Burnet Member 2020-2021 | YMCA Of Greater Williamson County

Child's Information
Name*
First Initial Last
Gender*
- Boy
- Girl
Date of Birth*
MM slash DD slash YYYY
Afterschool Start Date
Program Type
District
Burnet Schools*
Charter Schools*
Georgetown Schools*
Georgetown Pre-K Schools*
Round Rock Schools*
Liberty Hill Schools*
Hutto Schools*
Leander Schools*
Grade*
Grade*
Grade*
Grade*
Password*

The Y is committed to the safety and security of your child. Therefore, if you wish to arrange for another person to pick up your child and the person is not on your authorized list, you must call the Y and give them this confidential password.
Child's Address*
Street Address City State Zip

Primary Parent/Legal Guardian's Information
Parent / Legal Guardian Name*
First Last
Parent / Legal Guardian Address*
Street Address City State Zip
Email*
Enter Email Confirm Email
Employer
Phone Type*
- Home Phone
- Work Phone
- Mobile Phone
- Alternate Phone
Home Phone*
Work Phone*
Mobile Phone*
Alternate Phone*
Add Optional Parent/Legal Guardian?
- Yes

Optional Parent/Legal Guardian
Name*
First Last
Address*
Street Address City State ZIP Code
Email*
Enter Email Confirm Email
Phone Type*
- Home Phone
- Work Phone
- Mobile Phone
- Alternate Phone
Home Phone*
Work Phone*
Mobile Phone*
Alternate Phone*
Is optional parent/legal guardian eligible to pick-up child?*
- Yes
- No
If no, please attach a copy of legal documentation*
Max. file size: 200 MB.
If you are unable to upload legal documentation, please fax it to 512-310-9372.

Main Emergency Contact
Local person other than those listed above to contact in case of emergency if the parent / legal guardian cannot be reached : (to be in compliance with Y association policies and the TDFPS, the individuals authorized to pick up your child must be at least 18 years of age)
Name*
First Last
Phone*
Alternate Phone*
Address*
Street Address City State ZIP Code
Add Optional Emergency Contacts*

Other Optional Emergency Contacts
Name*
First Last
Phone*
Alternate Phone*
Address*
Street Address City State ZIP Code
Optional Emergency Contact 2
Name*
First Last
Phone*
Alternate Phone*
Address*
Street Address City State ZIP Code
Optional Emergency Contact 3
Name*
First Last
Phone*
Alternate Phone*
Address*
Street Address City State ZIP Code

Emergency Information
In the event of an emergency and a parent / legal guardian is not available, your designated physician, hospital or clinic will be contacted for emergency management / transportation (please refer to the medical waiver ahead).

Immunization records including tuberculosis (TB) test are located at:
Immunization Location

Licensed Physician
Name*
First Last
Phone*
Office Address*
Street Address City State ZIP Code

Hospital or Clinic
Name*
Phone*
Office Address*
Street Address City State ZIP Code

Additional Needs
In order to best meet your child’s needs, we require that you list any special needs that your child may have, such as physical limitations, emotional or behavioral issues, allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other information the staff should be aware of:
Additional Needs Statement*
- Add Additional Needs Treatment Instructions
- N/A
Additional Needs Treatment Instructions*

Discipline & Guidance Policy
Texas Administrative Code, Title 40, Chapters 746 and 747, Subchapters L, Discipline and Guidance Policy.

Discipline must be:
1. Individualized and consistent for each child
2. Appropriate to the child’s level of understanding
3. Directed toward teaching the child acceptable behavior and self-control
A caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control and self-direction, which include at least the following:
1. Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior
2. Reminding a child of behavior expectations daily by using clear, positive statements
3. Redirecting behavior using positive statements
4. Using a brief cooling off period when appropriate; which is limited to the child’s decision to rejoin the group
There must be no harsh, cruel or unusual treatment of any child. The following types of discipline and guidance are prohibited:
1. Corporal punishment or threats of corporal punishment
2. Punishment associated with food, quiet time or bathroom use
3. Pinching, shaking or biting a child
4. Hitting a child with a hand or instrument
5. Putting anything in or on a child’s mouth
6. Humiliating, ridiculing, rejecting or yelling at a child
7. Subjecting a child to harsh, abusive or profane language
8. Placing a child in a locked or dark room, bathroom or closet with the door closed
9. Requiring a child to remain silent or inactive for inappropriate periods of time
Parent/Guardian Acknowledgement

My signature verifies that I have read and received a copy of this discipline and guidance policy.
Signature*
Parent/Guardian Signature*

Registration Fee due today (see amount in blue box).
Auto Draft*
- Make Payment and Sign-Up for Auto Draft with Credit Card
- Make Payment and Sign-Up for Auto Draft with SEPARATE Credit Cards
- Make Payment and Sign-Up for Bank Draft
- Make Payment and DO NOT Sign-Up for Auto Draft
Semi-monthly is only available if you choose an Auto Draft option.

