YMCA of Greater Erie

Child's Name*

First Last

Date of Birth*

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Gender

Male
Female
Disabled

Gender*

Age Group*

Parent's Name*

First Last

Email*

Phone*

Address*

Street Address City State ZIP Code

Membership Status*

YMCA MEMBER
NON-MEMBER

YMCA Branch (If you selected YMCA MEMBER above)

Has this child or any others in the household attended a YMCA Program?*

Yes
No

Where (If you selected Yes above)

Does this child currently attend school?*

Yes
No

School Currently Attending*

Do you have ELRC funding?

Yes
No

If yes, please provide Caseworker and Case #:

Caseworker

(If you have ELRC funding)

Case #

(If you have ELRC funding)

SERVICES TO BE PROVIDED AS PART OF THE CHILD CARE FEE: The YMCA of Greater Erie Child Care Center will provide care and developmentally appropriate activities for the age group during the hours listed below. These will include but not be limited to feeding, care, supervision, planning, and implementation of developmentally and age appropriate activities.

Please be advised that the YMCA of Greater Erie provides full time care. Therefore, by choosing to enroll your child or dependent in our program, you acknowledge and agree that the full rate will apply even if the child is taken out of care early or dropped off late, as this charge is for access to full time care. If you have any questions or require clarification about the fee agreement or the type of care requested, please do not hesitate to contact the site director for assistance.

Type of Care*

Before School
After School
Summer Camp
My child has not entered Kindergarten yet

Check all that apply

Child's Arrival Time*

:

Child's Departure Time*

:

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Extended Day Care (Downtown Branch Only)
Saturday (Downtown Branch Only)
Second Shift Care (Early Learning Center at Poplar Street Only)

Childcare Program Location*

Authorized Pick-up People

PERSON(S) DESIGNATED BY PARENT TO WHOM THE CHILD MAY BE RELEASED

Name*

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

EXTRA FEES TO BE CHARGED IF APPLICABLE 1. $35.00 NSF fee for all returned checks 2. Late Fee: $1.00 per minute per child past current closing time 3. Adaptive programming supplies

Early Learning Resource Center (ELRC) Policies: 1. If a child is absent for 5 days in a row, the child may no longer be eligible for subsidized care. 2. If your child is absent more than 40 times, you will have to pay the YMCA the CCIS daily rate for each day your child is absent starting with the 26th day in addition to your weekly copay up to $35.50/day. 3. A family that receives part-time subsidized child care for only one child who is in school, must pay the full co-payment amount for the entire year.

Consent

I, the parent/guardian agree to abide by the rules there in:

• Received complete written program information at time of my child’s enrollment including the parent handbook which contains center
rules, emergency procedure and other valuable information.
• Agree to update emergency contact/parental consent form information whenever changes occur or every 6 months minimum.
• Agree to provide the child care center with an updated health assessment and immunizations in accordance with American Academy Pediatrics recommendations.
• Understand I am responsible for all charges and must pay for services in advance on a weekly basis. I will give a two week notice before withdrawing my child from the program.
• Agree to treat YMCA staff and other program members with respect and choosing not to do so will result in termination of services.
• Have received the original of this document. My signature acknowledges my understanding of the Agreement to the above.

Signature of Parent or Guardian*

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Date

Hidden

Discount Fee Type

Hidden

Payment is due:

Friday Before Service Week

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Registration Fee

$20.00 Child / $30.00 Family

Hidden

Published Weekly Rate

Hidden

Early Dismissal / No School Add On Fee

Hidden

Parent Contract Rate w/ Applied Discounts

Hidden

Daily Rate if Exceed Contracted Days

Hidden

Enrollment Date

Hidden

Rate Effective Date

Hidden

Withdrawal Date

Hidden

Signature of YMCA Staff Person

Hidden

Date

Fee Agreement and Polices (2 of 3)

Authorized Pick-up People