Summer Success Center Registration Form

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Grade Leaving

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Name

First NameLast Name

Cell Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Pick Up & Drop Off: Who is Allowed to Pick Up Your Child?

(Legal First & Last names; must show ID)

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

Does your child have any allergies, chronic illness, medical conditions, or dietary restrictions? If yes, please describe.

Does your child have any behavioral issues? If yes, please describe:

Does your child receive learning support or any other special services at school? If yes, please describe:

Are there any academic subjects/concepts your child is behind in or struggles with? (Check all that apply)

Payment Plan & Cancelation

Registration Fee: $100 (non-refundable) is due at registration, this will be deducted from your tuition and will hold your child's spot. Complete one form per child and submit the form along with payment.

2025 Fee:

$235 per week

Late Pick Up Until 5pm: $250 per week

Space is limited each week
Sign up for one week at a time or multiple at once
Registration is required at least one week in advance (Monday of the week prior)
Registration closes Friday @ 6:00 PM of the week prior
Full payment is DUE at the time of registration for each week you enroll in.
A late pick up fee of $1 per minute will be charged if your child is picked up later than scheduled. Late fees will not be charged for the first 10 minutes of a late pick up.
NO transfers/refunds less than one week prior to the start of camp
A 10% fee will be applied to all refunds
Forms of payment: Cash, Venmo, PayPal & Cash App. Checks are not accepted.

Please select the weeks your child will be attending:

I Will Pay:

Cancelation: Parents are required to give a five-day notice in writing if their child will no longer be involved with the Summer Success Center.

Student Survey

Has your child attended other summer camp programs?

Is your child potty-trained? Can your child tell an adult when they need to use the restroom?

Can your child redress on their own, if needed?

Can you child swim?

Does your child have siblings?

What are your child’s favorite activities? (games, sports, hobbies, etc.)

What goals do you hope to accomplish with tutoring this summer?

Is there anything specific that we should know about your child to help him/her be successful at camp?

Facility Policies

Pick up and Drop off

The Summer Success Center is not responsible for your child before Sign In and after Sign Out.

I understand that I or an authorized person is required to sign my child or children in and out every day. Children may not be dropped off and are not able to leave care by themselves.

I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child (including older siblings and other relatives) must be listed, be at least 18 years of age, and have a valid photo ID. Any other arrangements must be made by calling the YMCA Child Care Office to inform them of a change.

I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child’s safety, staff may have no recourse but to contact the police. Please do not put staff in a position where they have to make this judgment call.

Late fees will occur if your child is not picked up by 4:15pm; 5:00pm for late pick up.

Behavior
I understand that having a successful summer is a joint venture for all who participate. While on the premises, specific behaviors from parents and children are not tolerated. These include but are not limited to: swearing, punching, kicking, bullying, threats towards others, or refusal to follow directions. We have the right to dismiss anyone from the program without warning.

Facility

I understand that the Summer Success Center is a home-based program.
I give permission for my child to go wading and swimming.
I give permission for my child to go on walking field trips. I will go over road safety with my child.
I give permission for my child to be transported by the facility.
I understand that the Summer Success Center is not responsible for damaged, lost, or stolen items.
I understand that the Summer Success Center is mandated by state law to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.

Photograph/Video Release

I understand that photographs and videos will be taken of children by staff and may be used for display or advertisements.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by the Summer Success Center during the camp session. I assume responsibility of my child for the associated risks when participating in physical activities that could result in physical injury. I am voluntarily registering my child and I release the Summer Success Center from any/all liability.

I will not bring my child to the center if they are exhibiting any of the following symptoms:

Fever of 100 degrees or higher
Constant runny nose that is yellow or green in color
Inflamed eyes, pink eye, or other infection
Any untreated, contagious, or persistent illness
Rash or other contagious skin condition
Diarrhea
Vomiting

Permission to Treat

I understand the inherent risk in physical activities and give permission for my child to receive medical treatment if needed. Parents/Guardians will be notified in the event your child has been injured; these are, but not limited to: an injury to the head, a physical fight, vomiting, a fever, stung or bitten. Parents/Guardians will be notified in the event your child needs to be taken to the emergency room. In case of injury to said child, I hereby waive all claims against the Summer Success Center.

Confirmation

I have read and I understand the Summer Success Center’s Registration Form. By signing this document, I agree to all of its terms.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

Summer Success Registration