After School Part Time 3-5 days per week. 1-2 days per week $234 $140

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1 June 15, 2015 Dear Parents/Guardians: Welcme t the Ott Family YMCA Afterschl Prgram fr schl year The fllwing frms must be filled ut and returned t the Ott Family YMCA befre yur child can attend the prgram. Ott YMCA Afterschl Prgrams will be pen n the first day f schl; July 20 in the Vail Unified Schl District and August 6 in TUSD and Academy f Tucsn. Mnthly fees include early release days and parent/teacher cnference days. Frm 1) Registratin and Billing Frm This frm prvides registratin infrmatin and explains ur payment system. In rder t be registered yu need t cmplete all sectins, select a payment ptin and prvide the necessary payment infrmatin (credit card r checking/savings accunt). Frm 2) Emergency Infrmatin and Immunizatin (EIIR) Frm The EIIR Frm is required by the AZ Dept. f Health Services fr child care licensing. We need a separate frm and a cpy f immunizatins fr each child attending. DUE TO LICENSING REGULATIONS EIIR FORMS MUST BE FILLED OUT IN THEIR ENTIRETY BEFORE A CHILD CAN BE REGISTERED IN OUR PROGRAM. Frm 3) Travel Permissin Frm This frm is required by the AZ Dept. f Health Services fr child care licensing fr the YMCA t transprt yur child frm their schl t the Ott Family YMCA. FEES: The annual, nn-refundable Prgram Membership fee is $25 per child. Our billing is based n 180 schl days and then divided int 10 equal payments. Each mnth, yu pay 1/10th f yur ttal Afterschl Prgram bill, regardless f the number f schl days actually ccurring in that mnth. Registratins submitted after the first week f the mnth will be pr-rated. The YMCA des nt give credits fr illnesses r family vacatins taken during schl days. Ott YMCA des nt have daily, weekly r hurly rates. Mnthly Fees Per Child After Schl Full Time After Schl Part Time 3-5 days per week 1-2 days per week $234 $140 There is a $20 per mnth per child discunt fr additinal children in the immediate family. Schlarships are available fr eligible families based n incme levels and need. Applicatins are available at the frnt desk f the Ott Family YMCA. Prf f incme must be prvided befre a schlarship can be granted. The Ott Family YMCA is a DES cntracted child care prvider. If yu are authrized t receive DES child care subsidies yu will need t prvide a cpy f yur Certificate f Authrizatin frm DES. Schl Break prgrams Grading Days, Intercessins, Fall/Winter/Rde/Spring Breaks are separate prgrams with separate fees. We welcme yu back if yu are a returning family, r welcme yu t ur family if yu are new. Please dn t hesitate t call if yu ever have questins r cncerns. Fr mre infrmatin please visit ur website at YMCA OF SOUTHERN ARIZONA Ott Family YMCA 401 S Prudence Rad, Tucsn AZ P F

2 OTT FAMILY YMCA AFTERSCHOOL PROGRAM REGISTRATION PARENT/GUARDIAN #1 (Payment Cntact/Primary Payer) First: Last: Hme Phne: Address: City: State: Zip: Cell Phne: Wrk Phne: PARENT/GUARDIAN #2 First: Last: Hme Phne: Address: City: State: Zip: Cell Phne: Wrk Phne: 1 st Child First Last Birthdate: First Date f Attendance: (REQUIRED) Attendance Plan (Check One) Full Time (3-5 Days/Wk) Part Time (1-2 Days/Wk) Are there any special needs t cnsider? If s, a special needs intake frm is required with registratin. 2 nd Child First Last Birthdate: n First Date f Attendance: (REQUIRED) Attendance Plan (Check One) Full Time (3-5 Days/Wk) Part Time (1-2 Days/Wk) Are there any special needs t cnsider? If s, a special needs intake frm is required with registratin. lities 1 Select District CHOOSE YOUR DISTRICT, SITE AND PROGRAM Vail Unified Schl District Tucsn Unified Schl District Academy f Tucsn 2 Select Site Cttnwd Elementary Desert Willw Elementary Octill Ridge Elementary Wheeler Elementary Blm TRANSPORT TO OTT YMCA* Bth-Fickett - TRANSPORT TO OTT YMCA* Academy f Tucsn Elementary Sycamre Elementary Dietz - TRANSPORT TO OTT YMCA* Ericksn- TRANSPORT TO OTT YMCA* If yur schl is nt listed call Select Prgram FULL TIME (3-5 days per week) M Tu W Th F $234 per mnth/per child PART TIME (1-2 days per week) M Tu W Th F $140 per mnth/per child *If yur child will be transprted frm their schl t the Ott YMCA, yu must cmplete a Travel Permissin Frm

