Student Information Form | 2026-2027 | YMCA Out of School Time Program

Student Information Form

YMCA OF KOKOMO | Before & After School Enrichment/Out of School Time 2026-2027
NOTE: This form requires multiple document uploads. Please make sure you have the appropriate documents ready for upload prior to starting this form, as it cannot be saved.

Before & After School Enrichment (BASE) takes place at the Downtown Y and serves students in grades K-6 who attend a Kokomo School Corporation school. BASE is operated by the Y's Out of School Time Program. Transportation to/from the YMCA is provided by Kokomo School Corporation. To set up transportation, please contact your student's school office.

Location: Downtown Delmar E. Demaree Family YMCA (114 N Union St. Kokomo, IN 46901)

Program Hours of Operation: 6:30 AM - 9:00 AM & 3:00 PM - 6:00 PM

Telephone: 765-457-4447

Email: sandi.maynard@kokomoymca.org

Coordinator: Sandi Maynard

Please complete this form prior to your student's first day at the YMCA.
- Student Name
  
  First NameLast Name
- Gender
- Student's Date of Birth
  
  MonthDayYear
  Ages 7-12
- Age
  Ages 5-12
- Grade in 2026-2027
- School
- Student's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Student Resides With
- Parent/Guardian Marital Status & Custody of Child
  IF THERE ARE ANY LEGAL DOCUMENTS PERTAINING TO THE CUSTODY OF YOUR CHILD, PLEASE SUBMIT THOSE WITH THIS FORM.
- Student Schedule
  
  Below you will have the option to select which session(s) your student will typically be in attendance. We understand that there will be variations in attendance at times. If your student is scheduled to attend after school, but will not be present on a particular day, please email us at ost@kokomoymca.org in advance so we are aware. Fees are assessed on a weekly basis. Attending fewer than five days does not change the weekly fee. The sole exception is if the YMCA closes the program for more than one day in a week. Fees are not assessed if a student is absent for an entire week. Please notify us by Thursday at noon for the following week if your child will be absent that week so we can remove the fee from your account.
- Student Schedule
- Billing
  
  Weekly fees for OST are $70.00 per student for Before OR After School and $140.00 per student for Before AND After School. There is a one-time enrollment fee of $25.00 per student due at the time of enrollment. Fees are paid on a scheduled draft (credit/debit card or ACH) that runs on Friday mornings for the following week. Repeated late payments will result in expulsion from the program.
  
  Please select below how payments will be made for your student:
- Payment Options
- If you need a Provider Information Form submitted to Firefly for your student's CCDF Vouchers, please select the box below:
- Please describe any allergies, dietary restrictions, or special needs of your student:
- Does your student have a communicable disease or condition which may prove to be a risk to others? If Yes, please comment:
- Insurance Carrier
- Policy Number
- The parent/guardian(s) listed on this student information form both have authorization to pick up your student from the YMCA and to ammend this student information form (including the authorized pick-up list) at any time. The sole exception would be if a court decree is on file with the YMCA specifically stating otherwise. If applicable, you will have the option to upload that documentation later in this form.
- Parent/Guardian #1
- Parent/Guardian #1 Name
  
  First NameLast Name
- Relationship to Student
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian #1 Email
  example@example.com
- Parent/Guardian #1 Employer
- Parent/Guardian #2
- Parent/Guardian #2 Name
  
  First NameLast Name
- Relationship to Student
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian #2 Email
  example@example.com
- Parent/Guardian #2 Employer
- Both parent/guardian email addresses will be added to our program email list for monthly newsletters and program updates.
- The following individuals are authorized to pick up my student from the YMCA program, in addition to the parent/guardian(s). Anyone coming to pick up a student from the YMCA should be prepared to show valid photo ID. Any changes to this authorized pick-up list must be submitted to the YMCA program office in writing by the student's parent/guardian.
- Emergency Contact/Authorized Pick-Up #1
- Emergency Contact #1 Name
  
  First NameLast Name
- Relationship to Student
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Emergency Contact/Authorized Pick-Up #2
- Emergency Contact #2 Name
  
  First NameLast Name
- Relationship to Student
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Emergency Contact/Authorized Pick-Up #3
- Emergency Contact #3 Name
  
