YSPP Registration

School Year*

Select the school year that your child will be attending YSPP.

Parent Name #1*

First Last

Parent #1 Email*

This email will be used for communication with YSPP staff.

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

This email will be used for communication with YSPP staff.

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

Primary emergency medical contact (OTHER THAN PARENTS ABOVE)*

Primary emergency medical contact phone*

Primary emergency medical contact relationship to student(s)*

Student Enrollment*

How many students do you want to enroll in YSPP?

Student #1 Name*

First Middle Last

Student #1 resides with?*

Student #1 Gender*

Student #1 Ethnicity*

Student #1 language spoken if English is not primary language*

Student #1 Birthday*

Student #1 Preferred School (Perry-Worth Registration Closed)*

You do NOT have to live within the residential district for the elementary school that you choose, but please be aware enrollment in a particular YSPP classroom location IN NO WAY GUARANTEES open enrollment acceptance in school for Kindergarten or beyond.

Has Student #1 or a sibling ever attended B.A.S.E., Summer Camp, or YSPP in the past?*

Yes
No

Will Student #1 need to attend B.A.S.E.?*

Please note regular B.A.S.E. (morning and afternoon) is free of charge for students enrolled in YSPP. However, if student attends during breaks or other days of full-day care, fees will apply. Separate B.A.S.E. Registration is required to attend.

For Student #1, you selected "Yes - 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.)

Does Student #1 currently receive special educational services or has received notification of eligibility for special educational services?*

Student #1 Start Date*

What date will your Student #1 be starting YSPP?

Student #1 Physician*

Student #1 Physician Phone*

Student #1 Physician Address*

Street Address Address Line 2 City State ZIP Code

Student #1 Allergies*

Type NA if none.

Student #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.

Student #1 Behavior Issues or Concerns*

Type NA if none.

Student #2 Name*

First Middle Last

Student #2 resides with?*

Student #2 Gender*

Student #2 Ethnicity*

Student #2 language spoken if English is not primary language*

Student #2 Birthday*

Has Student #2 or a sibling ever attended B.A.S.E., Summer Camp, or YSPP in the past?*

Yes
No

Student #2 Preferred School (Perry-Worth Registration Closed)*

You do NOT have to live within the residential district for the elementary school that you choose, but please be aware enrollment in a particular YSPP classroom location IN NO WAY GUARANTEES open enrollment acceptance in school for Kindergarten or beyond.

Will Student #2 need to attend B.A.S.E.?*

Please note regular B.A.S.E. (morning and afternoon) is free of charge for students enrolled in YSPP. However, if student attends during breaks or other days of full-day care, fees will apply. Separate B.A.S.E. Registration is required to attend.

For Student #2, you selected "Yes - 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.)

Does Student #2 currently receive special educational services or has received notification of eligibility for special educational services?*

Student #2 Start Date*

What date will your Student #2 be starting YSPP?

Student #2 Physician*

Student #2 Physician Phone*

Student #2 Physician Address*

Street Address Address Line 2 City State ZIP Code

Student #2 Allergies*

Type NA if none.

Student #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.

