2010-11 Before and After School Program
Laugh, Learn and Grow with the
Childcare Enrichment Program!
The YMCA of Greater Louisville, in partnership with Jefferson County Public Schools, offers the
Childcare Enrichment Program — where your child will learn, grow and have a great time!
ymcalouisville.org
en
kindergart
through
hool
middle-sc
Financial assistance available.
Childcare Enrichment Program ● (502) 637-1575
We’re Everywhere
The Childcare Enrichment program is available to all JCPS students from
kindergarten through age 14. Transportation by JCPS school bus between
your child’s school and CEP is available. We are the largest provider of childcare
in the state, offering over 50 sites throughout Jefferson County.
Enrichment is our Name
We pride ourselves on providing a safe environment where your child can
participate in fun activities that enrich, strengthen and expand their learning.
Our activities are focused around literacy, arts and humanities, recreation,
science & technology, academic support, healthy actions and fitness, character
development and asset building. Our goal is to help your child build a healthy
spirit, mind and body.
Daily Schedule
Regular program hours are 7 a.m. until the start school and close of school until
6 p.m. Continuous care is also available from 7 a.m. until 6 p.m. when school is not
in session, at select locations. Spring Break, Winter Break and Summer programs
require a separate registration. In addition to planned activities and programs,
each child will receive healthy morning and afternoon snacks. Breakfast is served
for children in the before-school program.
And for Preschoolers . . .
Before- and after-school care is available for any child enrolled in one of the JCPS
tuition-based preschool sites in the district (see site location list for details). Full day
care is not available for preschoolers.
Trained Staff
Our outstanding staff members receive extensive hours of professional development
training that exceeds state licensing requirements. All staff are CPR and First Aid
certified and we meet or exceed state staff-to-child ratios.
Parental Involvement
All our programs have an open door policy and parents are welcome and encouraged
to take part in their child’s day. Each site will host special family events. We welcome
parents to join our Parent Advisory Committee, where monthly luncheon
meetings give you the opportunity to provide key input, feedback and program
development ideas. Throughout the year, we distribute surveys to parents and
participants. Your feedback is valuable and greatly appreciated!
visit ymcalouisville.org or email us
at [email protected]
Weekly Rates
First Child
Each Additional Child
Program
Members
YMCA Facility Member/
Partnership Employee
Dependents
Program
Members
YMCA Facility Member/
Partnership Employee
Dependents
4- or 5-day
Before School Only
After School Only
Before & After School
$45
$58
$72
$40
$53
$67
$35
$48
$62
$30
$43
$57
1-, 2- or 3-day
Before School Only
After School Only
Before & After School
$37
$47
$59
$33
$43
$55
$29
$39
$51
$25
$35
$47
Registration Fees
Per Child
Through August 9, 2010
$30 per child
August 10, 2010 throughout school year
$45 per child
In-service and snow days are included in total number of days attended for the week.
Registration
Registration for the before- and after-school programs will continue throughout
the school year based on space availability. All sites have minimum and maximum
enrollment numbers and registrations are processed on a first-come, first-served basis.
Completed registrations must be received at least 2 business days prior to your child’s
start date. All parents must pay the registration fees.
To register submit your registration form and non-refundable registration fee one of
the following ways:
• Online at ymcalouisville.org through August 9th
• Bring registration form and fee to your CEP Site Director
• Mail the registration form and fee to:
YMCA School-Age Child Care Services
2411 Bowman Avenue
Louisville, KY 40217
Mail must be post-marked one week prior to start date.
Payment Options
All payments are to be made by bank or credit card draft. Automatic draft payments
must be set up prior to the first day of attendance in order for the child to attend the
program. Drafts will occur each Wednesday for the current week, unless otherwise
scheduled through our main office.
In-Service & Snow Days
Full day care available during in-service and snow days from 7 a.m. until 6 p.m. Site
locations may vary due to site consolidation. In addition to completing the registration
form, participants must be signed up to attend these days at the site of their choice. Details
available at your site or at ymcalouisville.org. In-service and snow days are included in
total number of days attended for the week. Full day care is not available for preschoolers.
