Register for the 20132014 School Year

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2013-2014

WHITTIER ELEMENTARY

REGISTRATION/PAYMENT FORM
Mail/Drop off:

CHILDS NAME ____________________________ GRADE _________

Waukesha YMCA

CHILDS NAME ____________________________ GRADE _________

320 E Broadway Waukesha,

CHILDS NAME ____________________________ GRADE _________

School Office place in an envelope labled

Or Drop off at: Whittier Elementary

YMCA before/after school program.

CHILDS NAME ____________________________ GRADE _________

PARENT/GUARDIANS NAME _____________________________

PHONE __________________ CELL ______________________

ADDRESS __________________________________________________________ Email _________________________________

THE BEFORE AND AFTER SCHOOL PROGRAM IS AVAILABLE FROM 7 AM UNTIL 6 PM (School Days Only). If you require care
on non-school days please see the site coordinator for information.

All payments are final. We do not offer credits or refunds.

TUITION SCHEDULE
Month
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY

Payment due on
Thrusday, August 15
Monday, September 16
Tuesday, October 15
Friday, November 15
Monday, December 16

Month

5-day

Month
FEBRUARY
MARCH
APRIL
MAY
JUNE

3-day

Payment due on
Wednesday, January 15
Monday, February 17
Monday, March 17
Tuesday, April 15
Thursday, May 15

2-day

Before

After

Before

After

Before

After

Fee

September

$66

$114

$46

$80

$33

$57

______

# of children

X_____ = $_______

Total

Days

M T W TH F

October

$73

$126

$51

$88

$36

$63

______

X _____= $_______

M T W TH F

November

$63

$108

$44

$76

$31

$54

______

X _____= $_______

M T W TH F

December

$49

$84

$34

$59

$24

$42

______

X _____= $_______

M T W TH F

January

$73

$126

$51

$88

$36

$63

______

X _____= $_______

M T W TH F

February

$70

$120

$49

$84

$35

$60

______

X _____= $_______

M T W TH F

March

$66

$114

$46

$80

$33

$57

______

X_____ = $_______

M T W TH F

April

$52

$90

$36

$63

$26

$45

______

X_____ = $_______

M T W TH F

May

$70

$120

$49

$84

$35

$60

______

X _____= $_______

M T W TH F

June

$31

$54

$22

$38

$15

$27

______

X _____= $_______

M T W TH F

(circle)

PAYMENT INFORMATION (PLEASE PRINT) CHECK SOURCE OF PAYMENT

CHECK #________

(PAYABLE TO WAUKESHA YMCA)

CASH ___

CREDIT CARD

VISA ___ MASTERCARD ___ AMEX ___ DISC ____

CREDIT CARD NUMBER

EXPIRATION DATE

_________________________________________

_________

AUTHORIZED SIGNATURE

DATE

x_________________________________________

_______________________

SECURITY CODE
_____

A monthly credit card payment plan is available if you wish to register your child for the Ys Before or After School
Program at Whittier Elementary for the entire school year. Payee agrees to follow the noted charges on the credit card
listed below.
By checking this box you agree to have tuition automatically withdrawn from the account listed above.
WAUKESHA YMCA
320 E BROADWAY
WAUKESHA WI 53189
P 262 542 2557 WWW.YMCACWC.ORG