Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

(1) Parent/ Guardian Name *

First Name

Last Name

(1) Parent / Guardian Date of Birth *

MM

DD

YYYY

(1) Parent/ Guardian Cell Phone *

(###)

###

####

(1) Parent/Guardian Work Phone *

Please if applicable provide your work phone and not cell phone number.

(###)

###

####

(1) Parent/ Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

(1) Parent/ Guardian Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will You Be Adding Another Parent/Guardian? *

Yes

No

Emergency Contact Name *

In the event of an emergency, if we are unable to reach the legal guardian(s), whom should the YWCA contact? This individual must be authorized to act on behalf of the parent or guardian in emergency situations.

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Does your child have any allergies? *

Yes

No

Your Child's Doctor's Name *

First Name

Last Name

Doctor's Phone Number *

(###)

###

####

Doctor's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have trouble with eyes or sight? *

Yes

No

Does your child have any difficulties with speech or hearing? *

Yes

No

Does your child require corrective eyewear, such as glasses or contact lenses? *

Yes

No

I agree and acknowledge that I have received and read ALL information about the program. *

The completion of the Child Information Form and payment of fees officially enrolls my child in the YWCA Afterschool Childcare Program(s). o complete the registration process, please contact the childcare office at 901-320-6021, or 901-320-6024 to make your payment and solidify your spot.It is my responsibility to update the information contained in this form as needed. I understand that the information received outlines these procedures. Should I need an additional copy, I understand that it is my responsibility to contact the YWCA by emailing or calling the YWCA at 901-323-2211 ext 6021. By enrolling in this program, I agree to abide by the policies and procedures as listed in the information received. I have also received the Department of Human Services Regulations for Child Care Centers (if applicable). Acknowledge: Parent Handbook *

Yes, I Agree

No, I Do NOT Agree

I agree and acknowledge that I will notify the YWCA of any disability accommodations needed for my child. *

I understand that if my child has special needs or needs a disability accommodation to access the program, I will inform YWCA Greater Memphis at 901-323-221 ext 6021 or 901-382-2294 at the time of registration (and before attendance in the program) to initiate an appropriate process to determine reasonable accommodations to access the program and scope of responsibility for provision of reasonable accommodations. Qualified students are admitted on a first come, first serve basis. Acknowledge: Accommodations *

Yes, I Agree

No, I Do NOT Agree

I understand that in case of an emergency, my child will be transported to the nearest Emergency Room for treatment *

Yes, I Understand

No, I do not understand

Would you be interested in serving on the Parent Council? Meetings will be conducted virtually via Zoom, allowing you to participate from the comfort of your home. Your involvement would be greatly valued as we work together to make a positive impact on our community. *

Yes

No