'21-'22 Signature After-School Program Enrollment Form

2021-2022 School Year: YMCA After-School Signature Program Enrollment Form for D90 Families
To begin the enrollment process for the Signature Program please complete the following enrollment form. You will receive an email notification that the enrollment has been received. A West Cook YMCA team member will follow up to confirm your enrollment has been finalized.

The form allows you to register for multiple children (up to 4) residing in the same household. You will need to provide your child(ren)'s health exam form. You will have an opportunity to upload with your registration packet. The form must be received by August 15th, 2021.

Enrollment Confirmations will be sent the week of August 2nd.

The YMCA After-School Signature Program follows the School District 90 Calendar, and for days those students are in school, the afterschool program will run, including half days or early release days. The program will not run on days that school is closed including inclement weather closures. The program will run Monday- Friday from the end of the school day until 6:00 pm.

Tuition Agreement

One of our team members will reach out to you to set up your automatic payment. The tuition for the After-School Signature Program will be split up in nine even payments of $600 per month. Tuition will be due on the 15th of the month with the first payment being due August 15th and the last payment due May 15th.
Please contact me about financial assistance *

Yes No
Each child will receive a complimentary youth membership from September 2021 through May 2021. This will provide families with discounted fees for programs including swim lessons and competitive swim team. You can upgrade to a household or single household membership so that all members of the family can have access to the West Cook YMCA. The complimentary membership is provided by an anonymous donor and is not a part of the YMCA After-School Signature Program Fees. *

I am already a member of the West Cook YMCA I would like to upgrade to a Household Membership for $62/month; regularly $89/month Single Household Membership for $55/month; regularly $82/month I would only like to have the complimentary youth membership for my child(ren) valued at $243 per child for the school year (September 2021-May 2022)
I acknowledge that I agree to the monthly tuition of $600 per month per child and I will have a payment on file for automatic drafts that will occur on the 15th of the month from August 2021 to May 2022. *

Clear
Date of Signature *

Month Day Year
Date

PARENT/GUARDIAN INFORMATION

Parent/Guardians listed on this page are allowed to pick up on a regular basis and under any condition.
Parent/Guardian 1 Name *

First Name Last Name
Parent/Guardian 1 Date of Birth *

Month Day Year
Date
Parent/Guardian 1 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 1 Place of Work
Parent/Guardian 1 Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 1 Email Address *
example@example.com
Parent/Guardian 1 Preferred Phone *
Please enter a valid phone number.
Parent/Guardian 1 Alternate Phone
Please enter a valid phone number.
Child(ren) resides with Parent/Guardian 1 *

Yes No
Would you like to add another parent/guardian? Please note: If a second parent or guardian will be picking up your child(ren), please add them here. *

Yes No

PARENT/GUARDIAN INFORMATION (Cont.)

Parent/Guardians listed on this page are allowed to pick up on a regular basis and under any condition.
Parent/Guardian 2 Name *

First Name Last Name
Parent/Guardian 2 Date of Birth *

Month Day Year
Same residence as Parent/Guardian 1 *

Yes No
Parent/Guardian 2 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 2 Place of Work
Parent/Guardian 2 Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 2 Email Address *
example@example.com
Parent/Guardian 2 Preferred Phone *
Please enter a valid phone number.
Parent/Guardian 2 Alternate Phone
Please enter a valid phone number.
Child(ren) resides with Parent/Guardian 2 *

Yes No

Family Information
Family Dynamics (please share situations that may have an impact on your child(ren) so we can best support them while they are in the after-school signature program.): *
When necessary, who should be contacted first? *

Parent/Guardian 1 Parent/Guardian 2 Other

Approval for West Cook YMCA Activities

Please check all the appropriate choices that you are approving or not approving.
Photo/Video Permission *

I give permission for my child(ren) to have their picture and/or video taken as part of the West Cook YMCA program. I understand that the picture or video may be displayed in marketing materials, within the facility, in the newspaper, or on other media outlets. I do NOT give permission for my child(ren) to have their picture and/or video taken for the purpose of using in marketing materials, within the facility, newspapers, or other media outlets.
Emergency Medical Authorization: The purpose of this authorization is to enable parents and guardians to authorize provision of emergency treatment for children who become ill or injured while under our supervision when parents or guardians cannot be reached.

