B.A.S.E. Registration

*Please see updated Fee Schedule for new pricing.

B.A.S.E. School Year Registration

**PLEASE ALLOW 24-48 HOURS FOR PROCESSING OF THIS REGISTRATION BEFORE YOU SEND YOUR CHILD TO BASE. Call the office at (765) 482-3020 if you have questions about when you can start to send your child.

BASE School Year*
Select the school year that your child will attend BASE.
Parent Name #1*
First Last
Parent #1 Email*
Enter Email Confirm Email
Parent #1 Phone*
Parent #1 Address*
Street Address Address Line 2 City State ZIP Code
Parent #1 Employer
Parent #1 Work Phone
Parent #1 Work Address
Street Address Address Line 2 City State ZIP Code
Parent Name #2
First Last
Parent #2 Email
Enter Email Confirm Email
Parent #2 Phone
Parent #2 Address
Street Address Address Line 2 City State ZIP Code
Parent #2 Employer
Parent #2 Work Phone
Parent #2 Work Address
Street Address Address Line 2 City State ZIP Code
Child Enrollment*
How many children do you want to enroll in B.A.S.E.?
Child #1 Name*
First Last
Child #1 Birthday*
MM slash DD slash YYYY
Has Child #1 attended B.A.S.E or Summer Camp in the past?*
- Yes
- No
Child #1 School*
Child #1 Grade Level for 2022-23 School Year*
Child #1 Attendance Options*
Please note, MHABC is now offering weekly plans only. You are welcome to prepay for a month at a time if you prefer. However, you must pay in advance.
- AM Only
- PM Only
- AM and PM
- As Needed (Prepaid punch card rate of $18.00/session)
- Breaks Only
For Child #1, you selected "As Needed" attendance option. Please provide more detail.*
Please indicate likely dates of attendance if sporadic. (Examples: Breaks only, delays, professional development days, Wednesdays only, etc.)
Child #1 Start Date*
What date will your child be starting B.A.S.E.?
MM slash DD slash YYYY
Child #1 Allergies*
Type NA if none.
Child #1 Medical Needs*
Type NA if none. If medical administration is needed by our staff, the Medical Release form will need to be signed. Please provide the medication name that your child is taking, the dosage, and the frequency.
Child #1 Behavior Issues or Concerns*
Type NA if none.
Child #2 Name*
First Last
Child #2 Birthday*
MM slash DD slash YYYY
Has Child #2 attended B.A.S.E or Summer Camp in the past?*
- Yes
- No
Child #2 School*
Child #2 Grade Level for 2022-23 School Year*
Child #2 Attendance Options*
Please note, MHABC is now offering weekly plans only. You are welcome to prepay for a month at a time if you prefer. However, you must pay in advance.
- AM Only
- PM Only
- AM and PM
- As Needed (Prepaid punch card rate of $18.00/session)
- Breaks Only
For Child #2, you selected "As Needed" attendance option. Please provide more detail.*
Please indicate likely dates of attendance if sporadic. (Examples: Breaks only, delays, professional development days, Wednesdays only, etc.)
Child #2 Start Date*
What date will your child be starting B.A.S.E.?
MM slash DD slash YYYY
Child #2 Allergies*
Type NA if none.
Child #2 Medical Needs*
Type NA if none. If medical administration is needed by our staff, the Medical Release form will need to be signed. Please provide the medication name that your child is taking, the dosage, and the frequency.
Child #2 Behavior Issues or Concerns*
Type NA if none.
Child #3 Name*
First Last
Child #3 Birthday*
MM slash DD slash YYYY
Has Child #3 attended B.A.S.E or Summer Camp in the past?*
- Yes
- No
Child #3 School*
Child #3 Grade Level for 2022-23 School Year*
Child #3 Attendance Options*
Please note, MHABC is now offering weekly plans only. You are welcome to prepay for a month at a time if you prefer. However, you must pay in advance.