Make Payment and Sign-Up for Auto Draft with Credit Card
Today's Payment
Credit Card Number*

Credit Card Number without spaces or dashes
Expiration Date*

In the style of mm/yy (01/16)
Card Type*
CVV Code*
Full Name on Card*
Payment Schedule*
Monthly Monthly Tuition Drafted 1st of the Month
Semi Monthly Draft Monthly Tuition split into two payments -1st and 15th of the Month

Sign-Up for Auto Draft
Credit Card Number*

Credit Card Number without spaces or dashes
Expiration Date*

In the style of mm/yy (01/16)
Card Type*
CVV Code*
Full Name on Card*
Payment Schedule*
Monthly Monthly Tuition Drafted 1st of the Month
Semi Monthly Draft Monthly Tuition split into two payments -1st and 15th of the Month

Make Payment and Sign-Up for Bank Draft
Bank Name*
Account Number*
Routing Number*
Payment Schedule*
Monthly Monthly Tuition Drafted 1st of the Month Semi Monthly Draft Monthly Tuition split into two payments -1st and 15th of the Month

Make Payment and DO NOT Sign-Up for Auto Draft
Credit Card Number*

Credit Card Number without spaces or dashes
Expiration Date*

In the style of mm/yy (01/16)
Card Type*
CVV Code*
Full Name on Card*

1. I understand that this transfer will occur monthly on the 1st; semi-monthly on the 1st and 15th of each month for checking / savings and credit card drafts. First draft begins Aug. 1.
2. I understand that should I choose to terminate or change Bank Accounts, Banks, Account Types or Child Care Plan in anyway, I must provide the Y with at least a 2 week written notice prior to my transfer date.
3. I understand that the information above will be used to transfer payment from my account.
4. I understand that if my payment is returned for non-suffcient funds (NSF) for any reason, the item(s) will be re-presented electronically and I understand I will be charged a $30 non-suffcient funds (NSF) processing fee. I am also responsible for all other recovery costs.
5. I understand that if my account has a late pick up fee or late payment fee, the amount will be drafted from my account on the next draft date.
6. The Y only accepts Visa, MasterCard and Discover.
7. I understand that after three returned items, I will be ineligible to use the automatic payment option. My account will then become cash or money order only
Signature*
Parent/Guardian Signature*
Email Notice Payment
Comments
This field is for validation purposes and should be left unchanged.

Program Sign-Up

Summary

Due Today

Due Every Month

Start Date

Child's Information

Primary Parent/Legal Guardian's Information

Optional Parent/Legal Guardian

Main Emergency Contact

Other Optional Emergency Contacts

Optional Emergency Contact 2

Optional Emergency Contact 3

Emergency Information

Immunization records including tuberculosis (TB) test are located at:

Licensed Physician

Hospital or Clinic

Additional Needs

Acknowledgements

Discipline & Guidance Policy

Discipline must be:

A caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control and self-direction, which include at least the following:

There must be no harsh, cruel or unusual treatment of any child. The following types of discipline and guidance are prohibited:

Parent/Guardian Acknowledgement

Make Payment and Sign-Up for Auto Draft with Credit Card

Today's Payment

Sign-Up for Auto Draft

Make Payment and Sign-Up for Bank Draft

Make Payment and DO NOT Sign-Up for Auto Draft

Summary

Due Today

Due Every Month

Start Date

Child's Information

Primary Parent/Legal Guardian's Information

Optional Parent/Legal Guardian

Main Emergency Contact

Other Optional Emergency Contacts

Optional Emergency Contact 2

Optional Emergency Contact 3

Emergency Information

Immunization records including tuberculosis (TB) test are located at:

Licensed Physician

Hospital or Clinic

Additional Needs

Acknowledgements

Discipline & Guidance Policy

Discipline must be:

A caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control and self-direction, which include at least the following:

There must be no harsh, cruel or unusual treatment of any child. The following types of discipline and guidance are prohibited:

Parent/Guardian Acknowledgement

Make Payment and Sign-Up for Auto Draft with Credit Card

Today's Payment

Sign-Up for Auto Draft

Make Payment and Sign-Up for Bank Draft

Make Payment and DO NOT Sign-Up for Auto Draft

Burnet

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Georgetown

Hutto

Round Rock

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Child Care

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