  First NameLast Name
- Relationship to Student
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Please read and initial the following program policies and authorizations. "YMCA" refers to the Young Men's Christian Association of Kokomo, Indiana, Inc.
- Initial: I understand that the YMCA's responsibility for my child begins when my child is signed in to the program by the parent or guardian. Students must be walked in to the program area by a parent or guardian. Dropping off at the door is NOT permitted and may result in suspension or expulsion from the program.
- Initial: I understand that the YMCA's responsibility for my child ends when an authorized adult (over the age of 18) or myself has signed-out my child. I understand that the YMCA will only release my child to the parent/guardian(s) and emergency contact(s) listed on this form. Photo ID will be required. I understand that I must notify the YMCA in writing of any changes to my child's authorized pick-up list. Students must be picked up by 6:00pm.
- Initial: I understand that YMCA staff and volunteers are not allowed to communicate with, babysit, or transport children at any time outside of the YMCA program.
- Initial: I understand that the YMCA is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.
- Initial: I understand that should a person arrive to pick up my child appear to be under the influence of drugs or alcohol, for my child's safety, YMCA staff may have no recourse but to contact the police department.
- Initial: I acknowledge it is my responsibility to keep the YMCA advised of any changes to my child's Student Information Form.
- Initial: The YMCA agrees to keep the parent/guardian informed of any incidents, injuries, exposure to communicable diseases, and behavioral concerns.
- Initial: I understand that neither the YMCA, nor its agents, officers, directors, employees, or volunteers, can be held responsible in the event of an accident, injury, or death. I understand that all precautions will be taken to ensure the safety and health of my child.
- Initial: I understand that if, after a reasonable period (at the administration's discretion) it is found that my child is unable to adjust to the program, the YMCA reserves the right to dismiss my child from the program.
- Initial: I understand that I am financially responsible for any damage to equipment or facilities caused by my child.
- Initial: I understand that my child may not bring any toys, electronic devices, or games to the program. I further understand that the YMCA is not responsible for any lost, stolen, or damaged personal items.
- Initial: I understand that if Kokomo School Corporation operates on a two-hour delay, the YMCA will provide before school care at no additional charge during the delay. Our site staff will make every effort to arrive to the program on time. If Kokomo School Corporation cancels school, the OST Program will also close. If school is cancelled after before school care has already started, you will need to come pick your student(s) up from the YMCA. The OST Program, at times, may have to adjust its program calendar and close on scheduled School's Out Days if there are not enough registrants or if there is a staff shortage.
- By signing below, I acknowledge that the above named student and I have read and discussed the established policies, procedures, and behavioral expectations as stated in the Program Guide. Further, we agree to abide by these policies, procedures, and behavioral expectations and understand that failure to do so may result in dismissal from our programs.
- I authorize the YMCA of Kokomo to use photos, images, and video of my child in any publication affiliated with the YMCA, YMCA of the USA, or with any news service for publicity, including, but not limited to, program newsletters, fundraising brochures, press releases to newspapers, social media, and the YMCA of Kokomo’s website and SmugMug page. I understand and agree that there will be no compensation for use of these materials. This release shall continue in full effect until I send in written notice to terminate the use of any photo, image, or video of my child. Such termination shall not affect the use of photos, images, or videos before the notice of termination. LEAVE BLANK IF AUTHORIZATION NOT GRANTED.
  
  Photo/Video Release (Optional)
- I hereby certify that my child (named in this enrollment form) is in normal health and capable of safe participation in the program in which he or she is enrolling. I further give permission for my child to be given emergency medical treatment by a Young Men’s Christian Association of Kokomo, Indiana (“YMCA”) staff member until parents can be reached and be present and/or emergency care arrives for treatment. In case of emergency, I understand that my child will be transported to Ascension Saint Vincent Hospital or Community Howard Regional Health Hospital by local emergency ambulance services for treatment, if YMCA staff deem it necessary. In the event that I cannot be contacted, I further consent to the medical, surgical and/or hospital care to be performed for my child by a licensed physician or hospital when deemed immediately necessary by the physician to safeguard my child’s health. It is understood that some medical situations will require YMCA staff to contact local emergency resources before the parent(s), child’s physician and/or adults acting on the parent’s behalf. I understand any costs incurred related to my child’s medical treatment are not the financial responsibility of the YMCA.
  
  Emergency Medical Treatment Authorization
- I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of Young Men’s Christian Association of Kokomo, Indiana (“YMCA of Kokomo”) facilities, services, equipment and premises (“Facilities”) and any participation in YMCA of Kokomo programs and activities (“Programs”) comes with inherent risk including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease, including, without limitation, COVID-19. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document. Waiver, Release, Indemnification and Covenant Not to Sue In consideration of Minor’s use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that the YMCA of Kokomo, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs. I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease, or accident of any kind, arising out of or in any way related to the use of Facilities or participating in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees. In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs.
  
  Minor Participant Liability Waiver
- By signing below, I authorize my minor child named in this student information form to participate in YMCA program field trips and activities, including swimming in the YMCA's pools. I understand that my child will be under the supervision of YMCA staff at all times. The YMCA will notify me of any off-site walking field trips at least one week in advance of the field trip. The YMCA will notify me of any scheduled swimming days at least one week in advance. Swimming is done under the supervision of certified YMCA lifeguards.
  
  Field Trip & Activity Authorization
- I have read the Youth Discipline Policy located in the Parent Handbook and agree to and understand the protocols listed and understand that failure to adhere to the policy may result in expulsion from the program.
  
  Youth Discipline Policy
- The Y requires adults (parents, guardians and caregivers) of enrolled students to behave in a manner consistent with our core values of Caring, Honesty, Respect and Responsibility. The Y's goal is to provide the most appropriate environment for students to learn, grow and thrive. Achieving this ideal environment is not only the responsibility of our staff, but also each adult who enters the program. Adults who fail to behave in an appropriate manner may be asked to leave and to not return to the YMCA. Students may be expelled from the program based on the behavior of their parent, guardian or caregiver.
  
  No adult is permitted to curse or use other inappropriate language in the program area, whether in the presence of children or not. This includes phone conversations and emails.
  
  Threats of any kind toward staff, students or other adults will not be tolerated.
  
  Adults are prohibited from addressing or correcting a child that is not their own. Any concerns regarding another child's behavior should be addressed politely with our staff. An adult attempting to question, correct or discipline a child in our program that is not their own will result in expulsion from the program.
- Signature
- Birth Certificate
  
  Cancelof
- Immunization Records
  
  Cancelof
- Custody/Court Decrees (If Applicable)
  
  Cancelof
- YMCA OF KOKOMO | 114 N Union St. Kokomo, IN 46901 | kokomoymca.org
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