Ymca Child Watch Registration Form (Page 2 of 2) in pdf

General Public

$8/Hour

ATTEDANCE:

PVCC Participants

$5/Hour

Date

Drop-off

Pick-up

Total Hours

Fee

PARENT/GUARDIAN CONSENT AND WAIVER AGREEMENT:

Please initial each of the following and sign below.

__________I give permission for the named child to be included in Child Watch photos and videos for promotional use.

__________I understand that a Commonwealth of Virginia School Entrance Health form must be filled out, signed, and returned. I agree to

provide the YMCA with my child’s Birth Certificate. I understand that my child is not registered and is unable to attend YMCA Child

Watch until the above documents are on file with the YMCA office.

__________In the event that I cannot be reached in any emergency involving the named child, I hereby give permission to the appropriate

medical personnel, selected by the YMCA staff, to provide medical treatment deemed necessary by such personnel. I agree to be

responsible for all charges incurred in the treatment of the child regardless of whether our insurance covers such charges. When I

receive a call from the YMCA staff indicating my child is ill, I agree to have my child picked up from Child Watch immediately.

__________Parent will inform the Piedmont Family YMCA within 24 hours or next business day after their child or any member of the

immediate household has developed a reportable communicable disease, as defined by the state Board of Health, except for life

threatening disease which must be reported immediately.

__________I understand that I am responsible for payment prior to the start of the program. There will be no refunds if the child does not

attend. There will be a $35 fee for all returned checks. There will be a $1.00 per minute, per child late fee after 10:15 PM.

__________I hereby certify that my child is in good health and capable of safe participation in this YMCA program. I assume all risks and

hazards incidental to this program and for the transportation to and from the program.

I have read and agree to abide by the Child Watch policies. I acknowledge this to be a legal and binding contract.

Parent/Guardian Signature_________________________________________Date_____________________________

YMCA Administrator_______________________________________________ Date_____________________________

Ymca Child Watch Registration Form Page 2