Chilton County Children’s Club After School Program 2017-2018 ____# of Children Enrolling YMCA Member ___Yes (Single or Family) ___No Student Name________________________________ Pathway ____ Grade________ School____________________ Date of Birth_______________ Gender: _____ Racial/Ethnic Group______________

Limited English ___Yes ___No

Circle all Y activities in which this child will participate: Basketball Baton Gymnastics Soccer Taekwondo YCross for kids Please list allergies and medical problems________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Student Name________________________________ Pathway_____ Grade________ School____________________ Date of Birth_______________ Gender_____

Racial/Ethnic Group______________

Limited English ___Yes ___No

Circle all Y activities in which this child will participate: Basketball Baton Gymnastics Soccer Taekwondo YCross for kids Please list allergies and medical problems________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Student Name_________________________________ Pathway_____ Grade________ School____________________ Date of Birth_______________ Gender_____

Racial/Ethnic Group______________

Limited English ___Yes ___No

Circle all Y activities in which this child will participate: Basketball Baton Gymnastics Soccer Taekwondo YCross for kids Please list allergies and medical problems________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Mother/Guardian Name_______________________________ Employment______________________ Cell_________ Father/Guardian Name________________________________ Employment ______________________Cell _________ Address: ___________________________________________________________________________________________ Accident Insurance ___________________________________ Policy Holder __________________________ Policy # ____________________________________________ Group # ______________________________ Permission to seek medical treatment if unable to reach parents ______Yes ________No Doctor’s Name___________________________________ Phone #__________________ Name and phone # of the persons to call in an emergency (other than parents): Name________________________________ Name________________________________ Name________________________________

Phone#________________ Phone #________________ Phone #________________

Relation__________________________ Relation__________________________ Relation__________________________

Tuition will be charged monthly at a rate of $70 per child for Pathway 1 and $85 per child for Pathway 2. Families with two children will be charged $140 for Pathway 1 and $170 for Pathway 2. Families with more than two children will pay an additional $20 monthly per child. All tuition is due by the 10th of each month. A $10 late fee will be accessed after the tenth of each month. Dismissal time will be 5:30 for Pathway 1 at CES and 5:456:30 for Pathway 2 at the YMCA (not available for Pre-k students). Any child still present ten minutes after pickup time will be considered late pickup. Three late pickups will result in your child being excused from the program, without refunding the remaining balance of the month.

Parent’s Signature_____________________________________________ Will tuition be covered by Family Guidance? ____yes ____ no

Date____________________________ 7/17