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This form must be returned in order to register your child.
Please inform us of any changes in information as they occur.
REGISTRATION FORM
CHILD’S INFORMATION
Name: _______________________________________________________________________________________________________________________ _______________________________________
(first)
(middle)
Birthdate: _____/_____/_____ Grade: _____________ Gender:
□ male □ female
(last)
Race: _____________________________________________________________
Address: __________________________________________________________________City: ____________________________________________ Zip: _______________________________
School Attending:________________________________________________________Site Attending:_____________________________________ ________________________________
Before Care:
After Care:
Before AND After Care:
Date child will begin program:____________________________
□ 3 days □ 5 days
□ 3 days □ 5 days
□ 3 days □ 5 days
(Please allow 3 days to process paperwork)
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name:_________________________________________________________________Relationship: _________________________ _____________________________
Address: _____________________________________________________________City: _________________________________________________ _ Zip: ______________________________
Place of employment: __________________________________________________________ Occupation: _________________________________ ______________________________
Home phone: _________________________________ Cell phone: _____________________________________Work phone: __________________ ____________________________
E-mail: _____________________________________________________________________________________________
Parent/Guardian Name:_________________________________________________________________Relationship: _________________________ _____________________________
Address: _____________________________________________________________City: _________________________________________________ Zip: ______________________________
Place of employment: ____________________________________________________________Occupation: ________________________________ ______________________________
Home phone: _________________________________ Cell phone: _____________________________________Work phone: __________________ ____________________________
E-mail: _____________________________________________________________________________________________
Parent’s Marital Status:
□ Married
□ Single
□ Divorced
□ Mother remarried
□ Father remarried
Please state custody arrangements and provide court documentation.
_____________________________________________________________________________________________________________________________ ________________________________________
_____________________________________________________________________________________________________________________________ ________________________________________
_____________________________________________________________________________________________________________________________ ________________________________________
_____________________________________________________________________________________________________________________________ ________________________________________
AUTHORIZED PICK UP/ EMERGENCY CONTACTS (Must be 18 years or older)
I hereby give my consent for the following individuals to pick up my child from the YMCA Childcare Program. I understand that
the YMCA of Greater Fort Wayne and Childcare Services are not responsible for my child once they have been signed out of the
Childcare Program.
In an emergency situation, the YMCA will always try to contact the parent(s)/guardian(s) first. In case the
parent(s)/guardian(s) cannot be reached, we will contact the following emergency contacts. Please list at least two emergency
contacts in order of preference for contact.
Authorized Pick Up:
□ Mother
□ Father
□ Guardian(s)
Name: __________________________________________
Name: __________________________________________
Name: ___________________________________________
Relation to child: ____________________________
Relation to child: ____________________________
Relation to child: _____________________________
Hm #: ___________________________________________
Hm #: ___________________________________________
Hm #: ____________________________________________
Cell #: ___________________________________________
Cell #: ___________________________________________
Cell #: ____________________________________________
Wk #: ___________________________________________
Wk#: ___________________________________________
Wk#: _____________________________________________
□ Authorized Pick Up
□ Emergency Contact
□ Authorized Pick Up
□ Emergency Contact
□ Authorized Pick Up
□ Emergency Contact
My child has permission to participate in YMCA Childcare activities. Basic first aid and emergency treatment are authorized.
PARENT/ GUARDIAN(S) CONSENT
I recognize and acknowledge that there are certain risks of physical injury, and agree to assume full risk of injuries, damages, or
loss which said participant may sustain as a result of participating in any and all activities connected with or associated with
such program. I authorize the YMCA to transport my child via emergency transportation should it be deemed necessary by the
YMCA staff.
I give my permission for my child to participate in field trips during Childcare program hours with the understanding that advance
notice and details will be provided.
I give the YMCA permission, without limitation or obligation, to use photography, video, or audio recordings of my child participating in YMCA Childcare programs for the promotion or interpretation of the YMCA.
I understand that my child cannot attend YMCA Childcare programs until all required forms are turned in to the YMCA.
