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Child Care Services YMCA – Afterschool Program, 2012-2013
Early registration is recommended. There is a one week waiting period from the date the completed application is received until the
date the child is able to start the program. Incomplete forms will delay a child’s start date.

CHILD’S NAME:__________________________SCHOOL LOCATION:________________________START DATE: ___________
□ Youth Information Form
You are required to complete a new Youth Information Form annually.
□ 2012-2013 Summer Day Camp and Afterschool Policy Signature Form
Please read our policies and procedures. Parent signature required.
□ Individualized Care Plan
Please complete if you have noted on the Youth Information Form your child will be taking prescription medication at afterschool
care, or has any special need and/or disability. A youth development director will review every ICP and will meet with parents if
necessary to determine how to best meet the child’s needs.
□ Please check if submitting multiple registrations and list the names of the children: ________________________________________________________
□ Current Copy of Immunization Record
We can use the immunization record on file if the information is the same and there are no updates.
□ Current Color Photo of Child (Wallet sized)
Please place on the Youth Information Form in the spot labeled photo.
Please note that by checking this box, you are notifying this office that you will be utilizing Child Care Subsidy Vouchers to assist
with your weekly child care fee. You hereby agree to fulfill all requirements while enrolled in this program, including the
proper usage of SEEK machines. Failure to adhere to all requirements may result in removal from the YMCA program.
□ Child Care Subsidy Vouchers
Three (3) original copies
□ Recipients of Child Care Vouchers
Please present SEEK card at time of registration.
□ YMCA Financial Assistance Application
Applications are accepted throughout the school year – early submission is recommended by July 3, 2012.
□ Registration Fee and Deposit and/or Weekly Payment
The Registration Fee and first week’s payment is due in full at time of registration.
Registration Fee: □ $50 per child
□ $75 per family

***EARLY REGISTRATION DISCOUNT*** – All completed registrations received and processed in the Child Care
Services YMCA office through May 31, 2012 will not pay the $50/$75 registration fee.
Weekly Payment Plan:
□ Full-time - 5 Days/wk.: $75
□ Part-time - 3 Days/wk.: $65 (Limited Availability: You must choose the 3 days attending each week).
Circle: M T W Th F
Payment Method: □ Check # _______ □ Cash □ Money Order □ Credit Card* □ Other *Balances under $10 paid by credit/debit
card will be assessed a $5.00 convenience fee.
Parent/Guardian Signature _____________________________________________________Total Payment Amount Enclosed $ ________________________

2012 Child Care Services Branch Youth Information Form
This youth information is effective for the 2012-2013 Summer Camp and Afterschool Programs.
Child’s Information:
Child’s name________________________________________ Male_____ Female_____ Birthdate__________
Age (as of 6/2012)_____Ethnicity____________________
School child attends during school year __________________________________________Grade (as of Aug. 2012) _____

Color photo of Child

If your child’s schools closes due to inclement weather, your child will:
___Ride the school bus home ___Be picked up by parent at school ___Attend YMCA Afterschool
The Y will make every effort to remain open for normal business hours should school close early. However, if we
must close early, we will post information on WLOS, the YMCA of WNC website (, and text those
signed up for the Y’s Text Message Alert System.

Please be specific and note level of severity, etc.
Current Medications:
Please note all medications AND complete the Individualized Care Plan if medications will need to be administered at the Y program:
__________________________________________________________________________________________________ ________________________________________________________________
Special Needs/Disabilities: _____Yes _____No
If yes, please complete the attached Individualized Care Plan Form.
What activities your child would enjoy while at Afterschool/Summer Camp? ________________________________________________________________________
What are your expectations for the Afterschool/Summer Camp Program? __________________________________________________________________________
Names and Ages of Siblings: ________________________________________________________________________________________________________________________________

Swimming Ability:
Check one: ___ Non-Swimmer ___ Beginner ___ Intermediate ___Advanced
Has your child taken YMCA Swim Lessons previously? __Yes __ No; If Yes, check level: __Starfish __Polliwog __Guppy __Minnow __Fish ___Flying Fish

