Buchanan YMCA New Traditions Elementary School

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1 Buchanan YMCA New Traditions Elementary School PROGRAM! I am enrolling my child in MONTHLY care for before and/or after school.! I am enrolling my child in DROP-IN care for before and/or after school. OFFICE USE ONLY Received: Enrolled: Waitlist: APPLICANT INFORMATION Student Name: Entering Grade ( School Year): Gender: Date of Birth: Are you registering online?! YES Complete pages 3-10! NO Please proceed and complete the entire application Home Address: Street City Zip Code Parent/Guardian Parent/Guardian #1 (emergency contact & authorized to pick-up child) Please list any allergies your child has: Name: Primary Phone: Secondary Phone: Please list medications your child takes: Parent/Guardian #2 (emergency contact & authorized to pick-up child) Name: Primary Phone: Is there anything else we should know about your child? Additional authorized pick-ups/emergency contacts: Pick-Up #1 Name: Pick-Up #1 Phone: Pick-Up #2 Name: Pick-Up #2 Phone: Pick-Up #3 Name: Pick-Up #3 Phone: Pick-Up #4 Name: Pick-Up #4 Phone: Family Doctor: Doctor s Phone: Preferred Hospital: Students entering 5th grade and up may sign out and leave program on his/her own with your consent. Do you approve this? Yes No If yes, what time is your student allowed leave program? PM 1

2 SCHEDULES & FEES MONTHLY BEFORE/AFTER SCHOOL SELECT SELECT SCHEDULE Applicants must have either Facility Membership (access to YMCA gym facilities and programs) or sign up as a Community Participant (access to YMCA programs only). If you are interested in a Facility Membership, please contact our membership department at for more information or visit BEFORE SCHOOL Rates with FACILITY Membership Monthly Fee Prorate (August & December Fee) 3 days/week $140 $70 5 days/week $175 $87 Rates as COMMUNITY PARTICIPANTS BEFORE SCHOOL Monthly Fee Prorate (August & December Fee) 3 days/week $ days/week $195 $97 AFTER SCHOOL Monthly Fee Prorate (August & December Fee) AFTER SCHOOL Monthly Fee Prorate (August & December Fee) 3 days/week $277 $138 5 days/week $380 $190 3 days/week $308 $159 5 days/week $422 $211 Please select the days your student will attend program: Before School: Monday Tuesday Wednesday Thursday Friday After School: Monday Tuesday Wednesday Thursday Friday SIBLINGS: We offer a 20% discount on monthly child care fees for siblings. The discount will be applied towards the older sibling. FINANCIAL ASSISTANCE: We offer financial assistance to qualifying families. If you are interested in applying, please complete a financial assistance application and submit with your income verification and registration packet. Please refer to financial assistance application for acceptable income verification documents. We will notify of your financial assistance award by . DROP-IN BEFORE/AFTER SCHOOL SELECT SELECT SCHEDULE Drop-in Rates Same for Facility members and Community Participants Type of Care Daily Fee Before School $20 After School $25 DROP ROP-IN POLICY: Parents who would like to utilize drop-in care must provide at least 24 hours advance notice by speaking directly with the Site Director, or by ing your request to BuchananReg@ymcasf.org This registration packet must be submitted prior to the child s first day of drop-in care with a payment method on file. 2

3 BILLING POLICIES & PAYMENT SELECT ONE By signing below, I acknowledge and agree to the following: BILLING POLICIES MONTHLY BEFORE/AFTER SCHOOL All child care payments are set up as automatic drafts by credit card or bank account transfer. Parents must provide a payment method either online or in person at Buchanan YMCA as part of the registration process. Child care payments are based on the selected schedule. Student s attendance and/or absence does not change the monthly fees due. Child care payments are due 10 days before the first of the month for the following month. A $15 fee will be applied to any late and/or returned payments. Parents must update billing information if there are any changes to their account, including credit card replacement and new expiration dates. This can be done online or in person at Buchanan YMCA. Parents will be contacted regarding any declined payments from their account. It is the parents responsibility to pay for child care by the 1st of the month. If payment is not received by the 10th, child care will be terminated. A 30 day written or notice to BuchananReg@ymcasf.org is required for program cancellation, and a 14 day notice is required for schedule changes. It is the parent s responsibility to notify Buchanan YMCA of program cancellation and/ or schedule changes. Withdrawal of student from program is not considered as notice of cancellation and will not terminate child care payments. Parent/Guardian Name PAYMENT DUE Signature Date $ Deposit This is the August fee and is due at registration. Deposit is non-refundable refundable. PAYMENT METHOD I have an existing payment method on file with the YMCA. Please charge my: Credit card EFT I do NOT have a payment on file and will submit my application in person at Buchanan YMCA. By signing below, I acknowledge and agree to the following: BILLING POLICIES DROP DROP-IN BEFORE/AFTER SCHOOL Parents must provide a credit card or bank account to be automatically charged throughout the school year for drop-in care. Drop-in fees will be charged every Friday during the school year for any days your child attended that week. Parents must update billing information if there are any changes to their account, including credit card replacement and new expiration dates. This can be done online or at the Buchanan YMCA front desk. Parents will be contacted regarding any declined credit card or checking account payments and are expected to provide a new payment method for payment. Future drop-in care cannot be utilized until all current balances are paid in full. Parent/Guardian Name Signature Date PAYMENT METHOD I already have payment method on file with the YMCA. Please charge my: Credit card EFT I do NOT have a payment on file and will submit my application in person at Buchanan YMCA. 3