Financial Assistance & 3rd Party Subsidies
Through the Spirit Program, we strive to turn no one away due to an inability to pay. The
Spirit Program is a sliding-scale income-based financial assistance program available
through the YMCA. Call (502) 637-1575 or go to ymcalouisville.org for a Spirit
Application. All sites are also eligible for third-party subsidy reimbursements provided by
4-C, Foster Care, United Way, etc. Valid contracts must be on file with our main office
prior to the program start date. Spirit Program assistance is only available for those
that do not qualify for 4-C or other third-party subsidies.
CEP Sites & Locations
The before- and after-school program begins on Tuesday,
August 17, 2010. Sites are conveniently located in these
Jefferson County Public Schools.
Northeast Area
Bowen Elementary, 1601 Roosevelt Avenue
Malcolm B. Chancey Jr. Elementary, 4301 Murphy Lane
Chenoweth Elementary, 3622 Brownsboro Road
Dunn Elementary, 2010 Rudy Lane
*Field Elementary, 120 Sacred Heart Lane
Greathouse Elementary, 2700 Browns Lane
Hite Elementary, 12408 Old Shelbyville Road
Lowe Elementary, 210 Oxfordshire Lane
Middletown Elementary, 218 North Madison Avenue
*Norton Elementary, 8101 Brownsboro Road
St. Matthews Elementary, 601 Browns Lane
*Joseph E. Stopher Elementary, 14417 Aiken Road
*Wilder Elementary, 1913 Herr Lane
Zachary Taylor Elementary, 9620 Westport Road
Southeast Area
Audubon Traditional Elementary, 1051 Hess Lane
Bates Elementary, 7601 Bardstown Road
Bloom Elementary, 1627 Lucia Avenue
Blue Lick Elementary, 9801 Blue Lick Road
Cochrane Elementary, 2511 Tregaron Avenue
*James E. Farmer Elementary, 6405 Gellhaus Lane
Fern Creek Elementary, 8703 Ferndale Road
Goldsmith Lane Elementary, 3520 Goldsmith Lane
*Hawthorne Elementary, 2301 Clarendon Avenue
Highland Middle, 1700 Norris Place
Jeffersontown Elementary, 3610 Cedarwood Way
Klondike Elementary, 3807 Klondike Lane
Laukhuf Elementary, 5100 Capewood Drive
Luhr Elementary, 6900 Fegenbush Lane
Rangeland Elementary, 1701 Rangeland Road
Smyrna Traditional Elementary, 6401 Outer Loop
Thomas Jefferson Middle, 1501 Rangeland Road
*Tully Elementary, 3300 College Drive
Watterson Elementary, 3900 Breckenridge Lane
*Wheeler Elementary, 5700 Cynthia Drive
Southwest Area
Cane Run Elementary, 3951 Cane Run Road
Conway Middle, 6300 Terry Road
Doss High School, 9601 St. Andrews Church Road
Fairdale Elementary, 10104 Mitchell Hill Road
Frederick Law Olmsted South Middle, 5650 Southern Parkway
(nationally accredited by the NSACCA)
Johnsontown Elementary, 7201 Johnsontown Road
Kerrick Elementary, 2210 Upper Hunters Trace
McFerran Elementary, 1900 South Seventh Street
Minors Lane Elementary, 8510 Minors Lane
Rutherford Elementary, 301 Southland Boulevard
Shacklette Elementary, 5310 Mercury Drive
Stuart Middle, 4601 Valley Station Road
Downtown Area
*Brandeis Elementary, 2817 W. Kentucky Street
Breckinridge-Franklin Elementary, 1351 Payne Street
Brown School, 546 South First Street
*Carter Traditional Elementary, 3600 Bohne Avenue
Coleridge-Taylor Elementary, 1115 West Chestnut Street
Foster Elementary, 4020 Garland Avenue
*Kennedy Montessori Elementary, 3800 Gibson Lane
Noe Middle, 121 West Lee Street
*Before and After School child care for 3- and 4-year olds enrolled
in the host school’s tuition-based Pre-K program will be provided at
these sites only. No full-day child care is available for preschoolers.
Feeder Schools
Locate your child’s school. All available CEP sites are listed
after the school name.
