You must have JavaScript enabled to use this form. Student’s Information Please provide information for your student(s) so we can place you on the appropriate interest lists. Student one's information is required. If more than two students, please provide additional information in the message box at the bottom of this form. Student One First Name Last Name Date of Birth Grade for 2022-23 School Year Select grade for 2022-23 school year Kindergarten123456 School Name School District Please select the type of care and day(s) of the week you would like care. Monday AM Care Tuesday AM Care Wednesday AM Care Thursday AM Care Friday AM Care Monday PM Care Tuesday PM Care Wednesday PM Care Thursday PM Care Friday PM Care Special Attention or Care Thank you for considering the Y as a safe place for your child. We seek to partner with you to best support your child’s experience and development. Does your child have any medical or behavioral considerations which may require special attention or care by our Y staff? This could include a documented accommodation (IEP, 504 plan) that would help us best support them. A member of your Y staff team will follow up for more information upon enrollment if you select “YES”. Select an answer YesNo Agreement I understand and agree to the following: Once enrolled in BASE, cancelling this program requires fourteen (14) days’ written notice via cancellation webform. Annual Registration fees are non-refundable and non-transferable; failure to complete requirements for attendance, including paperwork and payment that result in days missed from program will not be refunded or credited. Select an answer YesNo . Add Another Student . Student Two First Name Last Name Date of Birth Grade for 2022-23 School Year Select grade for 2022-23 school year Kindergarten123456 School Name School District Please select the type of care and day(s) of the week you would like care. Monday AM Care Tuesday AM Care Wednesday AM Care Thursday AM Care Friday AM Care Monday PM Care Tuesday PM Care Wednesday PM Care Thursday PM Care Friday PM Care Special Attention or Care Thank you for considering the Y as a safe place for your child. We seek to partner with you to best support your child’s experience and development. Does your child have any medical or behavioral considerations which may require special attention or care by our Y staff? This could include a documented accommodation (IEP, 504 plan) that would help us best support them. A member of your Y staff team will follow up for more information upon enrollment if you select “YES”. Select an answer YesNo Agreement I understand and agree to the following: Once enrolled in BASE, cancelling this program requires fourteen (14) days’ written notice via cancellation webform. Annual Registration fees are non-refundable and non-transferable; failure to complete requirements for attendance, including paperwork and payment that result in days missed from program will not be refunded or credited. Select an answerYesNo . Contact Information Please provide the contact information of the parent or guardian of the students(s). All fields are required. First Name of Contact Last Name of Contact Phone Number of Contact Email Address of Contact . Leave a Message If you have an additional message that you'd like to share with us, please enter it below. .
