Payment Authorization Form

YMCA OF GREATER SEATTLE Child Care Interest Form 2016-2017 School Year, Public Registration YMCA School Age Programs – West Seattle (Arbor Heights, Fairmount Park & West Seattle Elementary)

CHILD’S INFORMATION Legal First Name MI Legal Last Name

School Attending in the Fall Grade in Fall

COMMUNITY MEMBER MONTHLY CARE OPTIONS FACILITY MEMBER RATE RATE □ After School Care EXTENDED $445/month $510/month  Cost includes After School Care and early release days  Does not include Non-Student Days and Breaks

□ After School Care EXTENDED PLUS  Cost includes After School Care, Early Release Days, Non- $495/month $565/month Student Days & Breaks

YMCA School Age Program Site: Arbor Heights Fairmount Park West Seattle

Please note: Financial assistance may be available through State or City funding, as well as limited funds through the Y. For City of Seattle subsidy call 206-386-1050 (see attached flyer) and for State DSHS subsidy visit www.washingtonconnection.org. If you don’t qualify for either you may be eligible for financial assistance through the Y and can find our financial assistance application online at www.ykids.org .

PARENT/ GUARDIAN CONTACT INFORMATION Legal First Name MI Legal Last Name

Email Phone Number

DISCLOSURE STATEMENT AND ACKNOWLEDGEMENT The YMCA will be accepting Child Care Interest forms from Monday, May 2nd through Sunday, May 8th for our school age child care programs. Filling out this Child Care Interest Form does not guarantee your child a spot in this program. IF demand is higher than available spots, your child’s name will be entered into a random lottery for available spaces for the Fall of 2016.

Selected families will be required to complete a Child Care Registration Packet to officially register your child. Those not selected at this time will be put on a waitlist and contacted if and when space becomes available. All families will be notified by May 13th as to whether your child will have a spot in the program or has been waitlisted.

Please return this form to Philip Giammarino, Program Registrar at [email protected] or in-person at the West Seattle or Fauntleroy YMCAs ATTN: Philip Giammarino by Sunday, May 8th to be entered into the lottery.

Thank you for your interest in the Y! For info on our other great programs visit us ykids.org!