Community Outreach Coalition
Young Achievers Christian Academy
*Print Option below*
Date of Birth
Work/Cell Phone Number
Person(s) Authorized to Pick up
List Allergies/Medical Problems or Dietary restrictions
Please list medications and reasons taken:
I authorize my child to be transported to and from YACA for field trips (Preschool and School Age) and to and from my child’s school (School Age only).
Parents will be notified of all field trips prior to the event taking place.
I release all liability from the Community Outreach Coalition and all its programs in case of a injury or damage of property/equipment. I will take responsibility for injury or damages caused by my child during the programs hosted by the Community Outreach Coalition.
I authorize YACA to take photographs of my child for class projects, school displays and/or publicity
Permission for Emergency Medical Treatment
I authorize YACA to obtain all necessary medical care for my child in the event of sickness or injury.
Please scan your child's birth certificate and shot record and send them to email@example.com
Which program are you registering for?
Financial Assistance( Apply through drop down tab)
After School Enrichment
Before/After School Enrichment
Upload your child's Birth Certificate
Max file size: 20MB
Name of School Child Attends
Upload your child's shot record
Max file size: 20MB
To ensure your child’s place in our program, all payments must be made in accordance with this financial agreement. Tuition is due weekly. Payments must be paid the Friday before the week your child will attend. If the payment is not met by the Friday prior, your child will not be allowed on the premises. The child is not the responsibility of the Community Outreach Coalition Inc. if the service for that week is not paid. If the child is dropped off without payment and without a sign-in signature of the parent or guardian the Department of Social Services will be called. Multiple weeks may be paid in advance.
Parents must give two weeks’ notice prior to withdrawal of their child (if notice is not given, you will still be responsible for tuition and any other fees).
Immediate suspension or termination can occur for excessive behavioral concerns/issues (fighting, bullying, profanity and being disrespectful to others). These types of behaviors will not be tolerated. Also, suspension or termination can occur for violations of the financial agreement, such as continued balances, non-payment, etc
I understand all of the terms and conditions above and hereby agree to abide by these terms while my child is in the
programs offered by the Community Outreach Coalition.
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