- AM Only
- PM Only
- AM and PM
- As Needed (Prepaid punch card rate of $18.00/session)
- Breaks Only
For Child #3, you selected "As Needed" attendance option. Please provide more detail.*
Please indicate likely dates of attendance if sporadic. (Examples: Breaks only, delays, professional development days, Wednesdays only, etc.)
Child #3 Start Date*
What date will your child be starting B.A.S.E.?
MM slash DD slash YYYY
Child #3 Allergies*
Type NA if none.
Child #3 Medical Needs*
Type NA if none. If medical administration is needed by our staff, the Medical Release form will need to be signed. Please provide the medication name that your child is taking, the dosage, and the frequency.
Child #3 Behavior Issues or Concerns*
Type NA if none.
Child #4 Name*
First Last
Child #4 Birthday*
MM slash DD slash YYYY
Has Child #4 attended B.A.S.E or Summer Camp in the past?*
- Yes
- No
Child #4 School*
Child #4 Grade Level for 2022-23 School Year*
Child #4 Attendance Options*
Please note, MHABC is now offering weekly plans only. You are welcome to prepay for a month at a time if you prefer. However, you must pay in advance.
- AM Only
- PM Only
- AM and PM
- As Needed (Prepaid punch card rate of $18.00/session)
- Breaks Only
For Child #4, you selected "As Needed" attendance option. Please provide more detail.*
Please indicate likely dates of attendance if sporadic. (Examples: Breaks only, delays, professional development days, Wednesdays only, etc.)
Child #4 Start Date*
What date will your child be starting B.A.S.E.?
MM slash DD slash YYYY
Child #4 Allergies*
Type NA if none.
Child #4 Medical Needs*
Type NA if none. If medical administration is needed by our staff, the Medical Release form will need to be signed. Please provide the medication name that your child is taking, the dosage, and the frequency.
Child #4 Behavior Issues or Concerns*
Type NA if none.
Authorized pick-up person(s)*
All authorized pick-up persons must be registered. Parents do not need to be listed as an authorized pick-up person. How many authorized pick-up persons do you want to register?
Authorized Pick-up Person #1*
Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.
First Last
Authorized Pick-up Person Phone #1*
Authorized Pick-up Person #2*
Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.
First Last
Authorized Pick-up Person Phone #2*
Authorized Pick-up Person #3*
Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.
First Last
Authorized Pick-up Person Phone #3*
Authorized Pick-up Person #4*
Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.
First Last
Authorized Pick-up Person Phone #4*
Payment method*
Please note there will be a convenience fee charged for all electronic forms of payment including credit card, debit card, e-check/bank transfer. Paper checks issued by bank on your behalf are not considered E-checks and are not charged a convenience fee. If you select Debit/Credit Card option below, right click on this link NOW, select “Open link in new tab”, and follow payment authorization steps >> Credit/Debit Authorization
- Debit/Credit Card
- E-check/ACH Bank Transfer
- Paper Check/Bank Check
- Other
Hidden
Rules Addendum and Waiver Consent*
I followed the link below and have completed the Rules Addendum and Waiver submission
Right click on this link NOW, select “Open link in new tab”, and follow steps to complete submission >> Rules Addendum and Waiver
Parent Agreement Consent*
B.A.S.E. PARENT AGREEMENT – Regular School Year – PLEASE READ THE FOLLOWING COMPLETELY – YOU ARE MAKING MULTIPLE AUTHORIZATIONS BY SIGNING THIS DOCUMENT, INCLUDING MEDIA RELEASE, GENERAL LIABILTY RELEASE, TRANSPORT RELEASE, MEDICAL RELEASE, and more:
For my child’s attendance in B.A.S.E. during the regular school year, generally described as August through May, I agree to the following:
1. I will adhere to the attendance plan chosen herein;
2. ANY AND ALL PLAN CHANGES MUST BE MADE WITH A TWO (2) WEEK NOTICE TO THE BASE OFFICE DIRECTLY at (765) 482-3020 x100 OR BY EMAIL TO BFETTIG@MHABOONECOUNTY.ORG. ENDING SERVICES IS ALSO CONSIDERED A PLAN CHANGE AND REQUIRES A TWO WEEK NOTICE. ALL CHARGES WILL APPLY AS NORMAL UNLESS A TWO WEEK NOTICE HAS BEEN PROVIDED TO THE MHABC VP OF BUSINESS, BECKY FETTIG AT BFETTIG@MHABOONECOUNTY.ORG (NOTE: PLEASE DO NOT PROVIDE PLAN CHANGES TO BASE SITE STAFF).
