2025-2026 Clipper Care Request for Registration Form

THIS FORM DOES NOT SERVE AS REGISTRATION

This form serves as a request for registration. YCS will register in the order we receive forms until all spots are filled. We will email registration confirmation whether your child is registered or placed on a waitlist.

YCS offers Before & After Care for Grades K-5 and After Care for Pre-K.

2025-2026 Pricing
After Care $20 per day
Before Care $15 per day

Program Hours
Before Care: 7:00 am to 8:30 am
K-5th After Care: school dismissal to 5:30 pm
Pre-K After Care: school dismissal to 5:00 pm

Child's Name Child's Name First Last
Child's Gender

Child's Gender Female Male Non-binary
Child's Grade for the 2025-2026 school year

Please Choose the program you are requesting registration for:
	After School Care
Rowe School Pre K	Rowe School Pre KAfter School Care

Please choose the program you are requesting registration for:
	Morning Care	After School Care
Rowe School K-1	Rowe School K-1Morning Care	Rowe School K-1After School Care

Please choose the program you are requesting registration for:
	Morning Care	After School Care
YES 2-5	YES 2-5Morning Care	YES 2-5After School Care

Scheduling Information

Please select the days/times you are requesting childcare
	Monday	Tuesday	Wednesday	Thursday	Friday	None
Morning Care (gr. K-5)	Morning Care (gr. K-5)Monday	Morning Care (gr. K-5)Tuesday	Morning Care (gr. K-5)Wednesday	Morning Care (gr. K-5)Thursday	Morning Care (gr. K-5)Friday	Morning Care (gr. K-5)None
After School Care (gr PK - 5)	After School Care (gr PK - 5)Monday	After School Care (gr PK - 5)Tuesday	After School Care (gr PK - 5)Wednesday	After School Care (gr PK - 5)Thursday	After School Care (gr PK - 5)Friday	After School Care (gr PK - 5)None

Date you wish to begin Childcare Date you wish to begin Childcare / MM / DD YYYY
List any scheduling notes, comments, or questions to YCS
Behavior and Social Concerns
To help us create a safe and positive experience for all participants, please share any behavioral, emotional, or social concerns we should be aware of (e.g. anxiety, ADHD/ASD, sensory sensitivities, difficulty with transitions, behavioral challenges, etc.). This information will help our staff provide appropriate support and accommodations.
Does your child have any behavioral or social concerns we should be aware of?

Does your child have any behavioral or social concerns we should be aware of? No Yes
If "yes" above, please explain.
Does your child have an IEP, 504 plan, behavior support plan, or other support plan during the school day? (If yes, you may provide a copy if you feel it would be helpful)

Does your child have an IEP, 504 plan, behavior support plan, or other support plan during the school day? (If yes, you may provide a copy if you feel it would be helpful) No Yes
You may upload your child's IEP/support plan here

Attach Files
If you would like the Yarmouth School Department to be able to communicate your child's IEP, 504, behavior plan or other needs with Yarmouth Community Services, please sign the YSD Release of Information waiver which can be found at the website below:
Does your child receive in-home behavior support?

Does your child receive in-home behavior support? No No, but we are on a waitlist Yes, through Maine Care Yes, through another agency
Child and Family Information
Child's Date of Birth Child's Date of Birth / MM / DD YYYY
Child's Home Mailing Address Child's Home Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent #1 Name Parent #1 Name Title First Last Suffix
Parent #1 Email

Confirm Email Address
Parent #1 Cell Phone Parent #1 Cell Phone - ### - ### ####

Use home phone if there is no cell number
Parent #1 Cell Phone Carrier Name

Information required by our texting service
Parent #1 Work Phone Parent #1 Work Phone - ### - ### ####
Parent #1 Home Phone Parent #1 Home Phone - ### - ### ####
Parent #2 Name Parent #2 Name Title First Last Suffix
Parent #2 Email
Parent #2 Cell/Home Phone Parent #2 Cell/Home Phone - ### - ### ####
Parent #2 Work Phone Parent #2 Work Phone - ### - ### ####
Which email(s) do you want the Childcare Invoice/Statements sent to?

