March 29Th- April

SCHOOL DAYS OUT Registration Form : March 29- April 5 2021 Louisville Area YMCA School Day Out Information: • Care will be held at the Louisville Area YMCA for the dates presented on this form from 6:30AM- 6:00PM • A staff member will be outside for curbside drop off and pick-up at the pavilion. • Please bring a morning snack, lunch, water bottle, swim suit and towel • Sign-up by Monday, March 22 by turning in this form to a child care staff member, Louisville YMCA from desk, or e-mail it to [email protected]. • MUST have a registration packet on file and PRE-REGISTER for the day • If pre-registration is not received, a $5.00 late fee will be added to the daily charge. Child’s Name: ________________________________________________________ Birth Date: ____________________________ Grade: ____________ Child’s Name: ________________________________________________________ Birth Date: ____________________________ Grade: ____________ Parent’s Name: _____________________________________________________ Phone: ___________________________ Dates Attending___________________________________________________________________________________________________________________________ Payment: This payment is non-refundable unless cancellation is received by: March 22,2021 Member: $30/day Non-Member: $40/day I authorize payment to be drafted from my bank/credit card account (school day out fee will be deducted on the next scheduled draft date after the day of care). I am an ODJFS client . I have completed and submitted a AUTHORIZATION FORM by March 22, 2021 am authorized for care at license number ____________. Copay is due upon registration for full week of School Day Out. If authorization is not received, private pay fee will be charged. My registration is past the deadline. I understand I will be charged a $5 late fee. Swimming: I give my child permission to participate in the below swimming activities in water over 18 inches of depth. My child is a _________ swimmer _________ non-swimmer Swim Site: Louisville Area YMCA (1421 S Nickelplate Louisville OH 44641) Swim Time: 1PM-2PM Swim Dates: Monday-Friday 03/29/2021-04/05/2021 *All campers will be tested and/or measured on their first swimming date by YMCA lifeguards. The YMCA will provide one additional staff member for every 10 children when on routine trips and when swimming. By signing below, I indicate that I agree to and understand the information presented above. Office Use Only: Date Received_________________ Time Received ________________ Registered in System: ___________ Date Sent: _________________ Caseworker ________________________ ODJFS School Day Out Authorization Form 2020/2021 School Year Please complete the form below and fax attention your case worker to 330.451.8438 or Email in order to authorize your child for School Day Out Days. Parent Name _________________________________________________________________________Case # _________________________________ Child Name(s) ___________________________________________________________________________________________________________________ Primary Site _____________________________________________________ License # ______________________ School Day Out Site ______________________________ License # ______________________ Please circle the days needed below: October November December January February March April May 9 & 12 25 & 30 21, 22, 15, 18 12, 15 29, 30, 1, 2, 5 27, 28 23, 28, 31 29, 30, By signing below I agree to fax or mail this form to my caseworker in order to obtain authorization for School Day Out attendance as well as TAP my child in and out each day I am authorized for care. If I am unable to TAP any day, I agree to return to the School Day Out site to TAP within the two week back TAP period. I also understand that if I do not fulfill these obligations I will be charged the private pay fee of $30per day, per child for Y members or $40 per day per child for non members. Parent Signature_________________________________________________________________________________ Date___________________________________ .

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