3. I understand that BASE is an enrollment-based program, and is not an a la carte, daily program. Once my child is enrolled, my fee for services will not change week to week whether my child attends zero days or 5 days per week. Refunds are not provided for illness, even if a child is out for an entire week. I understand that charges for the first and final weeks of the school year will be charged separately from Summer Camp if my child is enrolled in summer camp. I understand this is separate from the summer enrollment fees if I plan on my child attending both the first or last few days of regular school year BASE on the same week as summer camp. I understand this is due to the administrative costs of both programs, and because both programs are considered distinct from one another.
4. I understand that the start date I select for my child on the registration will determine when my billing starts. For example, if I select that my child will start Thursday or Friday (the first two days of school), I will pay for those days even if my child does not attend. (**PLEASE SELECT YOUR CHILD’S START DATE CAREFULLY FOR THIS REASON!!).
5. I agree to be responsible for all expenses incurred for medical and/or emergency transportation costs;
6. I authorize MHABC/B.A.S.E. to transport my child for purposes such as transporting my child(ren) to a central site for school closures, or to their own school should a child be located at a site that is not their own school during closures or delays, for special activities/clubs, or to receive necessary medical attention. I recognize and acknowledge that there are certain risks of physical injury associated with being transported by bus/car by an MHABC staff member. I agree to assume the full risk of injuries that may be sustained by any minor child/ward of mine, as a result of being transported by bus/car by an MHABC staff member and all activities connected or associated therewith. I agree to waive and relinquish all claims on behalf of my minor child/ward that the minor child/ward may have against MHABC as a result of the minor child/ward’s being transported by bus/car/other vehicle by an MHABC staff member.
7. I have provided all necessary information regarding my child(ren)’s medications, allergies and medical conditions. I understand that if my child uses an Epi-pen or similar device, I MUST provide this to the B.A.S.E. administration prior to my child’s attendance at B.A.S.E.
8. I understand that I and the other parent will initially be required to present a photo I.D. when picking up my child until site staff becomes familiar with us. I understand that when a person other than myself or the other parent will be picking up my child, that individual needs to be on the authorized pickup list and must provide a picture ID in order to be permitted to pick the child up. I further understand that if I need to make a change to the authorized pickup list, I must do so in writing to PFETTIG@MHABOONECOUNTY.ORG by using the email listed on my MHABC/BASE account, preferably with a 24 hour notice. If I am unable to give a 24 hour notice of a change, I will call the MHABC office at (765) 482-3020 x100 and inform staff of the change, and also do so in writing to PFETTIG@MHABOONECOUNTY.ORG.
9. I understand that if custody or a protective order are an issue affecting who may or may not pick up my child(ren), I will IMMEDIATLY communicate this to MHABC administration at 765-482-3020 x100 and provide a copy of the relevant court order. I understand that without a court order stating otherwise, B.A.S.E. staff cannot prevent a legal parent from picking up a child. I further understand that if the child I am registering is a ward of the state, I will let the administration know by contacting the CEO at 765-482-3020 x100 or emailing him at pfettig@mhaboonecounty.org and by providing any related paperwork to administration.
10. I understand that all MHABC staff are mandated to report any signs of abuse or neglect;
11. I understand MHABC reserves the right to exclude any child from B.A.S.E. or request that a child be picked up from B.A.S.E. should the child be exhibiting symptoms related to any illness if those same symptoms would require a child be excluded or sent home according to school policies. I understand this could affect my childcare plans and that I should have backup plans in place should this occur.