4 STUDENT CONTRACT Parent/Guardian: Please read this over carefully with your student. I, (student name), understand and agree to meet the following requirements: I will report to program immediately after school and sign in. I will follow school rules and directions from staff members. I will be respectful to the adults and other students. I will not engage in bullying, name calling, or any inappropriate interactions with peers. I understand that this is not tolerated in the After School Program. I will use words to solve conflicts, or ask an adult for help. I will never use violence to solve a problem. I will leave electronics at home and get permission from a staff member before using my cell phone. I will take care of our school building and our equipment. I will clean up after myself. I understand that if I break these rules: I will receive a warning. If I continue to break the rules or if the incident is serious, my parent/guardian will be contacted. If I fight in the After School Program, I will participate in Restorative Practices. Depending on the severity of the situation, I may be suspended from program. After the 3rd warning, a restorative meeting will be held. Depending on the severity of the situation, I may be on a behavioral contract or suspended from program. I understand that I must sign this contract in order to be admitted into the program. I also understand that by signing this contract I am agreeing to adhere to the rules. Student Signature: Date: ACKNOWLEDGEMENT I understand that Buchanan YMCA assumes no financial obligation for medical treatment, but in the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the director to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for my student as named on this application. I also authorize Buchanan YMCA to obtain a copy of my student s immunization records from the school in the event this information is necessary for medical treatment. As the parent/guardian, I have read and agree with the Before/After School Program rules and policies. I give permission for my child to attend offsite field trips organized by the program and to use transportation arranged for the purpose of field trips (chartered bus, MUNI, or by foot). I also give permission for Child Care Licensing to access my student s records for purposes of reviewing the center s license. Parent/Guardian Signature: Date: ABOUT YOUR STUDENT This section asks for information that is required by our funders. The below information will in no way determine your student s status in the program or be used for any purpose other than program evaluation. Student Race/Ethnicity (select one): African American Black-Other (specify): Asian-Chinese Asian-Filipino Asian-Indian Asian-Japanese Asian-Korean Asian-Laotian Asian-Thai Asian-Vietnamese Asian-Other (specify): Hispanic/Latino-Mexican American Hispanic/Latino-Central American Hispanic/Latino-South American Hispanic/Latino-Caribbean Hispanic/Latino-Other (specify): Middle Eastern-Arab Middle Eastern-Iranian Middle Eastern-Other (specify): Native American Native Alaskan Pacific Islander-Guamanian Pacific Islander-Hawaiian Pacific Islander-Tongan Pacific Islander-Samoan Pacific Islander-Other (specify): White Multiracial/Multiethnic Other (specify): Declined to state Home Language (select one): English Spanish Cantonese Japanese Khmer/Cambodian Korean Laotian Other (specify): Mandarin Samoan Tagalog Toishanese Vietnamese Arabic Russian American Sign Language Student English Fluency (select one): Fluent Somewhat Fluent Not Fluent 4

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6 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative CHILD S NAME LAST MIDDLE FIRST ADDRESS NUMBER STREET CITY STATE ZIP SEX TELEPHONE BIRTHDATE FATHER S/GUARDIAN S/FATHER S DOMESTIC PARTNER S NAME LAST MIDDLE FIRST HOME ADDRESS NUMBER STREET CITY STATE ZIP MOTHER S/GUARDIAN S/MOTHER S DOMESTIC PARTNER S NAME LAST MIDDLE FIRST HOME ADDRESS NUMBER STREET CITY STATE ZIP PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST HOME TELEPHONE ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY BUSINESS TELEPHONE HOME TELEPHONE BUSINESS TELEPHONE HOME TELEPHONE BUSINESS TELEPHONE NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER DENTIST ADDRESS MEDICAL PLAN AND NUMBER IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? TELEPHONE TELEPHONE CALL EMERGENCY HOSPITAL OTHER EXPLAIN: NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) NAME RELATIONSHIP TIME CHILD WILL BE CALLED FOR SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE DATE OF ADMISSION TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE DATE LEFT LIC 700 (8/08)(CONFIDENTIAL)