Atkinson: All CEP sites available
Auburndale: Fairdale, Jacob, Frederick Law Olmsted, South
Middle, Rutherford
Audubon: Audubon, Bates, Farmer, Goldsmith, Hawthorne,
Highland, Jeffersontown, Klondike, Noe, Rangeland, Thomas
Jefferson Middle, Tully, Watterson, Wheeler
Barrett Traditional Middle:
Bowen, Chancey, Chenoweth,
Dunn, Greathouse, Lowe, Middletown, Norton, St. Matthews,
Zachary Taylor
Bates: Bates, Farmer, Fern Creek Elementary, Goldsmith,
Jeffersontown Elementary, Luhr, Price, Rangeland,
Watterson, Wheeler
Blake: Blue Lick, Laukhauf, McFerran, Smyrna,
Thomas Jefferson Middle
Bloom: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite,
Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully
Blue Lick: Blue Lick, Laukhuf, McFerran, Minors Lane, Smyrna,
Thomas Jefferson Middle
Bowen: Bowen, Chancey, Coleridge-Taylor, Dunn, Norton, Wilder,
Zachary Taylor
Brandeis: All CEP sites available
Breckinridge-Franklin:
Bowen, Breckinridge-Franklin, Chancey,
Chenoweth, Coleridge-Taylor, Dunn, Field, Norton, Wilder,
Zachary Taylor
Brown: Brown
Byck: All CEP sites available
Camp Taylor: Audubon, Blue Lick, Laukhauf, McFerran, Noe, Smyrna
Cane Run: Cane Run, Carter, Conway, Foster, Johnsontown,
Kennedy, Kerrick, Shacklette, Stuart
Carrithers Middle:
Tully
Carter Traditional Elementary:
Audubon, Bloom, Brandeis, Cane
Run, Coleridge-Taylor, Conway, Doss, Fairdale, Field, Highland,
Johnsontown, Kerrick, Noe, Shacklette, Stuart
Chancey: Bowen, Breckinridge-Franklin, Chancey, Chenoweth,
Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor
Chenoweth: Bowen, Breckinridge-Franklin, Chancey, Chenoweth,
Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor
Cochran: Blue Lick, Kennedy, Laukhauf, McFerran, Minors Lane,
Noe, Stuart
Cochrane: Bloom, Cochrane, Hawthorne, Hite, Klondike, Lowe,
Middletown, Smyrna, St. Matthews, Stopher, Tully
Coleridge-Taylor:
Bloom, Bowen, Breckinridge-Franklin,
Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Highland,
Jeffersontown, Lowe, Middletown, Noe, Norton, St. Matthews,
Tully, Wilder, Zachary Taylor
Conway Middle:
Cane Run, Conway, Shacklette
Coral Ridge: Fairdale Elementary, Jacob, Rutherford
Crosby Middle:
Lowe, Middletown
Crums Lane: Cane Run, Carter, Conway, Foster, Johnsontown,
Kennedy, Kerrick, Shacklette, Stuart
Dixie: Cane Run, Foster, Johnsontown, Kennedy, Kerrick,
Shacklette, Stuart
Dunn: Bowen, Breckinridge-Franklin, Chancey, Chenoweth,
Coleridge-Taylor, Dunn, Field, Greathouse, Norton, Wilder,
Zachary Taylor
Eisenhower: Cane Run, Conway, Foster, Johnsontown, Kennedy,
Kerrick, Shacklette
Engelhard: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite,
Klondike, Lowe, Middletown, Noe, St. Matthews, Stopher, Tully
Fairdale Elementary:
Fairdale, Frederick Law Olmsted South
Middle, Jacob, Rutherford
Farnsley Middle:
Cane Run, Conway, Frederick Law Olmsted
South Middle, Kerrick, Shacklette
Farmer Elementary:
Bates, Farmer, Fern Creek Elementary,
Goldsmith, Jeffersontown, Luhr, Price, Rangeland,
Watterson, Wheeler
Fern Creek Elementary:
Bates, Farmer, Fern Creek Elementary,
Goldsmith, Jeffersontown, Luhr, Price, Rangeland,
Watterson, Wheeler
Field: Bowen, Breckinridge-Franklin, Chancey, Chenoweth,
Coleridge-Taylor, Dunn, Field, Highland, Norton, Wilder,
Zachary Taylor
Foster: All CEP sites available
