YCO Palmyra 25-26 After-School Registration

YCO 25-26 ASES After-School Registration

Welcome Palmyra GATE Magnet Families! We are so excited to be the ASES After-School Program at your school and serve your child! Please fill out this registration form for your child. As of August 19, we have a waitlist, please register to be added to the waitlist. Our team will contact you when space is available. For any questions, contact us at (714) 450-0759 or info@ycorange.org.
Are you interested in

ASES 2-6PM ProgramELOP 7-7:45AMELOP 2-4PM
Student Information
Child's Name

First NameLast Name
Birthdate
00/00/0000
Gender

FemaleMale
Age
Grade
Race/Ethnicity
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Parent/Guardian Information

Lives with child
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Secondary Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Student Health Information
Does your child have a Special Disability?

YesNo
If yes, please select
If your child has and IEP or 504 Plan, please upload the file here.

Cancelof
Student Health Information
Does your child have any medical conditions or allergies?

YesNo
If yes, please explain
Authorized Adult Pick-Up

Parents must be present when signing in (before school care) and out (after school care) their child. If parents are aware that they will not be able to pick up their child on time, they must call in advance to let the YCO know. The child can only be released to an adult who is on the Authorized Adult Pick-Up list and over the age of 18. Siblings who are not 18 years of age cannot sign out a child. In addition, if a child is picked up after 6:00 p.m. a Late Letter will be issued as a reminder that the YCO closes at 6:00 p.m.
First Name Last Name Phone Number Relationship to child
First Name Last Name Phone Number Relationship to Child
First Name Last Name Phone Number
First Name Last Name Phone Number Relationship to child
First Name Last Name Phone Number Relationship to child
First Name Last Name Phone Number Relationship to child
First Name Last Name Phone Number Relationship to child
Medical Emergency

I hereby certify that my child(ren) is/are in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by Youth Centers of Orange. I acknowledge that Youth Centers of Orange will not assume any responsibility or liability for personal injury or damages caused by the injury. In the event Youth Centers of Orange Classic Program 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 the staff or employees to provide for, approve and authorize health care at hospital.
Insurance Provider
Name of Insured

First NameLast Name
Policy Number
Physician Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Photograph/Video Permission

I hereby grant and authorize Youth Centers of Orange the right to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of my child(ren) to be used in and/or for legally promotional materials and digital communications. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of and will not be returned.
Parent/Guardian Acknowledgment

I, the undersigned, certify that all information provided in this document is true, accurate, and complete to the best of my knowledge. I understand that providing false or incomplete information may affect my child’s eligibility or participation in the program.
Parent/Guardian Signature

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YCO 25-26 ASES After-School Registration

Student Information

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

Student Health Information

Student Health Information

Authorized Adult Pick-Up

Medical Emergency

Photograph/Video Permission

Parent/Guardian Acknowledgment