Success Academy After School

Important Note

The registration form on this page is for a single upfront payment. If you would like to make monthly payments, you can register here instead.

Downloadable Forms

Medical Form
Pick-Up Form
Teacher Form

$225.00 – $5,000.00

Number of Months
Days Per Week
Is Wednesday one of the days that you are registering for?	Clear

Step 1 of 3 - Registration Form

Product Name
Extended Hours (until 7pm)
Days of the Week*
Which weekdays are you registering for?
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Applicant Information
Applicant Name*
First Last
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
School*
Grade*
Address*
Street Address Address Line 2 City State Zip Code
Medical Conditions*
Please list any allergies and/or medical conditions that we should know about:
Diet*
Please list any dietary restrictions:
Does your child have an IEP or receive any additional services (including speech, SEIT, OT, PT Psychology, etc.)? If yes, please explain:*
Does your child have an IEP or receive any additional services (including speech, SEIT, OT, PT Psychology, etc.)? If yes, please explain:
Parent/Guardian 1
Name*
First Last
Occupation
Place of Occupation / Business Name
Relationship
Email Address*
Primary Number*
Other Number
Parent/Guardian 2
Name
First Name Last Name
Occupation
Place of Occupation / Business Name
Relationship
Email Address
Primary Number
Other Number
Untitled
Please let us know if you or both parents/guardians are interested in the following:
- I am interested in helping organize fundraising events.
- I would like to volunteer at special events and/or holiday events.
How did you hear about us?
Emergency Contact
Emergency Contact Name*
First Name Last Name
Relationship*
Cell Number*
Total

Downloadable Forms
Medical Form
Pick-Up Form
Teacher Form
Authorized Pickups
Authorized Pickup Agreement*
Please complete this form, stating the names of the individuals who are allowed to pick up your child from the Afterschool program. Please be as thorough as possible with this list, as we will not allow your child to leave with anyone who isn’t named here. Also, please be advised that the person picking up your child must have a valid form of photo ID on them, such as a driver’s license, a passport or current school – issued ID. There will be NO exceptions.
- I HAVE READ THE ABOVE AUTHORIZATIONS AND AGREE TO ABIDE BY THEM.
Authorized Pickup 1 Name*
Relation*
Phone Number*
Authorized Pickup 2 Name*
Relation*
Phone Number*
Authorized Pickup 3 Name
Relation
Phone Number
Authorized Pickup 4 Name
Relation
Phone Number
Trip Authorization Form & AUTHORIZATION FOR EMERGENCY MEDICAL AND/OR SURGICAL TREATMENT
Trip Authorization Form & AUTHORIZATION FOR EMERGENCY MEDICAL AND/OR SURGICAL TREATMENT*
Please complete this consent form which will be used for general trip/activity authorization but also in the event of an emergency. It is our hope to never use this form for a medical emergency but in the event that we do, please know that we will make every effort to contact you and your designee as soon as possible. In the case of an emergency during my child's enrollment, presence, or association with the Kings Bay YM-YWHA, I hereby authorize the doctor or hospital to which my child may be brought (and whomever they may designate as their assistants) to perform any emergency procedure or operation, to give treatment and to administer anesthetic to my child, as deemed necessary. I have read and acknowledge the above statement and authorize the listed individuals to take my child out of the care of the Kings Bay YM-YWHA.
- I give my child permission to go on all trips and to participate in all program activities
Child's Name*
First Last
Child's Grade*
Parent/Guardian Name*
First Last
Mobile Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Information
Name of Insurance Plan*
Policy #*
Policy Holder Name*
First Name Last Name
Relation to Child*
Emergency Contact Name*
First Last
Relation to Child*
Emergency Contact Number*