Which email(s) do you want the Childcare Invoice/Statements sent to? Parent #1 Only Parent #2 Only Both Parent 1 & 2
Authorized Pick-Up List

Please list any individuals other than parents/guardians that may pick-up your child from the program.
Authorized Pick-Up Person #1 Authorized Pick-Up Person #1 First Last
Authorized Pick-Up Person #2 Authorized Pick-Up Person #2 First Last
Authorized Pick-Up Person #3 Authorized Pick-Up Person #3 First Last
Authorized Pick-Up Person #4 Authorized Pick-Up Person #4 First Last
Authorized Pick-Up Person #5 Authorized Pick-Up Person #5 First Last
PARENTAL / GUARDIAN PERMISSIONS
Does your child have permission to walk/bike home?

Does your child have permission to walk/bike home? no yes, with a sibling only, at program end / other specified time Yes, with a sibling only, at any time. Yes, with a sibling only, after a call or text from a guardian. Yes, on their own, at program end / other specified time. Yes, on their own, at any time. Yes, on their own, after a call or text from a guardian.
Any special instructions to YCS staff regarding Child leaving a program (i.e. They may leave each day after 4:30)
Emergency Contact Information

To be contacted in the event we are unable to reach child's parent's/guardians.
Emergency Contact Name: Emergency Contact Name: First Last
Emergency Contact's Relationship to Child
Emergency Contact Primary Phone Number. Emergency Contact Primary Phone Number. - ### - ### ####
Child's Physician Name Child's Physician Name First Last
Child's Physician Phone Number Child's Physician Phone Number - ### - ### ####
Medical Insurance Policy Number
Medical Insurance Carrier
Medical Insurance Phone Number Medical Insurance Phone Number - ### - ### ####
KEY CHILDCARE POLICIES & NOTICES
POLICY #1 - You understand this is NOT a drop-in childcare program and you will be charged for the number of days you register for?

POLICY #1 - You understand this is NOT a drop-in childcare program and you will be charged for the number of days you register for? Yes, I understand Policy #1
POLICY #2 - You understand that in order to withdraw from this program you must notify the YCS office in writing two weeks prior to your child's last day.

POLICY #2 - You understand that in order to withdraw from this program you must notify the YCS office in writing two weeks prior to your child's last day. Yes, I understand Policy #2
POLICY #3 - You understand that you will be billed for each day your child is registered for regardless of time off or time away. The only exceptions to this are school holidays, weather closures or other closures determined by Yarmouth Community Services and/or the Yarmouth School Department.

POLICY #3 - You understand that you will be billed for each day your child is registered for regardless of time off or time away. The only exceptions to this are school holidays, weather closures or other closures determined by Yarmouth Community Services and/or the Yarmouth School Department. Yes, I understand Policy #3
POLICY #4 - You understand that in order for your child to remain in attendance, they must be able to maintain safe behavior towards themselves and others. Inability to maintain safe behavior may result in removal from the program.

POLICY #4 - You understand that in order for your child to remain in attendance, they must be able to maintain safe behavior towards themselves and others. Inability to maintain safe behavior may result in removal from the program. Yes, I understand Policy #4
POLICY #5- You understand that childcare bills will be emailed to the email address(es) listed above and the balance must be paid in full by the final day of each month.

POLICY #5- You understand that childcare bills will be emailed to the email address(es) listed above and the balance must be paid in full by the final day of each month. Yes, I understand Policy #5
Parent / Guardian Digital Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

2025-2026 Clipper Care Request for Registration Form

2025-2026 Clipper Care Request for Registration Form

Scheduling Information

Behavior and Social Concerns

Child and Family Information

Authorized Pick-Up List

PARENTAL / GUARDIAN PERMISSIONS

Emergency Contact Information

KEY CHILDCARE POLICIES & NOTICES