YMCA DC KIPP SCHOOL AGE CHILD CARE 2026-2027

KIPP DC School Age Child Care Registration Form
Thank you for choosing to enroll your child in YMCA School Age Child Care!

To complete your child’s registration and reserve their spot, please ensure the following steps are completed:
- Submit all required information on the registration form
- Complete all required OSSE forms (If you are a current KIPP family, we will obtain these forms directly from KIPP)
- Email a copy of your voucher to Laurence.Nurse@ymcadc.org
- If you have a co-pay or are paying privately, please complete and return the Credit Card/ACH authorization form (PDF)
- All necessary forms will be sent to you once your application is received.
Please note: Your child is not fully registered until you receive a confirmation email from the YMCA.
The YMCA seeks to make its’ services available to all persons regardless of their ability to pay. Please call your Y for details regarding the financial assistance / scholarship application procedures. Financial aid is awarded to applicants in need as funds are available through the support of generous donors.

Each year, donors that support the “Send a Kid to Camp” campaign ensure that every child in your area has access to a quality summer camp experience, regardless of financial ability. If you wish to make a contribution to the YMCA Send a Kid to Camp campaign, you may do so by clicking here.
KIPP Benning Road

August 10, 2026 - June 11, 2027

Grades: Kindergarten - 8th

KIPP Webb

August 10, 2026 - June 11, 2027

Grades: 1st - 8th

OSSE & Private Pay Rates

Before and After Care: $110.20 per week

Before or After Care: $80.50 per week
Please select your YMCA branch/location

PARTICIPANT INFORMATION
Participant's Name

First NameMiddle NameLast Name
Participant's Date of Birth

MonthDayYear
Date
PARENT / GUARDIAN'S CONTACT INFORMATION
Name of Parent / Guardian #1

First NameLast Name
Phone Number of Parent / Guardian #1
Please enter a valid phone number.Format: (000) 000-0000.
Email of Parent / Guardian #1
example@example.com
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Address of Parent / Guardian #1

Street Address

Street Address Line 2

CityState

Zip Code
Place of Employment of Guardian #1 (If not applicable, enter "N/A")
Work Phone Number of Guardian #1 (If not applicable, enter "555-555-5555")
Please enter a valid phone number.Format: (000) 000-0000.
Is there another parent or guardian we should have on file?
Name of Parent / Guardian #2

First NameLast Name
Phone Number of Parent / Guardian #2
Please enter a valid phone number.Format: (000) 000-0000.
Email of Parent / Guardian #2
example@example.com
Address of Parent/Guardian #2 is the same as Parent/Guardian #1
Address of Parent / Guardian #2

Street Address

Street Address Line 2

CityState

Zip Code
Place of Employment of Parent / Guardian #2 (If not applicable, enter "N/A")
Work Phone Number of Parent / Guardian #2 (If not applicable, enter "N/A")

EMERGENCY CONTACTS
Please note that 2 emergency contacts that are not a parent/guardian are required.
Name of Emergency Contact #1

First NameLast Name
Phone Number of Emergency Contact #1
Please enter a valid phone number.Format: (000) 000-0000.
What is the relationship to your child?
This individual is authorized to pick-up your child
Name of Emergency Contact #2

First NameLast Name
Phone Number of Emergency Contact #2
Please enter a valid phone number.Format: (000) 000-0000.
What is the relationship to your child?
This individual is authorized to pick-up your child
Additional authorized person’s to pick up your child. Please list their name, phone number, and relationship to child.
Name of person(s) NOT AUTHORIZED to pick-up your child. Please provide documentation at a later date if applicable.

MEDICAL INFORMATION
Your child's care and safety are critical to the YMCA. Please carefully complete the following information to the best of your knowledge. For any question that is required but not applicable to your child, enter "N/A".

If the YMCA staff is to administer medications during the day, either emergency or routine, please complete the Medication Authorization section of this form. You are required to complete separate forms to authorize the YMCA to administer specific medications to your child, including use of epi-pen and/or inhalers. The link to these forms will be included in your registration confirmation email and also accessible here.

