, etc.), If none, please answer "N/A"
Medical Conditions/ Diagnosed Special Needs (Autism, ADHD, Asthma, etc.) If none, please answer "N/A":
YesNoNo Medical Conditions/ Diagnosed Special Needs listed
If you answered yes, please provide us with as much detail as you can.
If your child's medical condition/ diagnosed special needs require special care, please list the instructions here.
Please list any Accommodations or Modifications and/or adaptive equipment you wish to provide for your child, with instructions on how to properly use the equipment.
YesNo
YesNo
Medications
PCP (Primary Care Provider: Doctor, Nurse Practitioner, Physician's Assistant) Name
PCP Clinic Name
PCP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student #3 Name

First NameLast Name
Student #3 Date of Birth

MonthDayYear
Date
Hispanic/ LatinXNon-Hispanic/ LatinX
White/CaucasianBlack/ African AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific Islander
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
After-SchoolSchool Breaks/Holidays
Full timePart Time
Monday, Wednesday, Friday OnlyTuesday, Thursday Only
School
Current Grade Level
Allergies (Food, Environmental, Medicinal, etc.), If none, please answer "N/A"
Medical Conditions/ Diagnosed Special Needs (Autism, ADHD, Asthma, etc.) If none, please answer "N/A":
YesNoNo Medical Conditions/ Diagnosed Special Needs listed
If you answered yes, please provide us with as much detail as you can.
If your child's medical condition/ diagnosed special needs require special care, please list the instructions here.
Please list any Accommodations or Modifications and/or adaptive equipment you wish to provide for your child, with instructions on how to properly use the equipment.
YesNo
YesNo
Medications
PCP (Primary Care Provider: Doctor, Nurse Practitioner, Physician's Assistant) Name
PCP Clinic Name
PCP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1*
example@example.com
Parent/Guardian #1 Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Employer Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Household Information

Household information is used to determine eligibility for scholarships/ assistance funding as it is made available to Southside Youth Senter; and for referral to outreach services with other agencies if needed. All information provided will be kept confidential and does not determine admission to Southside Youth Senter.
Number of People in Household:*
Annual Household Income (including income from non-employment sources such as: Unemployment, Social Security Income/ Disability, Food Benefits, Child Support, ETC.):*
Food BenefitsWICCHIP (Children's Health Insurance Program)MedicaidTANFSocial SecurityOtherNone
First/Last Name*
Age*
First/Last Name*
Age*
First/Last Name
Age
First/Last Name
Age
First/Last Name
Age
First/Last Name
Age
First/Last Name
Age
First/Last Name
Age
Emergency Contact/Authorized Pickup Information

Please provide two additional adults (Not Parent/Guardians listed above) who are authorized to make medical decisions and/or pick up your child from Southside Youth Senter. Emergency Contacts do not have to be local to Wichita Falls, TX.
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 Relation to Child(ren)*
YesNo
Emergency Contact/Authorized Pickup Information

Please provide two additional adults (Not Parent/Guardians listed above) who are authorized to make medical decisions and/or pick up your child from Southside Youth Senter. Emergency Contacts do not have to be local to Wichita Falls, TX.
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 Relation to Child(ren)*
YesNo
Emergency Contact #3 Name

First NameLast Name
Emergency Contact #3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #3 Relation to Child(ren)
YesNo
Emergency Contact #4 Name

First NameLast Name
Emergency Contact #4 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #4 Relation to Child(ren)
YesNo
Insurance/ Liability Waiver & Transportation Policies
INSURANCE & LIABILITY WAIVER: I hereby certify that my child(ren) listed below is/are, unless indicated above, in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by Southside Youth Senter. I acknowledge that Southside Girl's Club, Inc. (DBA Southside Youth Senter) will not assume any responsibility or liability for personal injury or damages caused by the injury. In the event Southside Girl's Club, Inc. (DBA Southside Youth Senter) is unable to reach a parent, guardian or any emergency contact, I hereby give permission for my child(ren) to be transported to the nearest hospital for treatment in case of an accident or emergency. I hereby further authorize(s) any of the staff or employees of Southside Youth Senter and the staff of any Field Trip Destinations to provide for, approve and authorize health care at hospital.*

