Superior Public Elementary Schools and Superior Douglas County Family YMCA
Before and After School Programs
2018-2019 Registration
Non-refundable $25 registration fee is due at the YMCA, 9 N. 21st Street.

Registration for the Before and After School Program will open on April 30th and will close again on August 15th. If you register after August 15th, your child will not be able to begin attending either program until September 17th.

If you have any questions, please contact Nicky Wilson at 715-394-8740 EXT 30127

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 2018-2019 *
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. District reserves the right to move program location to provide various program opportunities for students. 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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