YKA Student application online

CHILD ENROLLMENT INFORMATION
Name of Child*
First Date of Attendance:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Birth Date
NoYes
Yes I Acknowledge
Infant Name

First NameLast Name
Sex
Preferred Name
List of Known Allergies & Special Needs

List of Known Allergies: Special Needs:
SNAP CASE #1XXXXXXXXX
Mother*

Name: E-mail
Address Same as Above
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Place of Employment

Name: E-mail
Work Address
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father

Name: E-mail
Address Same as Above
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Place of Employment

Name: E-mail
Work Full Address
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Child’s Physician

Officer Name: E-mail
Address Same as Above
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Format: (000) 000-0000.
YESNo

Other persons to be notified in case of illness or accident.
Name

Name

Home Address:

PhoneEmail:

Postal / Zip Code
Name

Name

Home Address:

PhoneEmail:

Postal / Zip Code
Name

Name

Home Address:

PhoneEmail:

Postal / Zip Code

Persons (s) permitted to remove child

Rows	Yes	No
Mother
Father

Name

Name

Home Address:

RelationshipPhone

Postal / Zip Code
Name

Name

Home Address:

RelationshipPhone

Postal / Zip Code
Name

Name

Home Address:

RelationshipPhone

Postal / Zip Code
Hospital

SECURITY CODE FORM
DESIGN YOUR OWN SECURITY CODE: CHOOSE AY FOUR (4) DIGITSTHAT WILL BE EASY FOR YOUR FAMILY AND FRIENDS TO REMEMBER. YOU WILL PUNCH INTHE FOUR DIGITS INTO THE PARENT CHECK-IN APPLICATION.
FOUR (4) DIGIT CODE*
Please write your Legal Full Name ( As it appears on your drivers license)*
Write Name
HOME TELEPHONE #:
CHILD AGE
By placing a check mark in the box you agree to sign all the page within the document excutive expressly acknowledge and agree and to the privacy and terms and condition to all the 22 pages in this agreement, by signing this agreement you expressly acknowledge and agree that you carefully read this agreement and fully understand what it means; You have enter into this agreement knowingly and voluntarily and on your own free will were not subjected to any undue influence or duress and assents to all the terms and condition contained herin with the intent to bound hereby.
Signature
Date*

MonthDayYear
Date
- Immunization Policy Acknowledgment
  
  I understand that, at the time of enrollment and throughout my child's attendance, there may be children enrolled at the center who are either exempt from immunizations or not fully up-to-date with the required immunization schedule for medical, religious, personal belief, or other reasons permitted by law.
  
  The Parent /guardian authorizes the staff to apply diaper rash cream, sunscreen, lotion, Bug repentant, etc. NON prescription daily use provided by parent
  No prescription or doctor's note is needed for standard OTC items like Desitin, A+D ointment, Coppertone sunscreen, etc.
  Staff use universal precautions (handwashing; gloves often required for diaper cream). Authorization can be "standing" (valid until revoked).
- Date
  
  MonthDayYear
  Date
- Should be Empty:

CHILD ENROLLMENT INFORMATION

Other persons to be notified in case of illness or accident.

SECURITY CODE FORM