KIDS CLUB APPLICATION
Please complete one form per child

If Middle School student, looking for Wednesday only, complete form and click Middle School for grade, and Wednesday as day.
Email *
Child's First Name
Child's Last Name
Parent's Name
GRADE *
Child's Birthdate *
MM
/
DD
/
YYYY
TEACHER
Home Phone #
Second Phone #
Family Email
Second Email
List of people who can pick up child
Days of weeks you will be attending
Would you attend our full day Wednesday program ?
Clear selection
Medical Issues our Staff need to know
Waiver and Permission
I do hereby grant permission for my Son / Daughter / Legal Dependent to participate in the Winthrop Area YMCA Kids Club, I agree to adhere to the policies set forth in the Program Information document. I agree to pay the agreed upon fees on schedule. I agree to the Code of Conduct and support any decisions made by staff I agree to give permission for photographs to be taken of my child, to be used in program publicity and website.
A copy of your responses will be emailed to the address you provided.
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