Mar 2010 10

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We require parents to initial that they have received the parent handbook. Please use the following link Parent Handbook to download an electronic PDF version for your records.

This form will be used to contact you in case of an emergency. Please be sure all information is correct and complete. Please notify the Front Desk Staff (in writing) if your information changes. Upon successful completion & transmission of this form we will notify you to come in and sign a copy for our records. Completion of this online enrollment form does not guarantee your child's position in any YES programs. Please call the Learning Center you are applying at to check availability prior to completing the online enrollment form. Any questions? Please call (605) 338-8061

Location*
Please select your location
Start Date*
Application Type*
How did you hear about us?*
Child's Information
Child's Name*
FirstLast
Date of Birth*
MM
DD
YYYY
Age*
Gender*
Address*
Street AddressCityStateZip Code
Child lives with*
Please specify
Elementary School Attending (or will be attending)*
Grade*
Attending*
Father's Information
(or legal guardian)
Father's Name*
FirstLast
Address*
Street AddressCityStateZip Code
Home Phone*
Cell Phone*
Email Address
Place of Employment*
Work Phone*
ext.
Mother's Information
(or legal guardian)
Mother's Name*
FirstLast
Address*
Street AddressCityStateZip Code
Home Phone*
Cell Phone*
Email Address
Place of Employment*
Work Phone*
ext.
Emergency Contacts
(2 people OTHER THAN PARENTS who may be notified in case of emergency)
Emergency Contact 1*
Relationship to Child*
Home Phone*
Cell Phone
Work Phone
ext.
Emergency Contact 2*
Relationship to Child*
Home Phone*
Cell Phone
Work Phone
ext.
Other Authorized Individuals
(who may pick up child with a valid photo ID)
Name
Name
Name
Name
Medical Information
PHYSICIAN'S NAME*
Phone*
Hospital*
Phone
Additional Information
Should YES staff be aware of any unusual family situations?
Please explain
Any Food Allergies
Other Allergies
(asthma, insect bites, medications, etc.)
Do any of these require an EPI Pen?
Please specify
Any physical disabilities that will require special accommodations?
Permissions & Release Agreements
Field Trip Permission*
- I give permission for my child (above mentioned) to participate in all Youth Enrichment Services, Inc. activities including but not limited to the following: field trips, gym activities, swimming, biking, etc. I will permit this participant to go with authorized YES staff/volunteers on field trips and release YES of all responsibilities other than reasonable care.
Mediacal Permission*
- The undersigned, individually and as parent(s) or guardian of the participant, hereby authorizes Youth Enrichment Services, Inc. to carry out any measures deemed necessary should an emergency occur, including treatment for the participant, and hereby release Youth Enrichment Services, Inc., its employees and agents, from any and all liability claims arising out of participant’s engagement in the above described events.
Photo Release*
- I hereby irrevocably give my consent to Youth Enrichment Services, Inc. to use my child’s likeness in promotional materials for use in slide shows, photographs, and video. I hereby release Youth Enrichment Services, Inc. and its agents, subsidiaries, affiliates, and all others from any and all liability arising out of such use.
Parent Handbook*
- I have received and agree to abide by the policies and procedures outlined in the Youth Enrichment Services Parent Handbook. If you do not have a current copy of this handbook it can be downloaded at the top of the page.
Computer Use Agreement*
- I agree to allow my child use of YES computer facilities for enhancing academic achievement. Computer use is a privilege and will be used properly in accordance with all federal and state regulations.
Preferred Email*
Choose an email to which you prefer correspondence sent to.

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Child's Information

Father's Information

Mother's Information

Emergency Contacts

Other Authorized Individuals

Medical Information

Additional Information

Permissions & Release Agreements

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