If there are any special accommodations that need to be made for your child, please complete the Inclusion section of this form.
What is your child's gender identity?

Other
Please list any allergies or intolerance to food, medication or any other substance your child has.
If an allergic reaction occurs, please enter details / list steps to relieve the reaction.
Please list any chronic physical, behavioral or psychological problems, pertinent developmental information, and any special accommodations needed for your child here. If this is applicable to your child, please note that you are required to complete the Inclusion section of this form.
Please list any medications or vitamins your child takes on doctor’s orders here.
For students residing in the United States (or US territory or DC); is your child exempt from any immunizations?
You selected "Yes". Please specify which immunization(s) your child is exempt from.
Child's Physician and Office Name
Child's Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE
Insurance Carrier
Insurance Policy Number

INCLUSION
The YMCA of Metropolitan Washington is committed to living out our value of inclusiveness, which guarantees non-discrimination and equal access for all in our programs, services, and activities, and will provide reasonable accommodations upon request. This form must be completed by parents / guardians of children enrolled in school age child care with any chronic physical, behavioral or psychological problems to provide the YMCA with pertinent developmental information and to request any special accommodations needed.

Inclusion information for children with special needs must be provided at the time registration and directly to the child’s Site Director on the first day of care. All parents / guardians of children with special needs or developmental disabilities must consult with staff prior to registration can be considered complete. The YMCA will make accommodations to the fullest extent possible based on available resources. One-on-one assistance is not guaranteed. If applicable, parents / guardians must submit Medication Authorization Forms for any medications (including OTC medications, Epi-pens, insulin or foods that treat medical conditions) that parents / guardians authorize the Y to administer.

If this is applicable to your child, please select "yes" below and complete the information requested in this section. If this is not applicable to your child, please select "no" below. If you need to complete an inclusion form for multiple children, please email member.service@ymcadc.org.
Is this applicable to your child?

Describe the characteristics of your child's special needs.
What type of support do you feel your child needs?
Does your child have any "triggers" the YMCA staff should be aware of?
Are there any special concerns that YMCA staff should be aware of?
Do you have any tips or suggestions to share with the YMCA to address special concerns?
Does your child have any favorite books, toys, or "security" items that would be appropriate to send to childcare (Note: Must be approved by the site director)?
Does your child exhibit severe emotional or physical reactions?
When should YMCA staff call the parent/guardian(s)? Please note that parents/legal guardians will always be called if a child requires medical attention.
Please list other pertinent information or concerns.

HOW DID YOU HEAR ABOUT YMCA SCHOOL AGE CHILD CARE?

We'd like to know how you learned about this school age child care opportunity for your child at the YMCA.
How did you hear about us? Please select all that apply.

Other

SCHOOL AGE CHILD CARE PAYMENT
I am enrolling my child in...
Payment Options
Please select the method of payment.
CREDIT CARD AUTHORIZATION

I authorize the YMCA to charge my credit card for program payments. I understand that I must provide written notice of cancellation. If at any time there is to be a change, deletion, or cancellation of my program enrollment, it is to be submitted in writing to the YMCA branch where the program was purchased two weeks prior to the date of my credit card draft in order to discontinue the debit.

DRAFTS WILL OCCUR ON APPROXIMATELY THE 10th or THE 26th.
Signature

Clear
BANK DRAFT AUTHORIZATION

I understand that my electronic funds transfer (EFT) drafts will occur automatically until I provide written notice to the YMCA two weeks prior to the date of my bank draft payment. Should any draft not be honored by said bank when received by them, it is understood that the payment is to be made by me in the amount of said payment, plus a service charge and will be re-processed on the first available draft day. If at any time there is to be a change, deletion, or cancellation of my program enrollment, it is to be submitted in writing to the YMCA branch where the program was purchased two weeks prior to the date of my draft in order to discontinue the debit. A voided check is required with all EFT applications.