I agree
TRANSPORTATION POLICY: I understand Southside Girls Club Inc, (DBA Southside Youth Senter) provides transportation from my child(ren)'s school to Southside Youth Senter Only. I understand that once my child(ren) is/are on the van, they will not be dismissed from the van until they get to Southside Youth Senter. I understand that in the event my child(ren) will not be riding the van/ attending Southside Youth Senter, I must notify Southside Youth Senter by either contacting Southside Youth Senter Staff or Marking my child absent in PLAYGROUND NO LATER THAN 2pm. Van Rules Sit in your assigned seat at all times, if applicable. Driver’s reserve the right to create and change a seating chart due to disciplinary, safety, or operational needs of the van route. Immediately fasten your seat belt and keep it on at all times. Eating or drinking is never permissible on the van. Do not take anything out of your backpack for any reason. Keep aisles clear at all times. No fighting, horseplay, or loud activity at any times in the van. Follow all instructions given by the driver. ALL Southside Youth Senter rules are still in effect while on the van.

I agree
Parent Name*

First NameLast Name
Signature*

Clear
Field Trips & Water Play Activities
Southside Youth Senter is happy to offer field trips during full day programming. The cost of each Field Trip is determined by the Venue, and is not paid for with the cost of tuition. Each child participating in field trips will be required to have a signed permission slip and field trip fees paid prior to departure for the Field trip. Payment methods for field trips will be posted on each field trip announcement, and may vary by destination. Field trip fees are non-refundable and non-transferrable. In the event you would like your child to have money while on the trip, you must pay cash to the office. Any monies received for spending money will be placed in an envelope for the child to use. The Field trip leader will hold the money and give out exact change (when Possible), or the amount rounded to the next dollar amount, to the child. Money that is not spent will be returned to the parent/guardian at pick up. Field trip details will be posted as soon as possible in the Playground app and sign ups will be no less than one week before each trip. If you do not sign your child up for a field trip, they will remain at the center. On the day of the field trip, students are required to be ready to go 10 minutes prior to boarding the vans. If a child arrives after the van leaves for the field trip, Southside Youth Senter will not return to pick up your child, and they will stay at the Senter. Parents are not allowed to drop their child off or pick their child up from a field trip. Departure and Arrival times for each field trip will be listed on the field trip flyers as well as the permission slips for the field trip. We will adhere to these as much as possible. In the event the group is leaving later or earlier than anticipated, parents will be notified through Playground. I give permission for my Child to Participate and be transported for all field trips Southside Youth Senter plans. In the event I do not want my child to attend a field trip, I will notify the Program Director or Executive Director no later than 24 hours prior to the field trips departure.

I agree
During Summer Full Day Programming, Southside Youth Senter may schedule water play activities. These activities will be supervised and will not require the children to be submerged or in more than approximately 6 inches of water. On days that water play occurs, children must wear a shirt, shorts, swimsuit and water shoes to participate; children may wish to bring a dry change of clothes to change into if they wish; Keep in mind, Southside Youth Senter Staff are not responsible for keeping up with your children's clothes. Children may wear their clothes over their swimsuit if desired. Water play activities include but are not limited to: Soaked sponge relays, water balloon fights, kiddie pool splash, water fights, etc. Water related field trips include swimming pools, water parks, and splashpads. I give my child(ren), listed below, permission to participate in waterplay activities/field trips

I agree
Parent Name*

First NameLast Name
Signature*

Clear
Photo/Video/Media/Marketing Waiver
I understand that my child(ren) whose name(s) are listed above in this enrollment contract may be photographed and/or video/audio recorded at Southside Youth Senter during normal business hours, field trips, or activities. I understand that these images and video/audio recordings may be used in promoting child care services, either in print, on tv, or on the Internet. I understand and agree that I or my child(ren) will not be compensated in any way for the use of the use of their photographs or likeness.

I understand and agree to allow Southside Youth Senter to use my child's photographs, videos, and audio.I do not agree to allow my child to be photographed, audio/video recorded.
Parent Name*