Frayser: Blue Lick, Laukhauf, McFerran, Minors Lane, Smyrna
Frederick Law Olmsted North:
Frederick Law Olmsted South
Frederick Law Olmsted South:
Frederick Law Olmsted South
Gilmore Lane: Blue Lick, Laukhauf, McFerran, Minors Lane,
Smyrna, Thomas Jefferson Middle
Goldsmith Lane:
Bates, Coleridge-Taylor, Farmer, Fern Creek
Elementary, Jeffersontown, Goldsmith, Luhr, Price, Rangeland,
Watterson, Wheeler
Greathouse/Shyrock:
Bowen, Chancey, Coleridge-Taylor, Dunn,
Greathouse, Lowe, Middletown, Norton, St. Matthews, Wilder,
Zachary Taylor
Greenwood: Cane Run, Conway, Doss, Foster, Johnsontown,
Kennedy, Shacklette
Gutermuth: Cane Run, Foster, Frederick Law Olmsted South,
Johnsontown, Shacklette
Hartstern: Blue Lick, Laukhauf, Minors Lane, Smyrna, Thomas
Jefferson Middle
Hawthorne: Bloom, Cochrane, Hawthorne, Highland, Hite,
Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully
Hazelwood: Fairdale, Frederick Law Olmsted South,
Jacob, Rutherford
Highland Middle:
Audubon, Bates, Bowen, Chenoweth,
Coleridge-Taylor, Dunn, Field, Frederick Law Olmsted South,
Hawthorne, Highland, Noe, Norton, Zachary Taylor
Hite: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite,
Klondike, Lowe, Middletown, Stopher, Tully
Indian Trail: Bates, Farmer, Fern Creek Elementary, Goldsmith,
Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler
Jacob: Cane Run, Fairdale, Jacob, Rutherford, Stuart
Jefferson County Traditional Middle:
Bates, Brandeis,
Hawthorne, Highland, Klondike, Laukhauf, Price
Bates, Farmer, Fern Creek, Goldsmith,
Jeffersontown Elementary:
Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler
Johnson Traditional Middle:
Blue Lick, Carter, Conway, Frederick
Law Olmsted South, McFerran, Shacklette, Stuart
Johnsontown Road:
Cane Run, Foster, Frederick Law Olmsted
South, Kennedy, Kerrick, Shacklette, Stuart
Kammerer Middle:
Chancey, Chenoweth, Dunn, Johnsontown,
Norton, Wilder, Zachary Taylor
Kennedy Montessori:
Audubon, Bates, Bloom, Blue Lick,
Brandeis, Cane Run, Carter, Chancey, Chenoweth, Cochrane,
Coleridge-Taylor, Conway, Doss, Dunn, Fairdale Elementary,
Farmer, Field, Foster, Frederick Law Olmsted South, Goldsmith,
Hawthorne, Highland, Johnsontown, Jeffersontown, Kennedy,
Kerrick, Klondike, Laukhauf, Lowe, Luhr, Middletown, Noe,
Rangeland, Shacklette, St. Matthews, Stuart, Thomas Jefferson
Middle, Tully, Watterson, Wheeler, Wilder, Zachary Taylor
Kenwood: Fairdale, Frederick Law Olmsted South, Jacob, Rutherford
Kerrick: Cane Run, Conway, Foster, Johnsontown, Kennedy,
Kerrick, Shacklette
King: All CEP sites available
Klondike: Bloom, Cochrane, Hawthorne, Hite, Klondike, Lowe,
Middletown, St. Matthews, Stopher, Tully
Knight Middle: Thomas Jefferson Middle
Lassiter Middle:
Fairdale, Frederick Law Olmsted South, Kennedy,
Minors Lane
Smyrna,
Laukhuf: Blue Lick, Laukhauf, Minors Lane, Rangeland,
Thomas Jefferson Middle
Layne: Carter, Fairdale, Jacob, Kennedy, Rutherford, Stuart
Lincoln: Chancey, Chenoweth, Cochrane, Coleridge-Taylor,
Dunn, Field, Goldsmith, Hawthorne, Lowe, Middletown, Norton,
St. Matthews, Wilder, Zachary Taylor
Lowe: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite,
Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully
Luhr: Bates, Farmer, Fern Creek Elementary, Goldsmith,
Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler
