Name____________________________________Address______________________________

City________________________State____Zip________Home Phone_____________________

Birthdate__/__/____ Sex: Male_____ Female____School_____________________ Grade____

Parent/Guardian Name________________________Relationship______Day Phone__________

Parent/Guardian ____________________________Relationship___________Day Phone______

Youth resides with: ___BothParents___Mother___Father___Other________________________

Emergency Contact_____________________Phone____________Relationship______________

Who: State-licensed program for children ages 5 to 12
Where: Grant Street School
When: Monday through Friday, 3:00 to 6:00PM
Call: 385-5811 for more information or email billkush@hotmail.com

FEES

Full-Time 4-5 days $160.00, Part -Time 2-3 days per week $115.00.
Drop in fee $25.00.

Field Trip Permission
I, _____________________________,herein grant my permission for________________
___________________(child's name) to participate in field trips planned by Y's Kids Staff,
given that all vehicles driven for transportation be operated by licensed, insured drivers and that
the children will be seat belted or in a booster seat provided by me.

If Applicable: ___DSHS ___DCFS/CPS ___DDD Case worker________________

Participation Release and Permission To Treat
I hereby certify that the above named child is in normal health and capable of safely participating
in YMCA programs. I assume all risks and hazards incidental to the conduct of this program for
the transportation to and from the program. I hereby authorize the Jefferson County Family
YMCA to obtain medical treatment including surgical procedures for the above named child in
the event that parents and/or emergency contact cannot be reached. I hereby authorize the YMCA
to provide sunscreen to my child. I support the YMCA program philosophy, which is based on
participation, fun, fitness and health, skill development, teamwork, fair play, family involvement and
volunteer leadership. I give permission for the Jefferson County Family YMCA to use any photos
or videos taken of the above named child, for future publicity purposes. I further give permission for
the YMCA to transport my child in marked YMCA vehicles for local or distant field trips.

Parent/Guardian Signature_______________________________Date_______________