7 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING CHILD S PREADMISSION HEALTH HISTORY PARENT S REPORT CHILD S NAME SEX BIRTH DATE FATHER S/FATHER S DOMESTIC PARTNER S NAME DOES FATHER/FATHER S DOMESTIC PARTNER LIVE IN HOME WITH CHILD? MOTHER S/MOTHER S DOMESTIC PARTNER S NAME DOES MOTHER/MOTHER S DOMESTIC PARTNER LIVE IN HOME WITH CHILD? IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN? DATE OF LAST PHYSICAL/MEDICAL EXAMINATION DEVELOPMENTAL HISTORY ( For infants and preschool-age children only) WALKED AT MONTHS SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS BEGAN TALKING AT MONTHS PAST ILLNESSES Check illnesses that child has had and specify approximate dates of illnesses: DATES DATES Chicken Pox Diabetes Asthma Epilepsy Rheumatic Fever Whooping cough Hay Fever Mumps TOILET TRAINING STARTED AT Poliomyelitis Ten-Day Measles (Rubeola) Three-Day Measles (Rubella) MONTHS DATES DOES CHILD HAVE FREQUENT COLDS? HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF DAILY ROUTINES (For infants and preschool-age children only) WHAT TIME DOES CHILD GET UP? WHAT TIME DOES CHILD GO TO BED? DOES CHILD SLEEP WELL? DOES CHILD SLEEP DURING THE DAY? WHEN? HOW LONG? DIET PATTERN: (What does child usually eat for these meals?) BREAKFAST LUNCH DINNER WHAT ARE USUAL EATING HOURS? BREAKFAST LUNCH DINNER ANY FOOD DISLIKES? ANY EATING PROBLEMS? IS CHILD TOILET TRAINED? WORD USED FOR BOWEL MOVEMENT IF YES, AT WHAT STAGE: ARE BOWEL MOVEMENTS REGULAR? WORD USED FOR URINATION WHAT IS USUAL TIME? PARENT S EVALUATION OF CHILD S HEALTH IS CHILD PRESENTLY UNDER A DOCTOR S CARE? DOES CHILD USE ANY SPECIAL DEVICE(S): PARENT S EVALUATION OF CHILD S PERSONALITY IF YES, NAME OF DOCTOR: IF YES, WHAT KIND: DOES CHILD TAKE PRESCRIBED MEDICATION(S)? DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME? IF YES, WHAT KIND AND ANY SIDE EFFECTS: IF YES, WHAT KIND: HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN? HAS THE CHILD HAD GROUP PLAY EXPERIENCES? DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.) WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL? REASON FOR REQUESTING DAY CARE PLACEMENT PARENT S SIGNATURE DATE LIC 702 (8/08) (CONFIDENTIAL)

8 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CONSENT FOR EMERGENCY MEDICAL TREATMENT- Child Care Centers Or Family Child Care Homes AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR. THIS CARE MAY BE GIVEN UNDER NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE LIC 627 (9/08) (CONFIDENTIAL)

9 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES PERSONAL RIGHTS Child Care Centers Personal Rights, See Section for waiver conditions applicable to Child Care Centers. (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME ADDRESS CITY ZIP CODE AREA CODE/TELEPHONE NUMBER DETACH HERE TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08)

10 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHILD CARE CENTER NOTIFICATION OF PARENTS RIGHTS PARENTS RIGHTS As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form. NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE. For the Department of Justice Registered Sex Offender database, go to LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents) ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS RIGHTS (Parent/Authorized Representative Signature Required) I, the parent/authorized representative of, have received a copy of the CHILD CARE CENTER NOTIFICATION OF PARENTS RIGHTS and the CAREGIVER BACKGROUND CHECK PROCESS form from the licensee. Name of Child Care Center Signature (Parent/Authorized Representative) Date NOTE: This Acknowledgement must be kept in child s file and a copy of the Notification given to parent/authorized representative. For the Department of Justice Registered Sex Offender database go to LIC 995 (9/08)