Maupin: All CEP sites available
McFerran: Blue Lick, Laukhuf, McFerran, Minors Lane, Smyrna, Stuart
Medora: Fairdale, Jacob, Rutherford, Stuart
Meyzeek Middle:
Bloom, Bowen, Brandeis, Chancey, Chenoweth,
Coleridge-Taylor, Dunn, Highland, Noe, Norton, Wilder, Zachary Taylor
Middletown: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite,
Klondike, Middletown, Lowe, Stopher, Tully
Mill Creek: Fairdale Elementary, Frederick Law Olmsted South,
Jacob, Rutherford
Minors Lane: Minors Lane, Smyrna,
Moore Middle: Bates, Frederick Law Olmsted South, Luhr,
Thomas Jefferson Middle
Myers Middle: Bowen, Brandeis, Chancey, Frederick Law Olmsted
South, Hawthorne, Klondike, Zachary Taylor
Newburg Middle:
Bates, Blue Lick, Highland, Laukhuf
Noe Middle: Bates, Bloom, Blue Lick, Bowen, Brandeis, Carter,
Chancey, Chenoweth, Conway, Dunn, Frederick Law Olmsted
South, Hawthorne, Highland, Laukhuf, Norton, Noe, Price,
Shacklette, Wilder, Zachary Taylor
Norton: Bowen, Breckinridge-Franklin, Chancey, Chenoweth,
Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor
Smyrna,
Okolona: Blue Lick, Laukhuf, Minors Lane, Rangeland,
Thomas Jefferson Middle
Portland: Bowen, Breckinridge-Franklin, Carter, Chancey,
Chenoweth, Coleridge-Taylor, Conway, Dunn, Field, Frederick
Law Olmsted South, Norton, Wilder, Zachary Taylor
Price: Bates, Farmer, Fern Creek Elementary, Goldsmith,
Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler
Ramsey Middle:
Wheeler
Rangeland: Bates, Farmer, Fern Creek, Goldsmith, Jeffersontown,
Laukhuf, Luhr, Price, Rangeland, Watterson, Wheeler
Roosevelt-Perry:
All CEP sites available
Rutherford: Fairdale, Frederick Law Olmsted South, Jacob, Rutherford
St. Matthews: Bloom, Cochrane, Coleridge-Taylor, Greathouse,
Hawthorne, Hite, Klondike, Lowe, Middletown, Stopher,
St. Matthews, Tully
Sanders: Cane Run, Conway, Foster, Johnsontown, Kennedy,
Kerrick, Shacklette
Schaffner Traditional Elementary:
Bates, Blue Lick, Cane Run,
Doss, Farmer, Frederick Law Olmsted South, Laukhuf, Luhr,
McFerran, Watterson, Wheeler
Semple : Fairdale, Frederick Law Olmsted South, Jacob, Rutherford
Shacklette: Cane Run, Carter, Conway, Foster, Johnsontown,
Kennedy, Kerrick, Shacklette, Stuart
Shelby: All CEP sites available
Slaughter: Bates, Farmer, Fern Creek, Goldsmith, Jeffersontown, Luhr,
Price, Rangeland, Thomas Jefferson Middle, Watterson, Wheeler
Smyrna: Blue Lick, Laukhuf, Minors Lane,
Smyrna
Stonestreet: Carter, Fairdale, Jacob, Kennedy, Rutherford, Stuart
Stopher: Bloom, Cochrane, Hawthorne, Hite, Klondike,
Middletown, Rangeland, Stopher, Thomas Jefferson Middle
Stuart Middle: Kennedy, Stuart
Thomas Jefferson Middle:
Bates, Bowen, Chenoweth, Dunn,
Frederick Law Olmsted South, Norton, Thomas Jefferson
Middle, Zachary Taylor
Trunnel: Fairdale, Frederick Law Olmsted South, Jacob,
Rutherford, Stuart
Tully: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite,
Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully
Watson Lane:
Cane Run, Carter, Foster, Johnsontown, Kennedy,
Kerrick, Shacklette, Stuart
Watterson: Bates, Farmer, Fern Creek Elementary, Goldsmith,
Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler
Wellington: Cane Run, Carter, Conway, Foster, Johnsontown,
Kennedy, Kerrick, Shacklette, Stuart
Western Middle:
Coleridge-Taylor
Brandeis, Chancey, St. Matthews, Zachary Taylor
