SCHOOL AGE SUMMER CONTRACT

ALTAVISTA AREA CHILDCARE REGISTRATION

PLEASE SELECT EACH WEEK THAT THE CHILD WLL ATTEND*: (Your account will be charged for each week selected whether the child attends or not, unless canceled per our cancellation policy stated in the contract)

May 31st -June 3rd (CLOSED May 30th) June 6th-10th June 13th-17th

June 20th-24th June 27th-July 1st July 5th-8th (CLOSED July 4th) July 11th-15th

July 18th-22nd July 25th-29th Aug 1st-5th Aug 8th-12th (Altavista Site Only)

First Name*

Middle Name

Last Name*

Name Child Goes By*

Sex*

Home Phone*

Address (Street, town, zip)*

Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed:
Yes No

If Yes please explain*

Previous (Child Care Programs or School Attended)*

Birth Date*

School Attending*

Grade Fall 2022*

PARENTS/GUARDIAN

Mother

First Name*

Middle Name

Last Name*

Place Employed*

Business Phone*

Address & Physical If Different*

Cell*

Home Phone*

Father

First Name*

Middle Name

Last Name*

Place Employed*

Business Phone*

Address & Physical If Different*

Cell*

Home Phone*

Person(s) or Agency Having Legal Custody of Child. Address and Phone tels if different from Parent/Guardian*

EMERGENCY INFORMATION

Food Allergies/Intolerances to Food or Medication*

Has your child ever been stung by a bee?
No Yes

If Yes. what was the reaction?*

Actions to Be Taken in An Emergency*

Child’s Physician*

Physician’s Phone #*

Names & Addresses (street, town, zip) of persons to contact if Parents can’t be reached. **Not Parent/Guardian

Full Name (First, Middle, Last)*:

DOB*:

Full Address*:

Relation to child*:

Phone*:

Full Name (First, Middle, Last):

DOB:

Full Address*:

Relation to child*:

Phone*:

Other Person(s) Authorized to Pick up your Child*

NOT AUTHORIZED to Pick up your Child* (Appropriate Legal paperwork shall be on file when the custodial parent requests the center not to released the child to the other parent)

What program is this registration for?* (Select One) Part Time Full Time

Infant

Younger Toddlers (16-24 months)

Older Toddlers (24-36 months)

Preschool

Discovery Place (Before & After School)

Camp Discovery (Summer Day Camp)

Which Site will your child attend?* (Select One)

Altavista YMCA
Rustburg Concord
Tomahawk Gretna
Yellow Branch Leesville Rd

AGREEMENTS

The childcare center agrees to notify the parent/guardian whenever the child becomes ill and the parent/guardian will arrange to have the child picked up as soon as possible if requested by the center.
The parent/guardian authorizes the childcare center to obtain immediate medical care if any emergency occurs when he/she cannot be located immediately.
I will notify the YMCA or the Discovery Site Director if my child or any member of my family shouldcontract a communicable disease. (ex. COVID-19, lice, scabies, conjunctivitis, fifth’s disease, etc.)
An “in house” photo of your child will be taken for their file, medication and for emergency use only. Other photo permissions below.
The parent/guardian must be aware the YMCA facility is under 24-hour video surveillance.

PERMISSIONS (Answer All Questions)

Signature below authorizes all of the following permissions:

The parent/guardian gives authorization for the YMCA to photograph child and use for publicity.
Yes No

Permission for child to swim in this childcare program.
Yes No

Ability to swim*:

The parent/guardian gives authorization for their child to ride the YMCA buses to and from school, field trips and other activities.
Yes No

The parent/guardian gives authorization for the child to participate in Field Trips.
Yes No

The parent/guardian gives authorization for child to use sunscreen provided by YMCA. (Members Mark Broad Spectrum Hypoallergenic Sunscreen SPF 30-50).
Yes No

Does your child have adverse reactions to sunscreen?
Yes No

If yes, list reactions*

The parent/guardian has received an electronic or paper copy of the parent handbook.

Yes No

Objection To Medical Attention:

State Objection and Reason

Sign if you have objection

The YMCA conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs, the YMCA reserves the right to cancel membership, end program participation, and remove visitation access.

