Mesabi Family YMCA Afterschool Program 
 
The Y's Afterschool Program is a collaborative between the Chisholm Public Schools and Mesabi Family YMCA. Program is available at Vaughan-Steffensrud Elementary. It is a safe, fun, structured environment for your child to go during after school hours, from the release of class until 5:30 pm. Students will participate in enrichment activities, homework help, physical fitness, games, and arts & crafts in a supervised environment! Students must be pre-registered and provide a weekly schedule to attend. Contact Nikki Lindquist at 749-8020 or nlindquist@mesabiymca.org for more information."

Y Afterschool Program
Grades Pre-K – 6th
2017-2018 Registration Form
Please complete a separate form for each child.
EMAIL:_________________________________________________________ Grade Entering:______________________________
**Required for communication to parents regarding special events and reminders**
Child’s Name: __________________________________________________________________________________________________
Home address:_________________________________________________________________________________________________ city state zip
Male/Female Age:______________________________ Date of Birth:_________________________________________
Mother/Guardian:__________________________________________________ Phone:__________________________________
Place of Work:______________________________________________________ Work Phone:____________________________
Father/Guardian:___________________________________________________ Phone:__________________________________
Place of Work:______________________________________________________ Work Phone:____________________________
EMERGENCY CONTACTS/ ALLOWED TO PICK-UP
Name:_____________________________________________ Name:_____________________________________________
Address:__________________________________________ Address:__________________________________________
Phone:_____________________________________________ Phone:____________________________________________
Relationship to child:____________________________ Relationship to child:___________________________
MEDICAL INFORMATION
Please list any allergies/medical conditions:______________________________________________________________
___________________________________________________________________________________________________________________
Will child need to take medication while in Afterschool care? Yes:_______________No:_________________
If yes, please list:_____________________________________________________________________________________________
**If yes, you will need to fill out a Medical Dispensing Form from the Camp Director.**
Child’s Clinic & Doctor:_______________________________________________________ Phone:_______________________
Child’s Dentist:________________________________________________________________ Phone:________________________
Does this child require any special accommodations ? YES:____NO:____
If yes, please explain:_________________________________________________________________________________________
Swim level/ ability:____________________________________________________________________________________________
SITE ATTENDING: _____Parkview Learning Center(Virginia) _____Merritt (Mt. Iron)
_____ Vaughan-Steffensrud (Chisholm) _____ Washington (Hibbing) _____ Greenhaven (Hibbing)
Y Afterschool Program - Parental Permission/ Liability Release Form
I give permission for my child to participate in the Y Afterschool Program. I understand that this is a participatory activity which includes swimming, sports, art projects and more. I hereby release the Mesabi Family YMCA and Y Afterschool Program staff from responsibility for injury to my child during his or her participation in the Y Afterschool Program.
Please initial __________
I give the YMCA and Y Afterschool Program staff permission to act in the best interests of my child to the best of their ability should an emergency arise. When family or named alternate party cannot be reached, Y Afterschool Program staff has my permission to contact the Emergency Medical Service (EMS) for transportation of my child to an appropriate medical facility.
Please initial __________
I understand that my child will have to follow the rules and will be expected to cooperate for safety at the Y Afterschool Program. I will discuss these Behavior Expectations with my child: BE KIND. BE SAFE. HAVE FUN.
Please initial __________
I understand that I am responsible for all program fees. I understand that payments must be made on time or Y Afterschool Program privileges will be suspended until my account is paid.
Please initial __________
I give permission for the Mesabi Family YMCA to use photo images of my child in promotional materials. My child’s artwork designated with his or her first name and age may be displayed and also published. I understand that photos of special events and artwork may appear in the local newspaper and may be used for promotion of Mesabi Family YMCA programs. I agree that I am owed no compensation for use of photographic images in Mesabi Family YMCA materials.
Please initial __________
I understand that evaluation is a part of this and all YMCA programs and give permission for my child to be involved in ongoing individual and program evaluations conducted by YMCA and program staff.
I understand that ALL information regarding my child remains confidential.
Please initial __________
I have read and understand the above statements.
Name of parent / guardian (Please print): _________________________________________________________________
Signature of parent/guardian: _______________________________________________________ Date: _______________