Superior Public Elementary Schools and Superior Douglas County Family YMCA
Before and After School Programs
2017-2018 Registration
Non-refundable $40 registration fee is due at the YMCA, 9 N. 21st Street.

The Before and After School registration will close on August 29th at 4:00 p.m. If you register your child for the program after August 29th, you will need to complete the on-line form, but will need to go to the Superior YMCA to pay the $40 registration fee and the fee for the month of September.

IF YOU REGISTER ON AUGUST 30 OR LATER, YOUR CHILD WILL NOT BE ABLE TO ATTEND THE PROGRAM UNLESS YOU CONTACT NICKY WILSON AT 715-394-8740 EXT 3127

Email address *
Program Location *
Program Time *
Requested Start Date
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First and Last Name of Student *
Your answer
Student Date of Birth *
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Student Grade in 2017-2018 *
Your answer
Special Health or Behavioral Concerns
Your answer
Custodial Parent or Legal Guardian (Identify ONE adult who lives with the student and will be responsible for all program communication and payments) *
Your answer
Relationship to Student *
Main phone number *
Your answer
Alternate phone number
Your answer
Email address (Updates and Billing statements are sent by email) *
Your answer
Street Address, City, State, Zip *
Your answer
Emergency Contact #2 (Identify one adult who can be reached if the parent or guardian is unavailable. Application will not be accepted unless an emergency contact is listed here. This person must be different than contact #1) *
Your answer
Relationship to Student *
Emergency Contact #2 Main Phone Number *
Your answer
Emergency Contact #2 Alternate Phone Number
Your answer
I give permission for students to participate in all Program activities, including field trips requiring transportation to/from the Program; understand that students may be photographed for print, video, or electronic media; all images are the sole property of the Program; and acknowledge that I am financially responsible for monthly payments. By typing my name below, and hitting submit at the end of this form, I agree to these terms. *
Your answer
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