Westport Middle:
Wheatley: All CEP sites available
Wheeler: Bates, Farmer, Fern Creek Elementary, Goldsmith,
Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler
Wilder: Bowen, Breckinridge-Franklin, Chancey, Chenoweth,
Coleridge-Taylor, Dunn, Field, Greathouse, Norton, Wilder,
Zachary Taylor
Wilkerson: Cane Run, Foster, Johnsontown Road, Kennedy,
Kerrick, Shacklette, Stuart
Smyrna,
Wilt: Blue Lick, Laukhuf, Minors Lane, Rangeland,
Thomas Jefferson Middle
Whitney Young:
All CEP sites available
Zachary Taylor:
Bowen, Breckinridge-Franklin, Chancey,
Chenoweth, Coleridge-Taylor, Dunn, Field, Norton, Wilder,
Zachary Taylor
If your child’s school is not a host site, JCPS will provide transportation for before- and after-school program students.
Transportation is dependent upon JCPS routing and is subject to change.
2010-11 School Year Childcare Enrichment Program Registration Form
Please attach a recent wallet
size photo and immunization
certificate for each child.
Please print legibly and include your registration fee.
Register Online through August 9th at ymcalouisville.org.
Program Start Date_ _____________________________________ E-mail Address to receive confirmation_ ______________________________________________________________
1st Child’s Name
First _____________________________ Middle _____________________________ Last_____________________________ Date of Birth _ _____/______ /______ Gender:
 African American/Black
Race:
 Alaskan
 Native Asian/Pacific Islander
 Caucasian/White
 Hispanic
 Native American
 M
 F
Age_ ________
 Other
Physical Conditions/Special Needs_________________________________________________________ Medications/Allergies___________________________________________________________________
To better serve your child, please indicate if he/she has been diagnosed with any of the following:
 ADD/ADHD
 Convulsions
 Rhett Syndrome
 Bleeding/Clotting Disorders
 Down Syndrome
 Yes
Does this child have an IEP?
 Autism
 Chronic Health Problems
 Aspergers
 Fragile X
 Asthma/Severe Allergies
 Cerebral Palsy
 Diabetes
 Bipolar Disorder
 Heart defect/disease
 Tourettes
 Other______________________________
 No
Childcare Enrichment Program Site_ _____________________________________________________ School Attending_ ____________________________________________________________________
Attendance:
 1-3 Days
Participation:
 Before-School Care
 4-5 Days
Grade in School (2010-11)_ ______________________________________________________________________
 After-School Care
 Before & After-School Care
 In-Service Day Care
 Snow Day Care
2nd Child’s Name
First _____________________________ Middle _____________________________ Last_____________________________ Date of Birth _ _____/______ /______ Gender:
 African American/Black
Race:
 Alaskan
 Native Asian/Pacific Islander
 Caucasian/White
 Hispanic
 Native American
 M
 F
Age_ ________
 Other
Physical Conditions/Special Needs_________________________________________________________ Medications/Allergies___________________________________________________________________
To better serve your child, please indicate if he/she has been diagnosed with any of the following:
 ADD/ADHD
 Convulsions
 Rhett Syndrome
 Bleeding/Clotting Disorders
 Down Syndrome
 Yes
Does this child have an IEP?
