SKAGIT VALLEY FAMILY YMCA

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1 Central Preschool Registration Child s First : MI: Last : Address: City: State: Zip Home Phone: ( ) Gender: Birth : Age: Child lives w/ Mother/Guardian: Cell Phone: ( ) Employer: Work Phone: ( ) Father/Guardian: Cell Phone: ( ) Employer: Work Phone: ( ) Mother s Address: Father s Address: Emergency Contact (other than parents or physician): Relationship: Phone: ( ) Does your child have any limitations or special medical or behavioral concerns that we should be aware of (medications, allergies or other additional forms may be required)? of last dental check-up/visit Immunizations current? Yes No of last physical examination Physician Address Phone ( ) Persons Authorized to pick-up child (must be at least 18 years old) Mother/Guardian yes no Father/Guardian yes Address no Phone ( ) ( ) Persons NEVER Authorized to pick-up child (Please attach legal documentation if available) Relationship Site Closure: I understand that any YMCA program may close throughout the year due to situations outside of YMCA control. Release/Participation: I am the parent or legal guardian of the above named child. I give permission for my child to participate in YMCA activities and field trips including transportation. I understand that accidents can sometimes happen. Therefore, in exchange for the YMCA allowing my child to participate in YMCA activities, I understand and express acknowledge that I release the YMCA, its employees, board members, volunteers or guests from all liability for any injury, loss or damage connected in any way whatsoever to participation in YMCA activities whether on or off the YMCA s premises and including transportation. I understand that this release includes any claims based on negligence, action or inaction of the YMCA, employees, board members, volunteers or guests. Medical Treatment: I give permission for YMCA staff or volunteers to provide emergency medical treatment for my child as necessary. I consent to medical treatment for my child deemed immediately necessary or advisable by a physician. I consent to emergency transport of my child via ambulance when deemed necessary. Insurance: I understand that the YMCA does not provide any accident or health insurance for its members or participants and further understand it is my responsibility to provide such coverage. Property Loss: The YMCA is not responsible for personal property lost, damaged or stolen while participating in YMCA programs, including parking lots. Photograph Permission: I give permission for the YMCA to use, without limitation or obligation, photographs, film footage or tape recordings which may include my child s image or voice for purposes of promoting or interpreting YMCA programs. Signature of Parent/Guardian: Print Parent/Guardian : : _ : Y Preschool Registration Form l Page 1 of 3

2 TUITION AGREEMENT Cost of Tuition: $210.00/Month $65 Registration and Program fee Attendance: I understand that when I enroll my child, I am reserving a space for him or Initials her. There are no credits given for absences. I agree to notify staff anytime my child will be absent. School Closure: I acknowledge the YMCA Preschool will be closed when the Elementary Initials school in which it is located is closed. (This includes all teacher in service days, weather related, closures, holidays and school breaks) NSF Charge: I understand that there is a $30.00 NSF charge for checks returned for non- Initials payment. I understand if a check is returned for non-payment, all future payments must be made by cash or money order. Initials Initials Withdrawal from the Program: If I plan to withdraw my child from the program, I will submit written notice two weeks prior to withdrawing. I understand that if I do not give prior written notice I will be responsible for the next month s fees. Monthly Payments: I understand all monthly payments are due on the first of each month. A late fee of $25.00 will be assessed after the 5 th of the month. I understand that if my child s fee is one-month delinquent in payment he/she will not be allowed to attend the program until my account is current. All accounts delinquent more than one month will be sent to collections and additional collection fees added to my account. Rates are charged on a monthly basis only. Our monthly rate is calculated on the amount of days preschool is offered throughout the school year. We do not pro rate months. If you attend September through May and pay full tuition each month, June s tuition is waived. Registration/Program Member Fee: I agree to pay an annual registration fee. This Initials fee is billed annually and is required for participation in any YMCA program. Full facility members of the YMCA do not have to pay this fee. Choose the Preschool your child will attend (check one) : CENTRAL AM CENTRAL PM District paperwork will need to be filled out immediately following registration at the YMCA. Please bring along your child s immunizations and birth certificate. Payment Method: Payments are not accepted on site. Refund Policy: All fees are non-refundable. Parent Signature Y Preschool Registration Form l Page 2 of 3