Terms & Conditions
Tuition is for the full school year (September - June) and school closings have been taken into account in computing these fees. Therefore, the month amount always remains the same regardless of the number of school days. If a refund is requested, a $100.00 cancellation fee will be deducted from the refund You may register your child at any time during the course of the year. You will pay only for those months that your child attends. Payment for the first month and for June is due upon registration. 1. All payments are due on or before the first of each month for the upcoming month. 2. For school closures/holidays, Mini Camps are offered for an additional fee. 3. An additional day is $30.00 if you sign up for 1 to 3-days registration and would like to add a pick-up day. The daily rate is $50 per day. 4. Medical forms must be completed and submitted prior to the child's admission to the program 5. The Kings Bay Y will not be responsible for damage to, or loss of, personal property. 6. I hereby give permission for my child to be photographed/videographed for promotional purposes. 7. I hereby give permission for my childto participate in all general activities. 8. Our program hours are Monday through Friday from 2:30pm to 6:00pm; extended day is available Monday through Friday from 6:00pm - 7:00pm at an additional fee. 9. Late Arrival Policy: For arrival after 6pm, a fee of $1 per minute will be charged. 10. It is the goal of our program to provide a healthy and safe environment for all participants. If a participant displays any inappropriate behavior, or endangers the health and safety of other participants and/or staff, we will contact the parent/guardian to immediately come to the site. We may suspend the participant from the program or consider permanent termination in extreme cases. In the event of suspension or expulsion, no refunds will be granted. Release: I hereby give my permission for my child to participate in all programs, swimming activities and trips. I understand and fully recognize that risks are involved and I hereby release the Kings Bay Y or any of its sponsors, benefactors, or employees from any liability arising out of any injury to my child in the event of a medical emergency or surgical emergency. I do hereby give authority to the after school program and staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. I grant permission to the physician designated by the Kings Bay Y to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child. Furthermore, I understand that payment for medical services is solely the family’s responsibility. I hereby give permission to the Kings Bay Y Inc. to take photographs of me and/or my child to be shown in a video, brochure, advertisement, or internet display for purposes of promoting interest in the Kings Bay Y. I release the Kings Bay Y Inc. from any claims resulting from the pictures taken on, before, or after the date of this communication. I do hereby give permission for my child to participate in all camp activities, including off-ground activities. I authorize the Kings Bay Y Inc. to act as a parent surrogate on my behalf. I realize that itineraries and/or programs are subject to change prior to, and during, the school year. I have read the terms of enrollment and agree to abide by them.
Hidden
Terms & Conditions
Tuition is for the full school year (September - June) and school closings have been taken into account in computing these fees. Therefore, the month amount always remains the same regardless of the number of school days. If a refund is requested, a $100.00 cancellation fee will be deducted from the refund You may register your child at any time during the course of the year. You will pay only for those months that your child attends. Payment for the first month and for June is due upon registration. 1. All payments are due on or before the first of each month for the upcoming month. 2. For school closures/holidays, Mini Camps are offered for an additional fee. 3. An additional day is $30.00 if you sign up for 1 to 3-days registration and would like to add a pick-up day. The daily rate is $50 per day. 4. Medical forms must be completed and submitted prior to the child's admission to the program 5. The Kings Bay Y will not be responsible for damage to, or loss of, personal property. 6. I hereby give permission for my child to be photographed/videographed for promotional purposes. 7. I hereby give permission for my childto participate in all general activities. 8. Our program hours are Monday through Friday from 2:30pm to 6:00pm; extended day is available Monday through Friday from 6:00pm - 7:00pm at an additional fee. 9. Late Arrival Policy: For arrival after 6pm, a fee of $1 per minute will be charged. 10. It is the goal of our program to provide a healthy and safe environment for all participants. If a participant displays any inappropriate behavior, or endangers the health and safety of other participants and/or staff, we will contact the parent/guardian to immediately come to the site. We may suspend the participant from the program or consider permanent termination in extreme cases. In the event of suspension or expulsion, no refunds will be granted. Release: I hereby give my permission for my child to participate in all programs, swimming activities and trips. I understand and fully recognize that risks are involved and I hereby release the Kings Bay Y or any of its sponsors, benefactors, or employees from any liability arising out of any injury to my child in the event of a medical emergency or surgical emergency. I do hereby give authority to the after school program and staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. I grant permission to the physician designated by the Kings Bay Y to hospitalize, secure proper treatment for, and order injections, anesthesia or surgery for my child. Furthermore, I understand that payment for medical services is solely the family’s responsibility. I hereby give permission to the Kings Bay Y Inc. to take photographs of me and/or my child to be shown in a video, brochure, advertisement, or internet display for purposes of promoting interest in the Kings Bay Y. I release the Kings Bay Y Inc. from any claims resulting from the pictures taken on, before, or after the date of this communication. I do hereby give permission for my child to participate in all camp activities, including off-ground activities. I authorize the Kings Bay Y Inc. to act as a parent surrogate on my behalf. I realize that itineraries and/or programs are subject to change prior to, and during, the school year. I have read the terms of enrollment and agree to abide by them.
In case of emergency during my child’s enrollment in the Kings Bay Y After-School or Day Camp Program, I hereby authorize the doctor or the hospital to which my child may be brought (and whomever they may designate as their assistants) to perform any emergency procedure or operation, to give treatment and to administer anesthetic to my child, as deemed necessary.

I give my child permission to go on all trips and to participate in all program activities