DRAFTS WILL OCCUR ON APPROXIMATELY THE 10th or THE 26th.
Signature

Clear

WAIVERS
PARTICIPANT WAIVER FORM ACKNOWLEDGEMENT

I hereby grant permission for my child to be transported by the YMCA for activities including, but not limited to, swimming and field trips. I understand that every effort will be made to contact me or my emergency contact. If I, or someone on the emergency form, cannot be reached, I give the YMCA permission to secure the medical treatment necessary for my child, including hospitalization, injection, anesthesia, or surgery. I understand that in emergencies requiring immediate medical attention, my child will be taken to the nearest hospital emergency room. My signature authorizes the responsible person at the child care facility to have my child transported to the hospital.

I understand that the YMCA of Metropolitan Washington assumes no responsibility for injuries or illnesses that I may sustain as a result of my physical condition or resulting from my participation in any athletic activities, sports programs, and the use of any equipment, exercise, or other activities. I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illnesses which may result from participation in these activities. I hereby release and discharge the YMCA of Metropolitan Washington, its agents, servants, and employees from any and all claims for injury, illness, death, loss, or damage which I may suffer as a result of my participation in these activities.

I understand that the YMCA of Metropolitan Washington is not responsible for personal property lost or stolen while members and/or program participants are using YMCA facilities or YMCA premises. I give my permission to the YMCA of Metropolitan Washington to use indefinitely, without limitation or obligation, photographs, film footage, or tape recordings which may include my or my heirs’ image or voice for the purpose of interpreting YMCA programs. I acknowledge the waiver set forth above.
Participant Waiver Form Acknowledgement
RELEASE

In consideration of the YMCA allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, classes, or other activities at the YMCA and/or sponsored by the YMCA, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results from the negligence of the YMCA and its employees, agents, or representatives or from some other cause.

My agreement to release the YMCA does not include any loss, damage or injury that results from the YMCA's gross negligence or willful, wanton, or reckless misconduct. This Release includes, without limitation, any claims I may have individually or derivatively arising out of injuries to my minor child(ren) or ward(s). I acknowledge that certain jurisdictions limit the enforceability of liability waivers involving minors. This Release is intended to be as broad and inclusive as permitted by law. If any portion is held invalid, the remaining provisions shall continue in full force and effect.
Release
MEDIA RELEASE & LIABILITY WAIVER

I also acknowledge that the YMCA often uses photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media for promotional purposes. I hereby consent to the use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes, even if my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es) are an integral part of such materials.

I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren)’s or ward(s)’ name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use. I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge the YMCA and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of such materials.
Media Release & Liability Waiver
INDEMNIFICATION

I hereby represent and warrant to the YMCA that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian, and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I or my minor child(ren) or ward(s) nevertheless asserts any claim against the YMCA arising out of or related to my or my minor child(ren)’s or ward(s)’ participation in any program, event, class, or other activity as set forth herein, I agree to indemnify, defend, and hold harmless the YMCA from and against any claims, demands, damages, losses, costs, or expenses (including reasonable attorneys’ fees) arising out of or related to: (a) my breach of this agreement; (b) any misrepresentation made by me; (c) the conduct or actions of my minor child(ren) or ward(s); or (d) any claim brought by or on behalf of my minor child(ren) or ward(s) inconsistent with the releases and assumptions of risk set forth herein, to the fullest extent permitted by law.
Indemnification
PERMISSION FOR MEDICAL CARE AND PAYMENT

I give the YMCA of Metropolitan Washington permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a certified staff member of the YMCA of Metropolitan Washington. I acknowledge that the YMCA is not a medical provider and that its staff are not acting in a medical capacity. I authorize the YMCA of Metropolitan Washington to obtain immediate emergency medical care for my child if an emergency occurs and I cannot be reached, including permission for my child to be transported by ambulance or aid car to an emergency medical facility for evaluation and treatment. I further authorize licensed medical providers to examine, treat, hospitalize, and perform necessary diagnostic tests, surgical procedures, and/or administer medications to my child or ward in the event of a true medical emergency when I cannot be located immediately. It is understood that this authorization applies only to emergency situations and only when reasonable efforts to contact me or my designated emergency contacts have been unsuccessful. I authorize medical providers to disclose protected health information to the YMCA of Metropolitan Washington for the limited purpose of coordinating emergency care. I/we will be responsible for payment of all medical expenses. I understand that medical treatment costs are covered by the medical insurance provider and policy I have listed on this form.
Permission for Medical Care and Payment
PARENTAL AGREEMENTS

1. Tuition Tuition is an annual fee divided into 10 equal installments for SACC. There are no tuition adjustments for absences, unscheduled closings or delays, vacations, or school holidays. Tuition is due in advance.