Student #2 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*

I agree to the Parent Agreement below

YOUNG SCHOLARS PREPARATORY PRE-K
PARENT AGREEMENT
***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 the current school year, I agree to the following with regard to my child’s enrollment in the Y.S.P.P. program:
1. I acknowledge that I am committing my child(ren) to enrollment in a 36-week pre-K program and will adhere to the chosen payment schedule for the length of the school year. If unforeseen circumstances should occur which would require my child(ren)’s early withdrawal, I acknowledge that one installment payment will be due as a penalty for such withdrawal. This penalty will be in addition to any monies due and owing for regular attendance.
2. I understand that enrollment in a particular Y.S.P.P location does not guarantee in any way that my child will be approved for the open enrollment process through their school corporation and be able to attend that school for the following year. I understand the MHABC/Y.S.P.P. and the school corporation are two different entities.
3. I agree to be responsible for all expenses incurred for medical and/or emergency transportation costs;
4. I agree that an authorized adult will pick up my child each day from YSPP (or from BASE if child(ren) attend(s) afternoon B.A.S.E.);
5. I agree to sign an authorization of release of information regarding my child’s needs at school;
6. I understand that all MHABC , YSPP, and BASE personnel are mandated to report any signs of abuse or neglect;
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 MHABC/YSPP administration prior to my child’s attendance at YSPP.
8. I understand that I and the other parent may 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/YSPP 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 will communicate with my child’s teacher regarding proper car rider procedures if my child will not be attending BASE after school.
10. 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, MHABC/YSPP 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.
11. I understand that all MHABC staff are mandated to report any signs of abuse or neglect;
12. I understand MHABC reserves the right to exclude any child from YSPP or request that a child be picked up from YSPP should the child be exhibiting symptoms of illness, and where those symptoms would require exclusion under school policies; I understand this could affect my childcare plans and that I should have backup plans in place should this occur.
13. I understand that currently parents are not permitted to enter school buildings when dropping off or picking up children for YSPP, and that I should first call the MHABC office at 482-3020 x100 if I need to access the school for any reason.
14. I understand that I am only authorized to enter a school building through the front office, and that BASE/YSPP 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/YSPP employee CANNOT allow the child back into the school to retrieve that item unless the parent has the express written consent as described above.
15. I understand that my child may be denied enrollment until this registration is submitted and processed;
16. I understand my child(ren) can be denied attendance in the case of non-payment;
17. I understand that a late fee of $40.00 may be added each month as a result of an unpaid or late-paid invoice(s), and that a 2% compounded interest rate will be assessed monthly on balances carried more than 30 days;
18. I understand I must pick up my child(ren) promptly at school release time (or have another approved adult do so, or make arrangements for the child to attend BASE), or a $5.00 per minute, per child fee will accrue and will be expected to be paid immediately to the MHABC office;
19. I/we, the parent(s) of the registered child/ren, acknowledge that I/we are responsible for any unpaid balance of Y.S.P.P. fees, late fees, and finance charges associated with my/our account;
20. 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 any unpaid fees herein, plus any and all costs of collection, including court fees.

Media release: I hereby authorize MHABC and YSPP staff to capture, edit and use my child’s video and photographic image solely for the purposes of sharing information about the YSPP program and for promoting and advertising the program on the YSPP and MHABC social media pages and website, in newspapers, newsletters, via email and other forms of media. In doing so, I release MHABC and YSPP staff from all claims, demands, and liability whatsoever in connection with the above. PARENT: IF YOU DO NOT WANT YOUR CHILD’S IMAGE USED IN THE MANNER DESCRIBED ABOVE, PLEASE CONTACT MHABC IN WRITING AT PFETTIG@MHABOONECOUNTY.ORG WITHIN 48 HOURS OF SUBMITTING THIS 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.

Transportation release: I authorize MHABC/Y.S.P.P 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, for field trips, 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.

Medical Treatment Release. I hereby consent to emergency medical treatment of my child(ren), herein registered, during BASE operation hours, should I not be able to be reached, to assure prompt treatment and prevention of undue delay. I understand such treatment, other than first aid required to be rendered immediately by a BASE staff person, will be provided by either a licensed physician or trained emergency care technician.
General Release of Liability: I, individually, and on behalf of my minor child (or children) and our respective heirs, successors, assigns and personal representatives, hereby release, acquit 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’s (or children’s) participation in the aforementioned activities, including but not limited to any damages, losses, illnesses or injuries to persons or property or both, which may be sustained or suffered by my child or any person in connection with my child’s (or children’s) association with, or participation in, activities at, sponsored by, or arising out of MHABC activities.

Parent Signature*

Name

This field is for validation purposes and should be left unchanged.

YSPP is currently full at both Hattie B. Stokes and Perry-Worth for the 2023-24 school year.

YSPP is currently full at Perry-Worth for the 2024-25 school year, but spots ARE still available at Hattie B. Stokes. You may inquire about being placed on the waiting list for Perry-Worth by calling our office (765) 482-3020. As a reminder, your child must be 4 years old in order to begin YSPP.

Young Scholars Preparatory Pre-K Registration