I hereby allow my child to participate in any aquatics related events at the Kings Bay YM-YWHA. I will permit emergency treatment in the event of injury or illness while participating in these aquatics related programs. I certify that I have read this waiver and release and understand and its content.
Hidden
Acquatics Agreement
In case of emergency during my child’s enrollment in the Kings Bay Y After-School or Day Camp Program, I hereby authorize the doctor or the hospital to which my child may be brought (and whomever they may designate as their assistants) to perform any emergency procedure or operation, to give treatment and to administer anesthetic to my child, as deemed necessary. I give my child permission to go on all trips and to participate in all program activities I hereby allow my child to participate in any aquatics related events at the Kings Bay YM-YWHA. I will permit emergency treatment in the event of injury or illness while participating in these aquatics related programs. I certify that I have read this waiver and release and understand and its content.
Terms Checkbox*
- I have read all the terms and conditions and agree to abide by them
By signing this form, you authorize regularly scheduled charges to your credit/debit card. You will be charged the total amount due for that period. Bank account debit will appear on your bank statement as "KINGS BAY YM-YWHA INC BROOKLYN NY" or, if credit card or debit card payment is selected, you will see a recurring charge to your card. You agree that no prior notification will be provided for recurring payments. Initially, and any time your account information changes, we may run a pre-authorization to make sure the card is valid at no cost to you. A pre-authorization is a temporary funds hold, not a true charge. You may see a charge of .10 cents that will get reversed after your account validation. Pre-authorizations will usually only show up on your credit card or banking statement as "pending charges." A receipt will be emailed to you based on selected preference.
Hidden
Autopay Authorization
By signing this form, you authorize regularly scheduled charges to your credit/debit card. You will be charged the total amount due for that period. Bank account debit will appear on your bank statement as "KINGS BAY YM-YWHA INC BROOKLYN NY" or, if credit card or debit card payment is selected, you will see a recurring charge to your card. You agree that no prior notification will be provided for recurring payments. Initially, and any time your account information changes, we may run a pre-authorization to make sure the card is valid at no cost to you. A pre-authorization is a temporary funds hold, not a true charge. You may see a charge of .10 cents that will get reversed after your account validation. Pre-authorizations will usually only show up on your credit card or banking statement as "pending charges." A receipt will be emailed to you based on selected preference.
By signing this form, you authorize regularly scheduled charges to your credit/debit card. You will be charged the total amount due for that period. Bank account debit will appear on your bank statement as "KINGS BAY YM-YWHA INC BROOKLYN NY" or, if credit card or debit card payment is selected, you will see a recurring charge to your card. You agree that no prior notification will be provided for recurring payments. Initially, and any time your account information changes, we may run a pre-authorization to make sure the card is valid at no cost to you. A pre-authorization is a temporary funds hold, not a true charge. You may see a charge of .10 cents that will get reversed after your account validation. Pre-authorizations will usually only show up on your credit card or banking statement as "pending charges." A receipt will be emailed to you based on selected preference.
Autopay Authorization checkbox*
- In consideration for the services provided by Kings Bay Y to me or program attendees I designate, I hereby authorize the above named organization to initiate credit, and, if necessary, debit entries and adjustments for any credit entries in error to my account as indicated in this authorization form according to the terms outlined herewith. I understand that the above named organization will provide services as requested by me from time to time and I agree to pay the purchase price for such services, and acknowledge, such amounts shall be collected by electronic debits or deductions by the above named organization. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of transaction being rejected for Non-Sufficient Funds (NSF), I understand that Kings Bay Y may, at its own discretion, attempt to process the charge again within 30 days, and agree to an additional $20 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. The pyament authorization is for the type of bill indicated above. I certify that I am an authorized user of this debit card/credit card (as applicable), and that I will not dispute the scheduled payments with my financial institution/credit card company, provided the transactions correspond to the terms of our agreement. This authorization is to remain in full force and effect until Kings Bay Y has received written notification from me of its termination in such time, and in such manner as to afford Kings Bay Y and Financial Institution a reasonable opportunity to act on it. I may only revoke this authorization by contacting Kings Bay Y directly at the address and phone number listed above, and only in the case that I return the goods, product and/or service provided to me by Kings Bay Y pursuant to their particular return policy in effect on the date this authorization is granted.
Signature*
Date*
Month
Day
Year
Stay Informed: Would you like to join our enews and stay informed about our upcoming events and programs?*
- Yes
- No
Kings Bay YM-YWHA is an equal opportunity provider and employer and does not discriminate any person on the basis of race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, marital status, family status or any other characteristic protected by Federal and State laws. Kings Bay YM-YWHA will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990. To file a complaint of discrimination, write Office for Civil Rights, U.S. DHHS 26 Federal Plaza - Suite 3313 New York, NY 10278 (212) 264-3313; (212) 264-2355 (TDD); (212) 264-3039 FAX In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (866) 632-9992 (voice) or (800) 877-8339(TDD). USDA is an equal

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SKU: N/A Category: Afterschool

Description
Additional information

Important Note

The registration form on this page is for a single upfront payment. If you would like to make monthly payments, you can register here instead.

Downloadable Forms

Medical Form
Pick-Up Form
Teacher Form

Additional information

Number of Months	1, 2, 3, 4, 5, 6, 7, 8, 9, 10
Days Per Week	1 Day, 2 Days, 3 Days, 4 Days, 5 Days
Is Wednesday one of the days that you are registering for?	Yes, No

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Kings Bay Y

Success Academy After School

Success Academy After School

Important Note

Downloadable Forms

Step 1 of 3 - Registration Form

Applicant Information

Parent/Guardian 1

Parent/Guardian 2

Emergency Contact

Downloadable Forms

Authorized Pickups

Trip Authorization Form & AUTHORIZATION FOR EMERGENCY MEDICAL AND/OR SURGICAL TREATMENT

Insurance Information

Terms & Conditions

Important Note

Downloadable Forms

Additional information