Central Labrador YMCA After Day Play Registration Form

Enrollment

Registration for the After Day Play Program is for September 2023-June 2024. If registering your child for the program on a drop-in basis, registration and payment can be made at the front desk. By completing this registration form, you are registering your child for the After Day Play Program for September 2024- June 2025.

Family Information

Parent/Guardian: First and Last Name(Required)

First Last

Parent/Guardian: Date of Birth(Required)

Parent/Guardian: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian: Home Phone Number

Parent/Guardian: Mobile Phone Number(Required)

Parent/Guardian: Work Phone Number

Parent/Guardian Email(Required)

Second Parent/Guardian: First and Last Name

First Last

Second Parent/Guardian: Date of Birth

Second Parent/Guardian: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Parent/Guardian: Home Phone Number

Second Parent/Guardian: Mobile Phone Number

Second Parent/Guardian: Work Phone Number

Second Parent/Guardian Email

Child: First and Last Name(Required)

First Last

Child: Date of Birth(Required)

Child: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child: Home Phone Number(Required)

Child: Mobile Phone Number

Authorized Alternative Pickup/Release and Emergency Contacts

Authorized Person #1: Name of the person to whom the child may be released, other than those authorized parent/guardian #1 or #2. (Enter "N/A" if not applicable)(Required)

Authorized Person #2: Name of the person to whom the child may be released, other than those authorized parent/guardian #1 or #2. (Enter "N/A" if not applicable)

Emergency Contact #1: Full Name(Required)

Emergency Contact #1: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact #1: Home Phone Number

Emergency Contact #1: Mobile Phone Number(Required)

Emergency Contact #2: Full Name

Emergency Contact #2: Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact #2: Home Phone Number

Emergency Contact #2: Mobile Phone Number

General Questions

Has your child had all immunizations?(Required)

Yes

Does your child have any allergies?(Required)

Yes

If yes, please list and describe any allergies including the treatment.(Required)

Is your child receiving medical treatment of any kind? (Orthopedic, psychiatric, medication, etc.)?(Required)

Yes

If yes, please provide the details of the medical treatment.(Required)

What is your child’s MCP number?(Required)

Does your child have special needs?(Required)

Yes

If yes, please provide the details.(Required)

Please state your relationship to the child (registrant).(Required)

Payment Information

Pre-Authorized Payments (PAPs) is applied to personal bank accounts (a void cheque or pre-authorized payment form from your bank is required). Fees are charged on a bi-weekly basis (1st & 15th of every month) to your bank account. In some cases, your payment date may change, for example if your Payment Method has not successfully settled. Note: it may take a few days for the charge to post to your account. NSF Policy: The YMCA is not responsible for bank fees incurred due to non-sufficient funds (NSF). Balances owing must be paid in full to continue child care services. Fee Changes: Notification will be provided to the email and/or mailing address on file a minimum of 15 days prior to any scheduled change in fees.

Please attach (upload) a void cheque or pre-authorized debit form from your financial institution, to process the bi-monthly child care fees.(Required)

Max. file size: 256 MB.

Will there be split billing?

Yes

If yes, please indicate payer information below.

Do you currently have or will be applying for childcare subsidy?(Required)

Yes

Notice to Parent:

When this registration request has been submitted, you will receive a confirmation email stating we have received your request. The Provincial Registrar will then process your registration request and send another email to you that will include a payment plan showing future scheduled payments that will occur on the 1st and 15th of all months for which your child(ren) have been registered. No payment is due upon registration. IMPORTANT: YOU MUST COMPLETE THE CENTRAL LABRADOR YMCA ASSUMPTION OF RISK AND WAIVER OF LIABILITY AFTER SUBMITTING THIS FORM.

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