3 Childcare Tuition Express Form Child s Site My Child Attends Please complete Option 1, 2, or 3 but not both. Option 1: Electronic Funds Transfer from Bank Account New Electronic Check Authorization. Funds to be withdrawn on the 1 st day of each month. Electronic Check Cancelation request. Please allow 14 days to process your cancelation request. on Bank Account Billing Phone Number Billing Address City State Zip Bank or Credit Union Routing Number Number Account I hereby authorize Skagit Valley Family YMCA to initiate electronic check charges to the referenced account on the date listed above. I further understand if a transfer fails due to insufficient funds or an unreported account change, I will incur a $30.00 NSF fee. Option 2: TuitionExpress.com Registration Cardholder Billing Phone Number Billing Address City State Zip Address (for Tuition Express ID) 4 Digit Login Preference I wish to register at so I can make online payments using my VISA or MasterCard. I understand the Skagit Valley Family YMCA will not maintain my credit/debit card information on file and I am responsible for processing my monthly payments no later than the contracted due date each month. I further understand if I submit a payment after the due date, I will incur a $25.00 late fee. Option 3: Single Payment by Cash, Credit, or Check Payments can be made in office at 204 N Skagit Street, Burlington, WA Signature Y Preschool Registration Form l Page 3 of 3

4 Certificate of Immunization Status (CIS) For Kindergarten-12 th Grade / Child Care Entry Office Use Only: Reviewed by: : Signed Cert. of Exemption on file? Yes No Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System. Child s Last : First : Middle Initial: Birthdate (): Sex: I give permission to my child s school to share immunization information with the Immunization Information System to help the school maintain my child s school record. Parent/Guardian Signature Required I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Required for School and Child Care/Preschool Required Only for Child Care/Preschool DTaP / DT (Diphtheria, Tetanus, Pertussis) Tdap (Tetanus, Diphtheria, Pertussis) Required s for School or Child Care Entry Documentation of Disease Immunity Healthcare provider use only If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider Td (Tetanus, Diphtheria) I certify that the child named on this CIS has: Hepatitis B 2-dose schedule used between ages a verified history of Varicella (Chickenpox). Hib (Haemophilus influenzae type b) IPV / OPV (Polio) laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. MMR (Measles, Mumps, Rubella) PCV / PPSV (Pneumococcal) Varicella (Chickenpox) History of disease verified by IIS Recommended s (Not Required for School or Child Care Entry) Diphtheria Mumps Other: Hepatitis A Polio Hepatitis B Rubella Hib Measles Tetanus Varicella Flu (Influenza) Hepatitis A HPV (Human Papillomavirus) MCV / MPSV (Meningococcal) MenB (Meningococcal) Rotavirus Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed

5 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand. To print with immunization information filled in: Ask if your healthcare provider s office enters immunizations into the WA Immunization Information System (Washington s statewide database). If they do, ask them to print the CIS from the IIS and your child s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at If your provider doesn t use the IIS, or call the Department of Health to get a copy of your child s CIS: or To fill out the form by hand: #1 Print your child s name, birthdate, sex, and sign your name where indicated on page one. #2 information: Write the date of each vaccine dose received in the date columns (as ). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guides below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. #4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS. Reference guide for vaccine abbreviations in alphabetical order DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 DTaP DTP Flu (IIV) HBIG Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, Pertussis Influenza Hepatitis B Immune Globulin Reference guide for vaccine trade names in alphabetical order For updated list, visit Trade Trade Trade Trade Trade ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1) Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix For updated list, visit Meningococcal Conjugate Hep B Hepatitis B MenB Meningococcal B Hib HPV (2vHPV / 4vHPV / 9vHPV) IPV Haemophilus influenzae type b Human Papillomavirus Inactivated Poliovirus MPSV / MPSV4 DTaP + Hep B + IPV RotaTeq Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib + IPV Trumenba MenB Rotavirus (RV5) Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B MMR MMRV Meningococcal Polysaccharide Measles, Mumps, Rubella Measles, Mumps, Rubella with Varicella If you have a disability and need this document in another format, please call (TDD/TTY call 711). DOH December 2016 OPV PCV / PCV7 / PCV13 PPSV / PPV23 Oral Poliovirus Pneumococcal Conjugate Pneumococcal Polysaccharide Rota (RV1 / RV5) Rotavirus Td Tetanus, Diphtheria Tdap VAR / VZV Tetanus, Diphtheria, acellular Pertussis Varicella

I certify that the information provided on this form is correct and verifiable. Month Day Year

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