SIGNATURES

Parent or Guardian*

Date*

Email address*

Upload Birth Certificate*

Upload Physical*

Upload Immunization (Signed & Stamped)*

**If new, MUST have forms**Please Check boxes once forms are uploaded OR if forms has been previously submitted

FOR OFFICE USE ONLY

Administrator of Center

Date

Date Child Entered Program:

Date Child Left Program:

Contract Physical Immunization USDA

IDENTITY VERIFICATION

Place of Birth:

Birth Date:

Birth Certificate #

Date Issued:

Other Form of Proof:

Proof of the child’s identity and age may include a certified copy of the child’s birth certificate, birth registration card, notification of birth (hospital, physician, or midwife record), passport, copy of the placement agreement or other proof of the child’s identity from a child placing agency, record from a public school in Virginia, or certification by a principal or his designee of a public school in the U. S., that a certified copy of the child’s birth record was previously presented. Viewing the child’s proof of identity is not necessary when the child attends a public school in Virginia and the center assumes responsibility for the child directly from the school (i. e. after school program) or the center transfers responsibility of the child directly to the school (i. e. before school program). While programs are not required to keep the proof of the child’s identity, documentation of viewing this information must be maintained for each child.

Registration Fee:

$ Paid Cash Credit Card Check

Date

Received by

FIELD TRIP/EMERGENCY INFORMATION FORM

Child’s Name*

Street Address*

State*

Zip Code*

Home Phone*

Birth Date*

Mother’s Name*

Business & Cell Phone*

Father’s Name*

Business & Cell Phone*

Child’s Physician*

Physician’s Phone*

List any allergies or intolerance to food, medication, etc.*

In case of allergic reaction what steps do you authorize the YMCA staff to take*:

EMERGENCY CONTACTS: (MUST HAVE 2) (DAY TIME CONTACTS) Not Parent/Guardian**

Name*

Relation to child*

Home Phone*

Business Phone*

Name*

Relation to child*

Home Phone*

Business Phone*

Parent or Guardian’s Signature*

2022 SCHOOL AGE SUMMER CONTRACT

Start Date: (Office Use Only)

Shirt Size:

Social Services (Y/N):

MUST COMPLETE ONE CONTRACT PER CHILD

Date of Contract*:

Parent/Guardian Responsible for Payment*:

Child’s Full Name*:

Please select site child will attend.*

Altavista YMCA Tomahawk Elem. Rustburg Elem. Gretna Elem.

Lessville Rd Elem. Yellow Branch Elem. Concord Elem.

Registration fee for each child ****$45 if received by 3/11/22; $60 if received by 5/16/22; $75 if received after 5/12/22 (Registration fee includes camp t-shirt)

Camp Fee: $130 for 1st child enrolled per week; $125 for each additional child enrolled per week

ALL SCHOOL YEAR ACCOUNTS MUST HAVE A ZERO BLANCE BEFORE STARTING THE SUMMER PROGRAM

ALL INFORMATION MUST BE FILLED OUT COMPLETELY. ANY INCOMPLETE CONTRACTS WILL BE RETURED AND A SPACE WILL NOT BE HELD FOR YOUR CHILD UNTIL CONTRACT IS COMPLETED AND RETURNED.

PAYMENT

A NON-REFUNDABLE registration fee of $45.00 if received by 3/11/22, $60 if received by 5/12/22, $75 is received after 5/16/22 is required along with the first payment. Space will not be reserved until paid. The undersigned party agrees to pay the Altavista Area YMCA $ per week for every week in which the child is enrolled in the program. NO BILLS WILL BE SENT. The Altavista Area YMCA reserves the right to increase fees upon two (2) weeks’ notice. Absence from the program or part of the week shall not affect the responsibility for full payment. YOU WILL BE RESPONSIBLE FOR THE FULL RATE FOR ALL WEEKS, EVEN IF YOUR CHILD DOES NOT ATTEND. THIS INCLUDES THANKSGIVING, CHRISTMAS, AND SPRING BREAKS. This agreement requires full payment on each Friday prior to starting on the following Monday OR YOUR CHILD CANNOT START ON MONDAY, unless canceled in writing as stated on reverse side of contract. Payments may also be made on a monthly basis and are due the 5th of each month, in advance. If schools close for non-scheduled calendar days, the full daily/weekly rate will be charged per child. This does not include the regularly scheduled calendar holidays for the Campbell and Pittsylvania County calendars. This also does not include snow days or 2-hour delays due to inclement weather.

