YWCA Child Enrichment 2023-2024 School Year Program Enrollment Form 
 Please enter in all data carefully in each respective field. Email confirmation will be sent once your applications have been accepted and approved. 

If you have more than 1 child you would like to register, please complete one response form and submit a new one for each additional child. 

Email cedirector@ywcaswil.org for any questions! 
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Email *
Name of Child *
Pronoun Preference *
Child's Race/Ethnicity  *
Child Birthdate  *
MM
/
DD
/
YYYY
Child Age *
Grade attending  *
School Child Attends: *
Date Child will Start Program 

*Cannot Guarantee First Day of School Enrollment*
 *
Allergies/Medical Conditions  *
Please indicate any restrictions for play indoors/outdoors.  *
Program Option
 *
If you selected part time, please indicate which days of week your child will be attending.  *
Required
 Vacation Week:  Each child is entitled to one week vacation (absences where you are not charged) per calendar year. Full time students receive 5 days, part time students receive 3 days. If your child surpasses the number of eligible vacation days, you will be charged according to your child's schedule. Please provide the week of your vacation below if applicable.  *
Please indicate if you will be paying Private Pay, CHASI, or DCFS. 
( 100% payment required until CHASI/DCFS approval)
 *
Household Size *
Annual Household Income received by all household members. (please indicate DTD if you do not wish to provide income amount)  *
Assistance Programs Utilized. Check all that apply.  *
Required
Does your Child have an IEP or 501 plan? If yes, please email a copy to CE Director so we may better serve your child in our program.  *
Site Attending  *
We utilize District transportation to pick up/drop off to our centers. If your child will be riding the bus, please indicate the bus number and time of pick up and drop off below. 
Parent/Guardian Name(s) *
Parent/Guardian email(s). Please separate  emails with a semicolon ;  *
Parent/Guardian Phone Number(s). Please indicate which number is which parents' if providing multiple. Please include at least 1 alternate phone number (work, or home phone) as another method of contact.  *
Secondary Contact Person Name and Phone Number *
Additional Contact Person Name and Phone Number 
Authorized Child Pick Ups (please provide names and numbers)  *
I give permission for my child to be included in publicity or press releases for the YWCA Child Enrichment Program and YWCA. This release shall cover written materials, Facebook posts, and YWCA Webpage. Children's full names shall not be utilized.  *
I have received and read the YWCA Child Enrichment Program Parent Handbook  *
I understand by completing this form, I will be charged a non-refundable enrollment fee of $35.00 per child.  *
Required
I understand YWCA Camp Days/Holiday Camp may be held only at one location (YWCA) when enrollment numbers are low. 
I acknowledge that my child must have a completed physical to participate in YWCA Child Enrichment Programs. The physical form must be completed by a physician and returned the to the YWCA before the child can attend the program.  *
I acknowledge I am responsible to all program charges. I understand that all weekly fees are due by 5:00pm on Friday. I understand my account must be current for my child to continue attending the program.  *
I acknowledge that I cannot give payment to Child Enrichment Site staff, and that all payments are to be made with YWCA administrative personnel.  *
I acknowledge I am responsible for any fees associated with a returned EFT or Check.  *
I acknowledge that I must, as soon as possible, notify the Child Enrichment Director by calling the YWCA office at 618-465-7774 or emailing cedirector@ywcaswil.org *
I acknowledge that I must, as soon as possible, notify the Child Enrichment Director in writing two weeks in advance if I elect to remove my child from the YWCA Child Enrichment Program.  *
I have read and understand the YWCA Child Enrichment Program Guidance and Discipline Policy.  *
I have read and understand the YWCA Child Enrichment Program Late Pickup Plan and Late Fee Policy.  *
I understand by completing this form, I am authorizing YWCA Child Enrichment Program to provide day care services to my child. (Please type in name for signature) *
In the event of a Medical Emergency,  I authorize YWCA Child Enrichment Program to secure EMERGENCY medical care for my child when I cannot be immediately reached at the time of the emergency. I/we will be responsible as the parent/guardian, for the emergency medical charges upon receipt of the statement. (Please type in name for signature) *
I/we authorize YWCA Child Enrichment Program to take my child on walking trips, special excursions and to nearby public park facilities. I/we also authorize the child to ride as a passenger in the vehicle owned or leased by the above named person(s). I/we understand that all such trips are under the supervision of the above named person(s). ( Please type in name for signature) *
A copy of your responses will be emailed to the address you provided.
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