First NameLast Name
Signature*

Clear
Meals
Southside Youth Senter is proud to partner with Wichita Falls Area Food Bank (WFAFB) to provide healthy, balanced, nutritious meals to any child (18 years and younger) with priority to Southside Youth Senter Members first, then any left-over meals may be given to community members upon request. If a child has medically necessary dietary needs; Southside Youth Senter will work with the parent/guardian to accommodate those needs upon receipt of documentation from the child’s medical provider. If a child is dropped off after mealtimes, and the parent/guardian wishes for them to eat before beginning activities at Southside Youth Senter, the parent/guardian is responsible for providing a meal for the child. After-School Programming (School days only) Dinner is served from 4:30 PM to 5:00PM. Students are not required to eat meals served but must go through the serving line before making their decision. There are no other meal/snack times offered during after school programming. Students may not bring their own meals or snacks during after school programming. Full Day Programming (School breaks/Holidays)- During full day programming during the school year (I.E., WFISD Staff Development Days, Christmas break, Holidays, Etc.) there will be the following mealtimes:7:30-8:00 Breakfast Southside Youth Senter will not provide breakfast for children; however, children are welcome to bring their own breakfast and will be given time to eat prior to going into their centers with their groups.12:00-12:30 Lunch The WFAFB will provide the meals as lunch, instead of dinner. Children who wish to bring their own meal from home may do so, so long as it meets the following requirements:- All components of the meal are non-perishable (doesn’t need refrigeration); and it does not require heating or cooking of any kind, The meals are stored in a non-breakable dish or container, All components of the meal are not past the expiration date. In the event that the WFAFB is closed, families will be required to provide their child with lunch that day. Notification of WFAFB closure will be announced the week prior to the closure.3:30-4:00 Snack Time Children who wish to have a snack are required to bring a snack from home. Snacks may be kept in the same lunchbox/ container as their lunch (should they choose to bring one), but must be labeled as their snack, to ensure they do not eat it at the wrong mealtime. During Summer Programming, the WFAFB will provide snacks for snack time; however, children may bring their own snacks, so long as they meet the same criteria as listed for lunches.If a child is dropped off after mealtimes, and the parent/guardian wishes for them to eat before beginning activities at Southside Youth Senter, the parent/guardian is responsible for providing a meal for the child.*

I agree
Parent Name*

First NameLast Name
Signature*

Clear
Discipline Policy
Discipline is essential to provide a safe, yet fun environment for everyone to enjoy. Without discipline, chaos will ensue and be counter-productive to our goal, which is to aid members in the development of social interaction and life skills.1. 1st Offense: Verbal warning2. 2nd Offense: Written warning and incident report. Staff will separate member from group or activity and administer an alternate activity such as trash duty, cleaning, writing sentences, etc.3. 3rd Offense: Member will be sent to Director's (Program or Executive) Office at which time members will be counseled and parents will be contacted to discuss the situation. The severity of the offense could lead to a 3-day suspension.4. 4th Offense: If the parent is receiving multiple phone calls regarding his/her child, a meeting will be set to discuss other courses of action for the member. Child could be suspended for a minimum of one week, or terminated from program.5. STRIKING STAFF OR FIGHTING IS NOT ALLOWED AT ANY TIME! If a member is caught fighting, parent/guardian will be called and asked to pick up his/her child. A minimum of a 3 days suspension and or program termination may be necessary depending on the severity of the infraction. This will be discussed with the parent on an individual basis when the parent arrives at the facility to pick up the child. While program staff have authority to discipline a member, Suspensions and Membership Terminations are at the discretion of the Executive Director.*

I agree
Parent Name*

First NameLast Name
Signature*

Clear
Program Fees
I have read the entire program fees listed in the Parent Handbook and on Southside Youth Senter's Website. I understand that weekly fees are to be paid whether or not my child attends, including in the event my child is suspended from Southside Youth Senter, except for when SYS is closed. No fee deduction is provided for emergency closings, legal holidays or vacations. I understand that I am not permitted to temporarily drop my child from service for a period of one or more weeks and then re-enter my child, without prior approval from a Director. I/we have read this contract between myself and Southside Youth Senter. I/we agree to pay the required weekly fee by Monday of each week. I further understand that if I have an outstanding balance of more than two weeks my child will not be allowed to participate in any SYS programs until all accounts are current or payment arrangements have been made. In the event my child is suspended from care due to nonpayment, and payment. If my child attends the SYS Summer Program, I understand any field trip or special event fees are additional and payment in full is required for my child to participate. I understand that in the event I withdraw my child(ren) my child(ren)’s spot could be filled and they may not have an available spot when they want to return.*

I agree
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Southside Youth Senter

Student Information

Parent/Guardian Information

Household Information

Emergency Contact/Authorized Pickup Information

Emergency Contact/Authorized Pickup Information

Insurance/ Liability Waiver & Transportation Policies

Field Trips & Water Play Activities

Photo/Video/Media/Marketing Waiver

Meals

Discipline Policy

Program Fees