•Payments can be made online. You may visit altavistaymca.com – click on childcare tab – click childcare dropdown – register at the bottom of the page. The family center can set up automatic payments, which is the preferred method of payment by calling 434-369-9622 ext. 36. Payment by check, credit card, money order or cash can be made to the FRONT DESK of the Family Center located at 1000 Franklin Ave., Altavista, Va. or you may mail a check or money order to YMCA Child Care 1000 Franklin Ave. Altavista, VA 24517.

•STAFF CANNOT ACCEPT PAYMENTS AT ANY SCHOOL SITE LOCATION.

•Returned checks are subject to a service fee of $25. If two checks are turned on the same account, the account must become a "cash, credit, or money order" account.

•A LATE FEE of $1.00 per minute per child is calculated starting at 6:01 PM.

•Late payments are subject ot a 5% late charge.

•If the childcare center and country sites are closed for more than two (2) days due to inclement weather in a week, you will not be charged for the days closed.

•We are aware that you may not know your schedule at this time, but PLEASE SELECT all weeks you anticipate needing. If you need to change a week, do so BY WEDNESDAY prior to the week you want to add or delete. You will not be charged for the deleted week. If you do not let us know to cancel a week by the dealine and your child does not attend, you will be responsible for that week. All changes must be emailed to cancel@altavistaymca.com.

ENROLLMENT/TERMINATION

SPACE FOR YOUR CHILD WILL NOT BE RESERVED UNTIL THE REGISTRATION FEE IS PAID ALONG WITH THE FIRST PAYMENT.

•The YMCA reserves the right to terminate immediately a child’s enrollment in the program for any act, word or condition of the child or parent causing disruptions, safety concerns or health concerns for the child, other children, or employees of the YMCA. You are subject to dismissal if your account is not kept current, after missing 1 WEEK PAYMENT.

•**THE CHILD’S ENROLLMENT CAN BE CANCELED BY THE UNDERSIGNED RESPONSIBLE PARTY BY GIVING A 2 WEEK WRITTEN NOTICE. NOTIFICATION MUST BE EMAILED TO cancel@altavistaymca.com.NO PHONE CALLS FOR CANCELLATIONS WILL BE ACCEPTED.

RESPONSIBILITIES

•The parties agree that the Altavista Area YMCA shall not be responsible for medical expenses, incurred by or for the child, not covered by insurance.

•If this account becomes delinquent, the undersigned responsible party shall be responsible for all service charges, expenses, court cost, attorney’s fees or collection agency fees incurred to collect this debt.

POST OFFICE BOXES ARE NOT ACCEPTABLE ON THIS CONTRACT. ALL INFORMATION HAS TO BE COMPLETED. THE HOME & WORK ADDRESS MUST BE COMPLETELY FILLED OUT WITH THEIR PHYSICAL 911 ADDRESS.

I/WE hereby agree to the terms of this contract.

DO NOT SIGN CONTRACT FOR SPOUSE.

Mother’s/Father's Signature*

Mother’s Printed Name*

Mother’s DOB*

Mother’s Physical Home Address*

Zip Code*

Mother’s Place of Employment and 911 Employment address*

Phone #s: Home*

Work*

Cell*

Email address*

Father’s Printed Name*

Father’s DOB*

Father’s Physical Home Address*

Zip Code*

Father’s Place of Employment and 911 Employment address*

Phone #s: Home*

Work*

Cell*

Email address*

Verification Code

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Altavista Area YMCA
718 7th St.
Altavista, VA 24517

Hours of Operation:
Monday-Friday: 5:00a.m.-9:00p.m.
Saturday: 8:00a.m.-5:00p.m.
Sunday: 1:00p.m.-5:00p.m.

Our Mission

The Altavista Area YMCA provides opportunities to all individuals, youth, adults, and families in the community

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SCHOOL AGE SUMMER CONTRACT

ALTAVISTA AREA CHILDCARE REGISTRATION

FIELD TRIP/EMERGENCY INFORMATION FORM

EMERGENCY CONTACTS: (MUST HAVE 2) (DAY TIME CONTACTS) **Not Parent/Guardian

2022 SCHOOL AGE SUMMER CONTRACT

EMERGENCY CONTACTS: (MUST HAVE 2) (DAY TIME CONTACTS) Not Parent/Guardian**