12. I understand that currently parents are not allowed to enter school buildings when dropping off or picking up children for BASE.
13. I understand that I am not authorized to enter a school building unless it is through the front office, and that BASE employees CANNOT grant access to the school building to parents for any reason. Should a child need to return to the building for an item that was left in his/her classroom, a BASE employee CANNOT allow the child back into the school to retrieve that item unless the parent has the express written consent as described above.
14. I understand that my child may be denied enrollment until the registration and all pertinent acknowledgments and forms are submitted, and that submitting this form in close proximity to the time at which I need my child(ren) to begin the program could impact my child(ren)’s start date.
15. I understand my child(ren) can be denied attendance in the case of non-payment.
16. I understand that a $15/week late fee may be added each Monday as a result of an unpaid invoice.
17. I understand that I must pick my child(ren) up before 6:00 p.m. or a $5.00/minute, per child fee will accrue and I will be expected to make payment immediately to the MHABC site staff or the next business day to MHABC administrative staff.
18. I/we, the parent(s) of the registered child(ren) acknowledge that I/we are responsible for any unpaid balance for attendance fees, late fees, and finance charges associated with my/our account;
19. I/we, the parent(s) of the registered child(ren) acknowledge that I/we are responsible for attorney’s fees required for purposes of collection of any unpaid fees herein, plus any and all costs of collection, including court fees.
20. I understand MHABC’s polices and procedures related to B.A.S.E. may change depending on various factors, and that MHABC administration reserves the right to do so. If that occurs, I understand that I will receive communication regarding such change.
21. I/we agree to contact MHABC administration at (765) 482-3020 x100 with any and all questions related to this document.
I hereby authorize MHABC staff to capture, edit, and use my child’s video and/or photographic image solely for the purposes of sharing information about the MHABC youth programs and for promoting and advertising the program on the MHABC social media pages and website, in newspapers and newsletters, via e-mail and via other forms of media. In doing so, I release MHABC and its staff, representatives, board members, and agents from all claims, demands and liabilities whatsoever in connection with the above. PARENT: If you do NOT want your child’s image used in this manner, please email PFETTIG@MHABOONECOUNTY.ORG within 48 hours of submitting your registration and advise you do not want your child’s image used. Please maintain record of such communication. *Note: If the child you are registering is a ward of the State of Indiana, you MUST inform of us of this information and we will NOT post their image, even with permission.
Medical Treatment Release: I hereby consent to emergency medical treatment of my child(ren) herein registered, during MHABC Summer Camp operation hours, should I not be able to be reached, to ensure prompt treatment and prevention of undue delay. I understand such treatment, other than first aid required to be rendered immediately by an MHABC staff member, will be provided by either a licensed physician or individual trained in emergency care.
General Liability Release: I, individually, and on behalf of my minor child(ren) and our respective heirs, successors, assigns, and personal representatives, hereby release, acquit, indemnify, hold harmless and forever discharge Mental Health America of Boone County and their administration, staff, site leaders, designated volunteers, agents, board members, officers, trustees, and representatives (in their official and individual capacities) from any and all liability whatsoever for any and all damages, losses, injuries or illnesses, including death, to persons or property or both, including but not limited to any claims, demands, actions, causes of action, damages, costs, expenses and attorney’s fees, which arise out of, during or in connection with my child(ren)’s participation in MHABC’s programs.
I agree the General Liability Release above is intended to be as broad and inclusive as permitted by the laws of the State of Indiana and if any portion is held to be invalid, it is agreed the balance of the release will continue in full force and effect.
In signing the Release, I hereby acknowledge and represent that I have read this entire document, that I understand its terms and provisions, that I understand it affects my legal rights and those of my child (or children), that it is a binding agreement, and that I have signed it knowingly and voluntarily.

I agree to the Parent Agreement below
Parent Signature*
Email
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