3 Select Payment Optin: Easy Payment Optin (EFT) I hereby authrize the YMCA f Suthern Arizna t debit the accunt listed belw fr mnthly After Schl Prgram sessins fr the payment schedule. The Easy Payment Optin (EFT) is the preferred billing methd fr the After Schl Prgram. Simply prvide a credit, debit card r checking accunt and tuitin will be autmatically paid n the 5 TH r 20 TH f each mnth. Select Payment Schedule: 5 th f the mnth 20 th f the mnth Split Plan 50% n the 5 th, 50% n the 20 th Select Payment Frm: MasterCard Visa Discver American Express Payment Schedule Payment fr Payment Late Fee Due Date Assessed August August 5 August 23 September September 5 September 23 Octber Octber 5 Octber 23 Nvember Nvember 5 Nvember 23 December December 5 December 23 January January 5 January 23 February February 5 February 23 March March 5 March 23 April April 5 April 23 May May 5 May 23 Accunt N: Exp. Date: / Accunt Hlder s Signature: Date: / / OR Checking Accunt (attach vided check) Accunt N: Ruting N: Accunt Hlder s Bank Statement Billing Payment is due n the 1 st business day f each mnth, late fees assessed after the 5 th f the mnth. My cmpleted Financial Assistance Applicatin is attached. I receive DES Child Care Subsidies (must prvide Certificate f Authrizatin). I cnsent t the enrllment f the child listed abve in this facility and have been advised and read all f the plicies regarding administratin f medicatins, fees, transprtatin and the services prvided by the facility, and the Arizna Dept. f Health Services, Office f Child Care Licensing regulatins under which it perates. I have prvided infrmatin n my child s special needs (Allergies, Diet, Disabilities, and/r Medical Infrmatin) t the prvider, as may be necessary t assist the facility in prperly caring fr my child in case f an emergency. I agree t review and update this infrmatin whenever a change ccurs and at least nce every twelve mnths. The infrmatin n this frm is cmplete and accurate. I have prvided the YMCA with all f the necessary infrmatin t prperly care fr my child s needs. I must ntify the YMCA staff immediately f any changes n this frm. The YMCA s respnsibility fr my child begins when the child has reached the prgram and checked in with YMCA staff. My child is respnsible fr walking frm the bus r classrm t the YMCA prgram. It is my respnsibility t arrange fr any necessary transprtatin with the schl my child attends. It is my respnsibility t ntify the YMCA staff if my child will be absent frm the prgram. It is my respnsibility t arrange fr my child t be picked up frm the prgram befre clsing. If my child is nt picked up n time and attempts t cntact me have failed, anther authrized persn will be cntacted. If all attempts t cntact an authrized persn t pick up my child have failed, the YMCA staff will cntact Child Prtective Services and/r plice fficials fr further instructins. Shuld a persn arrive t pick up my child wh appears t be under the influence f drugs r alchl, fr the child s safety, staff may have n recurse but t cntact the plice. The YMCA is mandated, by state law, t reprt any suspected cases f child abuse r neglect t the apprpriate authrities fr investigatin. I understand and agree t the child care cnduct, transprtatin, and participatin plicies as utlined in the parent handbk. I am aware that a hard cpy f the handbk is available upn request. The YMCA has permissin t use phtgraphs and vides f my child in prmtinal materials such as brchures, ads, YMCA website, r newspaper releases. MY SIGNATURE ACKNOWLEDGES MY UNDERSTANDING OF AND AGREEMENT TO THE ABOVE. Parent/Guardian Signature Parent/Guardian Name (please print) Date