____________________________________________________________
Parent / Guardian Signature
____________________________________________________________
Printed Name
_____________________________________________
Date
HEALTH FORM
CHILD’S INFORMATION
This form must be returned in order to register your child. Please inform us of any changes in information as they occur.
Name:________________________________________________________________________________________________________________________ ______________________________________
(first)
(middle)
Birthdate: _________/_________/_________
Grade ___________
Gender:
(last)
□ male
□ female
Race: _____________________________________
IMPORTANT: Please notify YMCA Childcare if your child’s information changes. Please give approximate dates:
HEALTH INFORMATION
Conditions
Allergies
Diseases
□Frequent Ear Conditions
□Heart Defect
□Convulsions
□Diabetes
□Bleeding Disorders
□Other ____________________________________
□Hay Fever
□Poison Ivy
□Insect Stings
□Penicillin
□Peanuts/nuts
□Other ____________________________________
□Measles _________________________________
□German Measles ______________________
□Mumps __________________________________
□Chicken Pox ____________________________
□Asthma _________________________________
□Other ____________________________________
Operations or serious injuries (please list dates)___________________________________________________________________________ ______________________________
Chronic or recurring illness ___________________________________________________________________________________________________________________________________
Is your child taking any medication? ___________ Name of Medication ________________________________________________________________________________
Dose _________________________________ Special instructions ________________________________________________________________ __________________________________
Any specific activities to be encouraged? ___________________________________________ Restricted? _____________________________________________________
Special needs or restrictions (dietary, health, physical, psychological, or educational) for staff awareness:
_____________________________________________________________________________________________________________________________ _________________________________________
IMPORTANT: Please notify YMCA Childcare if your child is exposed to any communicable diseases.
Family Physician ________________________________________________________________________Phone ______________________________ __________________________________
Dentist/Orthodontist __________________________________________________________________Phone ________________________________ ________________________________
Medical Insurance Carrier _____________________________________________________________Policy # _____________________________________________________________
IMPORTANT: MUST BE COMPLETED FOR ATTENDANCE
This health history is correct to the best of my knowledge and the child herein described has permission to engage in all prescribed activities except as noted. I hereby give permission to the physician selected by the director to order x-rays, routine
tests and treatment for the health of my child, and in the event I cannot be reached in an emergency. I hereby give permission to
the physician selected by the director to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or
surgery for my child as named above.
_____________________________________________________________ _________________________________________________________ __ __________________________________________
Parent/ Guardian Signature
Printed Name
Date
TO BE COMPLETED BY A HEALTH CARE PROVIDER
Immunization Record
This form must be returned upon registration.
This form will be updated annually.
Child’s full name _____________________________________________________________
Birthdate___________/___________/_____________
Parent/Guardian name_______________________________________________________ Phone _________________________________________
Hep B
DtaP/ DTP/ Td
Hib
MMR
IPV
Varicella
(Chicken Pox)
PCV / Prevanar
Date of last Tetanus shot: _____________________________________________________________________________________________________
Child has documented history of Chicken Pox? _________ No _________Yes
If yes, age ____________________________
Parent Comments: (Please indicate religious objections, if any.) _____________________________________________________
________________________________________________________________________________________________________________________________________
Health Care Provider Comments: (Please list immunizations excluded for medical purposes.)
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Please check the appropriate response:
_____ Child has received age-appropriate immunizations.
_____ Child is currently in the process of receiving age-appropriate immunizations.
Signed ______________________________________________________________________________ Date________________________________________
Health Care Provider’s Signature
Printed Name and Title _________________________________________________________________________________________________________
Behavior Management Agreement
Philosophy
The YMCA strives to maintain a positive approach to managing children's behavior at all times. “Discipline” is the process of
teaching self-control and the ability to live within limitations and agreed upon guidelines. Expected behavior guidelines are
established by staff and children. Positive behavior is self-rewarding and allows for program activities to occur. When children choose to behave outside of the guidelines, some consequence is required to avoid future problems. The overall safety
of all children is our highest priority.
Process
When positive behavior is displayed, the consequence is participation and enjoyment of planned activities. In cases of negative or inappropriate behavior, the following will be employed.
