2023-2024 Clipper Care Registration Form

YCS offers Before & After Care for Grades K-5.

Which program(s) are you registering your child for?

Please note, the option for Pre-K before and after care is currently only to gauge interest. If there is enough interest in the program and we are able to hire appropriate staff, registration and program details will become available at a later date. *

Which program(s) are you registering your child for?

Please note, the option for Pre-K before and after care is currently only to gauge interest. If there is enough interest in the program and we are able to hire appropriate staff, registration and program details will become available at a later date. Before School Care Only @ YES (Grades K-5) After School Care Only @ Rowe (Gr. K-1) After School Care Only @ YES (Gr. 2-5) Before School @ YES & After School Care @ Rowe (Gr. K-1) Before & After School Care @ YES (Grades 2-5)

Choose all that apply
Child's Name Child's Name * First Last
Child's Grade for the 2023-2024 school year *
Teacher's Name (if known)
Child's Date of Birth Child's Date of Birth * / MM / DD YYYY
Child's Gender *

Child's Gender Female Male Non-binary
Please list any physical/mental limitations, restrictions, allergies or conditions that we should be aware of. If there are none, please type "None". *
Child's Home Mailing Address Child's Home Mailing Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
PARENT / GUARDIAN CONTACT INFORMATION
Parent #1 Name Parent #1 Name * Title First Last Suffix
Parent #1 Email *

Confirm Email Address *
Parent #1 Cell Phone Parent #1 Cell Phone * - ### - ### ####

Use home phone if there is no cell number
Parent #1 Cell Phone Carrier Name

Information required by our texting service
Parent #1 Work Phone Parent #1 Work Phone - ### - ### ####
Parent #1 Home Phone Parent #1 Home Phone - ### - ### ####
Parent #2 Name Parent #2 Name Title First Last Suffix
Parent #2 Email
Parent #2 Cell/Home Phone Parent #2 Cell/Home Phone - ### - ### ####
Parent #2 Work Phone Parent #2 Work Phone - ### - ### ####
Which email(s) do you want the Childcare Invoice/Statements sent to? *

Which email(s) do you want the Childcare Invoice/Statements sent to? Parent #1 Only Parent #2 Only Both Parent 1 & 2
SCHEDULING INFORMATION
What days do you need BEFORE SCHOOL Care?

What days do you need BEFORE SCHOOL Care? Monday AM Tuesday AM Wednesday AM Thursday AM Friday AM
What days do you need AFTER SCHOOL Care?

What days do you need AFTER SCHOOL Care? Monday PM Tuesday PM Wednesday PM Thursday PM Friday PM
Date you wish to begin Childcare Date you wish to begin Childcare * / MM / DD YYYY
List any scheduling notes, comments, or questions to YCS
Authorized Pick-Up List

Please list any individuals other than parents/guardians that may pick-up your child from the program.
Authorized Pick-Up Person #1 Authorized Pick-Up Person #1 First Last
Authorized Pick-Up Person #2 Authorized Pick-Up Person #2 First Last
Authorized Pick-Up Person #3 Authorized Pick-Up Person #3 First Last
Authorized Pick-Up Person #4 Authorized Pick-Up Person #4 First Last
Authorized Pick-Up Person #5 Authorized Pick-Up Person #5 First Last
PARENTAL / GUARDIAN PERMISSIONS
I grant my Child (listed below) permission to leave the YCS childcare program on their own at the end of or during the program. *

I grant my Child (listed below) permission to leave the YCS childcare program on their own at the end of or during the program. I grant permission for my child to walk home alone. I grant permission for my child to bike home alone. My child does NOT have permission to walk or bike home. Name of Child you are granting this permission to:
Any special instructions to YCS staff regarding Child leaving a program.
Emergency Contact Information

To be contacted in the event we are unable to reach child's parent's/guardians.
Emergency Contact Name: Emergency Contact Name: * First Last
Emergency Contact's Relationship to Child *
Emergency Contact Primary Phone Number. Emergency Contact Primary Phone Number. * - ### - ### ####
Child's Physician Name Child's Physician Name * First Last
Child's Physician Phone Number Child's Physician Phone Number * - ### - ### ####
Medical Insurance Policy Number *
Medical Insurance Carrier *
Medical Insurance Phone Number Medical Insurance Phone Number * - ### - ### ####
KEY CHILDCARE POLICIES & NOTICES
POLICY #1 - You understand this is NOT a drop-in childcare program and you will be charged for the number of days you register for? *

POLICY #1 - You understand this is NOT a drop-in childcare program and you will be charged for the number of days you register for? Yes, I understand Policy #1
POLICY #2 - You understand that in order to withdraw from this program you must notify the YCS office in writing two weeks prior to your child's last day. *

POLICY #2 - You understand that in order to withdraw from this program you must notify the YCS office in writing two weeks prior to your child's last day. Yes, I understand Policy #2
POLICY #3 - You understand that childcare bills will be emailed to the email address(es) listed above and the balance must be paid in full by the final day of each month. *

POLICY #3 - You understand that childcare bills will be emailed to the email address(es) listed above and the balance must be paid in full by the final day of each month. Yes, I understand Policy #3
Parent / Guardian Digital Signature: *

Clear

2023-2024 Clipper Care Registration Form

2023-2024 Clipper Care Registration Form

PARENT / GUARDIAN CONTACT INFORMATION

SCHEDULING INFORMATION

Authorized Pick-Up List

PARENTAL / GUARDIAN PERMISSIONS

Emergency Contact Information

KEY CHILDCARE POLICIES & NOTICES