Family Information:
List both parents/guardians AND check the one parent/guardian completing this form to contact for payments and questions.
___ Parent/guardian’s name _________________________________________________________________ Employer ___________________________________________________
E-mail address ____________________________________________________________Please provide the email address that we may use for contacting you.
Home address _______________________________________________________________________ City _________________________________________________ Zip _____________
Home # __________________________________ Work # __________________________________ ext. ______________ Mobile # __________________________________________
___ Parent/guardian’s name _________________________________________________________________ Employer ___________________________________________________
E-mail address ____________________________________________________________ Please provide the email address that we may use for contacting you.
Home address _______________________________________________________________________ City _________________________________________________ Zip _____________
Home # __________________________________ Work # __________________________________ ext. ______________ Mobile # __________________________________________

Emergency Information:
If you do not have a doctor/dentist, please list Buncombe County Health Department or another provider of your choice. All
information is REQUIRED, including hospital name.
In case of emergency, please contact the following first: ____Mother/Guardian ___Father/Guardian
Child’s doctor ________________________________________________________________________Doctor’s # _______________________________
Child’s dentist ________________________________________________________________________Dentist’s # _______________________________
Hospital preference _________________________________________________________________________________________________________ _______
Insurance company ________________________________________________________________________ Policy # _________________________________
Emergency Contact Information: - When a parent/guardian is not available, I authorize these individuals to pick-up my child:
1. Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________
2. Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________
3. Name _________________________________________Relationship to child ____________________________ Home # _________________________
Work # _____________________ ext. ____ Mobile # __________________

Child Care Services YMCA – Individualized Care Plan
This form will be utilized when a parent/guardian has indicated on the Youth Information Form that their child will be
taking a prescription medication, has a special need and/or disability while participating in the YMCA program.


CHILD’S NAME: _________________________________________________________________CHILD’S DATE OF BIRTH _ _______________________________
Name of Prescription Medication to be taken at the Y:_________________________________________________________________________________
Expiration Date: _________________ Time to Be Taken and Frequency: __________________________________________________________________
Dosage Amount: ___________________Beginning Date: ________________________________ Ending Date: ____________________________________
Special Instructions:_________________________________________________________________________________________________ ________________________
_____________________________________________________________________________________________________________________________ _____________________
Possible Reactions/Allergies:______________________________________________________________________________________ ________________________
___________________________________________________________________________________________________________________________ _______________________
Prescribing Provider: ________________________________________________________________ Phone: _____________________________________________
Pharmacy: _____________________________________________________________________________ Phone: _____________________________________________
I give the YMCA staff authorization to give medicine noted above and to call the health care provider if needed.
Parent/Guardian Signature: __________________________________________________________________________ ______ Date: ______________________

If you listed a special need or medication on the previous sheet, please explain so our staff are familiar prior to your child
attending program:
_____________________________________________________________________________________________________________________________ _____________________
_______________________________________________________________________________________________________________________________ ___________________
________________________________________________________________________________________________________________ __________________________________
If the Y staff and/or the parents/guardians feel it is necessary, a meeting will be scheduled in advance to discuss specific
information. The Y program welcomes all children to the extent that it is reasonably able to do so. A child who requires
measures that constitute a fundamental alteration to the program or other undue hardship, or a child that poses a direct
threat to the health and safety of others, will not be able to participate in the program. All children, regardless of their
circumstances, are subject to Y disciplinary procedures.
OFFICE USE ONLY: ____ Y is to contact family regarding admission into Afterschool Program
____ Parent requests contact with Y staff prior to Afterschool