4 CDC/SGH# r name: Arizna Department f Health Services Bureau f Child Care Licensing Emergency, Infrmatin and Immunizatin Recrd Card Child s Date Enrlled: Updated: Hme Address (#, Street, City, State, Zip Cde): Date Disenrlled: Hme Phne: Date f Birth: Sex: male female Mther r Guardian Hme Address (#, Street, City, State, Zip Cde): Cell Phne (ptinal): Father r Guardian Hme Address (#, Street, City, State, Zip Cde): Cell Phne (ptinal): I authrize the fllwing individuals t cllect my child frm the facility in case f emergency r if I cannt be cntacted: (Pursuant t R B, at least tw cntact persns are required.) If Medical care is necessary, call: Health Care Prvider* *A Health Care Prvider is a physician, physician assistant r registered nurse practitiner. In case f injury r sudden illness, I request that this individual be called first: The fllwing individual(s) may NOT remve my child frm the facility: Name(s): Custdy papers have been prvided and are n file at the facility. yes n Telephne Authrizatin Cde (ptinal):

5 Immunizatin Infrmatin (A licensee shall attach an enrlled child's written immunizatin recrd r exemptin affidavit t the enrlled child's Emergency, Infrmatin and Immunizatin Recrd card.) Fr infrmatin regarding current immunizatin requirements g t: r cntact the Arizna Immunizatin Prgram Office at (602) One f these items must accmpany the EIIR card at all times: Cpy f current fficial dcumented immunizatin recrd attached Religius Beliefs exemptin frm signed by parent/guardian attached Medical Exemptin frm signed by physician and parent/guardian attached Signed Labratry Prf f Immunity frm attached Ntificatin f immunizatins needed sent t Parent(s) r Guardian(s): Updated immunizatins received and attached: m /day/ yr m /day/ yr m /day /yr m /day/ yr m /day/ yr m /day /yr Medical Infrmatin Is child allergic t fd r ther substances? N Yes If yes, describe symptms, name fds r substances t be avided, and the prcedure t fllw if reactin ccurs: Is child usually susceptible t infectins and if s, what precautins need t be taken? N Yes If yes, list precautins: Is child subject t cnvulsins and what shuld be ur prcedure if ne ccurs? N Yes If yes, specify prcedure: Is there any physical cnditin that we shuld be aware f and what precautins shuld be taken (heart truble, ft prblem, hearing impairment, hernia, etc.)? If yes, list precautins: N Yes Additinal cmments: Other special instructins: This Emergency Infrmatin and Immunizatin Recrd Card is accurate and cmplete, frnt and back, and was prvided by: Parent/Guardian PRINTED SIGNED DATE: G:\Frms\Emergency Infrmatin and Immunizatin Recrd Card (9/11) (4/14)

6 Arizna Department f Health Services Bureau f Child Care Licensing Travel Permissin Frm R A.1.a-e R A.1 Child's name: PERMISSION t transprt a child frm the Facility r Grup Hme My child has permissin t be drpped ff at r picked up frm his/her schl, bus stp r anther lcatin. Name f lcatin where the child will be drpped ff and/r picked up: *Beginning date: *End date: *The time perid is nt t exceed 12 mnths, during which permissin is given fr ther trips away frm the facility r grup hme. Time(s) t be drpped ff and/r picked up: Special Instructins: Parent/Guardian Signature: Date: R B.1. - Maintain a cpy f the written permissin fr 12 mnths after the date f the last trip. R A.2 - Maintain a cpy f the written permissin n facility premises fr 12 mnths after the date n the written permissin. G:\Frms\Travel Permissin frm (10/11)