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
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.
Place of Employment

Name: E-mail
Address
Work Phone
Please enter a valid phone number.
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.
Place of Employment

Name: E-mail
Home Full Address
Work Phone
Please enter a valid phone number.
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
May Facility consult the above physician if parent/guardian cannot be reached?

YESNo

Persons (s) permitted to remove child

	Yes	No
Mother
Father

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

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Date

MonthDayYear
Date
Date

MonthDayYear
Date

CHILD ENROLLMENT INFORMATION