 Autism
 Chronic Health Problems
 Aspergers
 Fragile X
 Asthma/Severe Allergies
 Cerebral Palsy
 Diabetes
 Bipolar Disorder
 Heart defect/disease
 Tourettes
 Other______________________________
 No
Childcare Enrichment Program Site_ _____________________________________________________ School Attending_ ____________________________________________________________________
Attendance:
 1-3 Days
Participation:
 Before-School Care
 4-5 Days
Grade in School (2010-11)_ ______________________________________________________________________
 After-School Care
 Before & After-School Care
 In-Service Day Care
 Snow Day Care
1st Parent/Guardian Name______________________________________________________________ Relationship to Child_____________________________________ Date of Birth ______ /______ /_ _____
Mailing Address_ _______________________________________________________________________ City_______________________________________ State_____________ Zip_______________________
Home Phone___________________________ Cell Phone_ _________________________ Work Phone __________________________ Employer_____________________________________________________ 2nd Parent/Guardian Name_ ____________________________________________________________ Relationship to Child_____________________________________ Date of Birth ______ /______ /_ _____
Mailing Address_ _______________________________________________________________________ City_______________________________________ State_____________ Zip_______________________
Home Phone___________________________ Cell Phone_ _________________________ Work Phone __________________________ Employer_____________________________________________________ Insurance Company _________________________________________________________________________________________ Policy Number_ __________________________________________________
Name of Physician_ _________________________________________________________________________________________ Physician Phone__________________________________________________
 Yes! I would like to learn more about FREE or LOW-COST health insurance for my children and teens.
Emergency Contact and Authorized Pick-Up Information
Please give the names and phone numbers of people to contact in an emergency and/or names of persons authorized to pick up your child/children. Anyone picking up your child/children must be 18 years
of age or older. A Photo ID is required at pick-up.
Name_______________________________________________ Relation to child_ __________________________________ Phone 1_____________________________Phone 2____________________________
Name_______________________________________________ Relation to child_ __________________________________ Phone 1_____________________________Phone 2____________________________
The YMCA has permission for my child(ren) to be photographed and/or interviewed for promotional purposes:
My child(ren) have permission to participate in basic health and fitness evaluations:
 Yes, I would like to make a charitable donation to The Spirit Campaign:
Check here if either parent is:
I currently receive a:
 YMCA Employee
 Spirit Program discount
 Yes
 $10
 $25
 School Partnership Employee
 4-C
 Yes
 $50
 No
I am registering a tuition-based Pre-K student:
 No
 $100
 Yes
 No
 Other/please contact me
 YMCA Family Facility Member
 Other 3rd party subsidy discount
You must choose one of the three options below in order to process your registration. Drafts will occur each Wednesday for the current week unless otherwise scheduled through our main office.
 I am currently on automatic draft. Please use the information on file to draft my account for my registration fee(s) and to set up my weekly payments. Account ending in ____ ____ ____ ____.
 EFT
 Credit Card
 I am authorizing a NEW bank draft from my checking account and I have attached a voided check.
 I am authorizing a NEW credit card draft and I have provided all the information below:
Credit Card Type:
Name as it appears on card ____________________________________________________________ Card Number_ _______________________________________ Expiration Date_ _______________
Billing Street Address_____________________________________________________________________________ _ _____________________________________________Billing Zip_ _______________
 Visa
 MasterCard
 Discover
I have the legal authority to sign up my child/children named on this form. I understand that this is an application and the named child’s/children’s participation is contingent upon space being available in this program. I also
understand that once my application is confirmed, I must complete payment by the deadline. I understand that the YMCA prohibits staff members from being alone with children they meet in YMCA programs outside of the YMCA.
This includes but is not limited to baby sitting, tutoring, sleep-over’s, etc. This health history is correct as far as I know and the child/children herein described have my permission to engage in all activities and field trips except as
noted by me. A photo of each child and a copy of each child’s current immunization certificate will be on file with the YMCA prior to my child/children attending the program. Failure to comply with the above could result in the loss
of child care space. In the event I cannot be reached in an emergency, I hereby give permission to the director of the program or designee to secure emergency medical services, including transportation and a physician. I also give
permission to the attending physician to order injection, anesthesia or surgery for my child/children as named above. Medical and accident insurance is the responsibility of the parent or guardian. My child/children attend Jefferson
County Public Schools and by signing this form I am giving the YMCA permission to communicate and exchange information with JCPS for the purposes of providing and enhancing services to my child/children. I understand this
specific release may be revoked by me at any time by written request. To the best of my knowledge; the information on this form is complete and accurate. I have read and agree to these terms and conditions.
Signature_______________________________________________________________________________________ Date Signed________________________