2012 YMCA Child Care Services Branch
Summer Day Camp/Afterschool Policy Signature Form
Parents/Guardians, please read each area below carefully. Your signature on this document indicates your
acknowledgement, understanding, and agreement with all policies of the YMCA of Western North Carolina.
Policies/Procedures — I have been informed of the Camp/Afterschool Handbook located online at and agree to all policies.
Registration Fees — A one-time nonrefundable and non-transferable CCS registration fee of $50 per child, $75 per family is due at
the time of Summer Camp AND Afterschool Registration. Payment of a separate registration fee is required for both programs.
Refunds and Cancellations — Any deposits and other fees paid are non-transferable and will not be refunded due to cancellation.
Two week notice – Should you need to withdraw your child from the afterschool program, a minimum two week notice is required. You
are responsible for payment for two weeks following the date of your written withdrawal notice was received in the Child Care Services
YMCA office. Should your child be suspended from the program, the two week notice policy does not apply.
Insufficient Funds — If drafts or checks are not honored you are still responsible for the payment plus a $30 service charge applied by
Federal Automated Recovery System. Child(ren) will be unable to attend any YMCA program until the account is paid in full.
Subsidy Voucher Participation — I agree to notify the YMCA of any changes in my subsidy voucher status and to abide by the rules set
forth by the issuing agency. All subsidy voucher participants are responsible for paying the rate discrepancy between what the YMCA
charges and what the voucher will reimburse. The parent/guardian is responsible for any payment for child care not covered by the
Emergency Treatment/Emergency Transportation — I agree that the operator, YMCA of Western North Carolina, may authorize the
physician of their choice to provide emergency care in the event that I cannot be contacted immediately. I authorize for my child to be
transported in the case of an emergency when medical attention by a physician is necessary. I understand that the YMCA will not
transport children in their personal vehicles at any time and a hospital or fire/emergency department will always be contacted.
I, as the operator – YMCA of Western North Carolina, do agree to secure transportation to an appropriate medical resource in the
event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not
administer any drug or any medication without specific instructions from the physician or the child’s parent, guardian, or full-time
custodian. Provisions will be made for adequate and appropriate rest and outdoor play.
Signature of Operator/YMCA Representative: James Spearin and Paul Vest Date: June 2012-June 2013
Field Trips/Transportation — I permit my child to leave the YMCA on authorized trips under the supervision of the YMCA staff. A
written schedule of all activities to be conducted off the YMCA Camp premises will be posted for parents to review. By signing this
form, you give your child permission to be transported in YMCA vehicles. I understand that field trips occur weekly in Summer Camp
and that some field trips have an additional cost to attend. Field trips are on an infrequent basis during Afterschool.
Activities Outside the Fenced Playground — I hereby give permission to the YMCA of WNC for my child to participate in
developmentally-appropriate supervised activities outside the fenced playground at Buncombe County School locations. I understand
this statement is required to be signed for licensing and that this space is still on the school property.
North Carolina Child Care Law and Rules — I have notified that a copy of the North Carolina Child Care Law and Rules from the YMCA is
located on the website
Registration Paperwork — Signature on this document indicates responsibility for payments and is the only one who can alter the
School Success — I understand that the YMCA works with the Buncombe County and Asheville City Schools to develop and deliver
activities that engage and impact children. I give permission for YMCA staff to talk with school staff in regards to my child’s grades,
behavior and other information.
Behavior Management Policy - I have read this policy in the Handbook and agree with all policies as outlined.
Sunscreen: (Initial the appropriate statement:)
______ I allow YMCA staff to provide “NO-AD 45” sunscreen for my child (sunscreen product information available by request).
______ I will provide sunscreen for my child (in an individual bottle labeled with their name and date stored in a zip lock bag)
YMCA Statement — I hereby, for myself, my family, heirs, executors, and administrators, waive and release any and all claims and
damages I may have against the YMCA of Western North Carolina and their respective agents, representatives, successors, and
assigns, for any and all injuries which may be suffered by me or my family in connection with participation in YMCA activities and
programs. I agree to adhere to all policies as outlined on this policy/signature page. I also grant full permission to the YMCA to use any
photographs or video recording taken of me or my family. I agree to comply with YMCA policies and procedures and understand that
my participation can be terminated without refund for exhibiting inappropriate behavior or abuse toward the YMCA staff and/or
Parent/Guardian Name:

__________________________________________ Parent/Guardian Signature:_____________________________________________________
(please print)
Child’s Name:_____________________________________________________________________ Date:____________________________