I hereby give my consent for the administration of any medical treatment deemed necessary by our family doctor or another licensed physician at the closed hospital facility. I do NOT give my consent for the emergency medical treatment beyond basic first aid for my child. In the event of sudden illness or injury requiring emergency medical treatment, I hereby give the YMCA staff authority to do the following listed in the next question.
If you do not give consent for emergency medical treatment as listed in previous question, please list what you do give the YMCA staff the authority to do: *
I approve as checked above and know the responsibility would rely on me for any medical costs that would come up. I give authorization based on the choices made above. *

Clear
Date of Signature *

Month Day Year
Date

Health History Form
Family Physician's Name *

Prefix First Name Last Name
Physician's Phone *
Please enter a valid phone number.
Physician's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Family's Dentist's Name *

First Name Last Name
Dentist Phone *
Please enter a valid phone number.
Dentist Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Serious illnesses and/or hospitalizations. If more than one child, please label by child's name. *
Special physical conditions or disabilities that may require accommodations (please be specific) If more than one child, please list by child *
Does your child need medication dispersed during camp? *

Yes, please send me the medical distribution form. No

Emergency Contacts

Emergency contacts will only be contacted in the case of a situation where we need to get a hold of parents/guardians and we have not been able to. Emergency contacts will also be allowed to pick up children from the program. If anyone other than those listed will be picking up your child, you must contact Youth Development Program Staff via d90asp@westcookymca.org. Phone authorization will not be sufficient. For the safety of your child, anyone picking up your child must have a picture ID. Anyone without proper authorization will not be allowed to take your child
Emergency Contact 1 Name *

First Name Last Name
Relationship to child *

Step-parent Grandparent Aunt/Uncle Sibling (18 years or older) Cousin (18 years or older) Family Friend Other
Emergency Contact 1 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact 1 Cell Phone *
Please enter a valid phone number.
Would you like to add another emergency contact? *

Yes No

Emergency Contact 2 Name *

First Name Last Name
Relationship to child *

Step-parent Grandparent Aunt/Uncle Sibling (18 years or older) Cousin (18 years or older) Family Friend Other
Emergency Contact 2 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact 2 Cell Phone *
Please enter a valid phone number.

Do you wish to authorize additional individuals to pick up your child? *

Yes No

Additional Authorized Pick-Up

All individuals who wish to pick up your child must be listed below, excluding parents and guardians listed under general information. If anyone other than those listed will be picking up your child, you must contact Youth Development Program Staff via d90asp@westcookymca.org. Phone authorization will not be sufficient. For the safety of your child, anyone picking up your child must have a picture ID. Anyone without proper authorization will not be allowed to take your child.
Additional Pick Up 1 Name *

First Name Last Name
Additional Pick Up 1 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Additional Pick Up 1 Phone *
Please enter a valid phone number.
Conditions for releasing child (if any)
Would you like to add an additional pick-up person? *

Yes No

Additional Pick Up 2 Name *

First Name Last Name
Additional Pick Up 2 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Additional Pick Up 2 Phone *
Please enter a valid phone number.
Conditions for releasing child (if any)
Would you like to add an additional pick up person? *

Yes No

Additional Pick Up 3 Name *

First Name Last Name
Additional Pick Up 3 Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Additional Pick Up 3 Phone *
Please enter a valid phone number.
Conditions for releasing child (if any)

Please submit your 2021-2022 YMCA After-School Signature Program Enrollment Form using the submit button below.

If we have any questions as we process the enrollment information, we will reach out to you. If you have any questions, please do not hesitate to email us at d90asp@westcookymca.org. We will be responding to inquiries on Mondays, Wednesdays, and Fridays.

Enrollment confirmations will be sent the week of August 2nd.

After enrollment confirmation, a YMCA team member will reach out to schedule out the payment for the monthly tuition for each child registered. Please email, fax, or drop off a copy of your child’s most recent copy of a physical. This will need to be submitted by August 15, 2021.

Thank you.
Please complete the following checklist to ensure your registration is completed prior to submission:

All fields for each child registration are complete Medical form is uploaded for each child registering for the program, or will follow up with email to d90asp@westcookymca.org by August 15th with most recent medical form for each child. For any additions or updates to authorized pick up for child, will email d90asp@westcookymca.org
Should be Empty:

2021-2022 School Year: YMCA After-School Signature Program Enrollment Form for D90 Families

Tuition Agreement

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION (Cont.)

Child 1 Information

Child 2 Information

Child 3 Information

Child 4 Information

Family Information

Approval for West Cook YMCA Activities

Health History Form

Emergency Contacts

Additional Authorized Pick-Up