2. Payment Options Semi‑Monthly EFT Drafts: Drafts occur on the 10th and 26th of each month. Payments are electronically retrieved from a bank account or credit card. If a draft is returned, you have 2 business days from written notice to replace the payment. If not replaced by the end of the 3rd business day, your child may not attend programs. Monthly EFT Draft: Draft occurs on the 26th of each month. The same replacement and attendance rules apply.

3. Other Fees Returned checks incur a $20 processing fee. Returned bank or credit card drafts incur a $20 processing fee. The first 2 weeks of tuition are required for all new participants; this fee is non‑refundable and cannot be applied to other YMCA programs if the child cancels before the start date. An annual non‑refundable activity fee applies per program.

4. Enrollment, Deposits & Withdrawal Any change, deletion, or cancellation must be submitted in writing at least two weeks prior to the draft date. If notice is not given, the next scheduled draft will still occur. No refunds will be issued.

5. Special Concerns Before registration, any behavioral, physical, emotional, psychological, or medication needs must be discussed with the Director.

6. Swimming Release Parent/guardian signature grants permission for the child to participate in swimming activities.

7. Medical Treatment The YMCA does not normally administer medication. Medication will only be administered with written direction from the parent/guardian and in accordance with licensure guidelines.

8. Absences The YMCA must be notified by 9:00 AM if your child will not be attending school that day.

9. Late Pick‑Up Policy The program closes at 6:00 PM daily, or within the 10‑hour policy, whichever comes first. Parents are responsible for late fees if a child is picked up after closing. Refer to the Parent Handbook for the full policy and fee schedule.

10. Illness If a child becomes ill during the program, parents must pick up the child as soon as possible. The YMCA cannot care for ill children. Communicable diseases must be reported within 24 hours or the next business day (immediately if life‑threatening). Refunds will not be issued for COVID‑19 related closures or absences.

11. Parent Handbook Parents are responsible for reading and understanding all policies, blanket permissions, and opt‑out procedures outlined in the Parent Handbook.

12. Emergency & Inclement Weather Policy Parent acknowledges receipt of the Emergency and Inclement Weather Policy.

13. Important Program Dates Parent acknowledges receipt of Important Program Dates and understands responsibility to review them.

14. Part‑Time Care If applicable, part‑time days are non‑transferable.

15. Policy Changes Policies and procedures are subject to change.
Parental Agreement. I understand and agree to the fifteen (15) acknowledgments outlined above.
GOVERNING LAW AND VENUE

This agreement shall be governed by the laws of the jurisdiction in which the YMCA program is operated, and venue for any dispute shall lie exclusively in that jurisdiction.

All information on this form is true and complete to the best of my knowledge. I understand and agree to the Emergency Medical Authorization and the Parental Agreements, and cancellation policy outlined above.
Date
Signature

Clear
FINAL CERTIFICATION

All information on this form is true and complete to the best of my knowledge. I understand and agree to the Emergency Medical Authorization and the Parental Agreements, and cancellation policy outlined above.
Date
Signature

Clear
ACCEPTANCE

I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form.
Date
Signature

Clear

ELECTRONIC SIGNATURE CONSENT
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
Should be Empty:

KIPP DC School Age Child Care Registration Form

PARTICIPANT INFORMATION

PARENT / GUARDIAN'S CONTACT INFORMATION

EMERGENCY CONTACTS

MEDICAL INFORMATION

INSURANCE

INCLUSION

HOW DID YOU HEAR ABOUT YMCA SCHOOL AGE CHILD CARE?

SCHOOL AGE CHILD CARE PAYMENT

WAIVERS

ELECTRONIC SIGNATURE CONSENT