Warning: Every effort will be made to help the child understand the inappropriateness of his or her actions and agree to
alternate from of behavior. A verbal warning will be given at the onset of inappropriate behavior.
Removal from the Specific Activity (Personal Time): When a warning has been issued and behavior has not changed, removing the child from the activity for a personal time out is necessary. Other duty-oriented consequences suitable to the
inappropriate behavior may also be utilized at this stage.
Behavior Reports: When staff is not successful in correcting behavior, or the behavior is of a serious nature, a behavior
write-up will occur. The write-up will be discussed with the child and parent, and requires a parent/guardian signature.
If a child receives three write-ups, a parent conference will be required.
Removal from the Program for Inappropriate Behavior: If the above process has not resulted in corrected behavior, the family will be asked to remove the child from the program.
*The YMCA reserves the right to skip steps and offer consequences appropriate to the behavior.
Behavior Related Issues
In addition to behavior management procedures outlined above, parents must be aware that:
No child will be allowed to continue in the program who becomes a safety hazard to him/herself or others.
No staff member will ever solicit or accept gratuities in consideration for any treatment of a child.
Staff members will engage children respectfully when discipline through the behavior management procedures is necessary.
Behavior Management
The safety of a child is the highest priority for setting behavior management procedures.
When a child has a serious discipline problem (on any one occasion), the parent may be called by the staff and asked to pick
up the child within one hour of the call. (Biting another child or injuring another child or staff member is a serious discipline
problem).
Should it be decided by YMCA Staff that a child poses a serious discipline problem, the child may be suspended from the program or may be removed from the program entirely.
Special Needs
When it is mutually determined by the YMCA Staff that a child needs professional help beyond the capabilities of the staff in
areas of social, emotional, cognitive, language, and/or motor development growth, the parent(s) will be informed that our
program does not have the adequate resources to care for their child.
The Parkview Family YMCA’s Day Camp Program Rules are:
1.
2.
3.
4.
5.
6.
Respect all children and the counselors
Be responsible for yourself and your belongings
Care for all YMCA equipment
Be honest
Display the Core Values at all times
Have Fun
My child and I have read, understand and agree to follow the above guidelines.
____________________________________________________
Parent Signature
________________________________
Date
Late Pick-Up and Fee Policy
The Parkview Family YMCA Day Camp Program ends at 6:00pm daily. If you are running late, please notify the front desk at
260-497-9996. A late pick-up fee will be assessed after the program closes. There will be an additional charge of $1.00 per
child per minute starting at 6:05pm. We will accept payments for late fees at the time of sign-out. You will receive a receipt
at the time of payment.
Parents/Guardians who have not notified the front desk or any other staff that they will be late can expect the following
sequence of events to occur. These steps are necessary to ensure the safety of the child as well as the YMCA staff members.



6:00pm: Program closes. Staff begins to call parents’/guardians’ contact numbers to check for problems or miscommunications. If contact is not made, alternate emergency contacts listed on the SACC Registration Form will be called.
6:30pm: Staff member in charge will contact local authorities and the Child Care Services Director or Executive Director
to make them aware of the situation.
6:45pm: If there is no contact from the parent/guardian and no other safe option, the child will be turned over to the
city or county police department.
You risk dismissal from the program if:
 You fail to pay the fee.
 You are late picking up your child three times within a 30 day period.
I have read and agree to all the above terms. I recognize that these fees will be assessed. If I do not adhere to the conditions, I understand that my child maybe dismissed from the program.
____________________________________________________
Parent Signature
________________________________
Date
Acknowledgement of Receipt for Parkview YMCA’s SACC Parent Handbook
My Child’s name is (please print)
______________________________________
I acknowledge that I have received a copy of the Parkview Family YMCA’s SACC Parent Handbook.
I have read the handbook, and agree to comply with the guidelines and obligations contained in the handbook.
I also understand and agree that the Parkview Family YMCA reserves the right to revise, modify, delete, or add to any and all
guidelines and procedures stated in this handbook or in any other document. However, any such changes must be in writing
and must be authorized by the SACC Site Director and/or Child Care Services Director.
____________________________________________________
Parent Signature
________________________________
Date