Registration for School Year

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1 For staff use only: Date received Registration for School Year Site Received by PLCS Verified Forms can be ed to: Faxed to: (call office to verify received) Mailed or dropped off in person to our office at: 242 W. Grant St., Papillion, NE All Kids Club enrollees must complete form and submit registration/activity fee payment to reserve a spot in the summer and/or school year program. All registrations are processed on a first come, first serve basis and are subject to availability. Any changes of status must be sent on a Change of Status form at least 2 weeks prior to changes, including withdrawing from either program. Refunds will not be issued if these guidelines are not met. *Parent/Guardians listed on this form will have access to billing/payment/account information. I have used/or currently use Kids Club services at the following school(s): Child s First and Last Name Club 56 Birth Date Child s First and Last Name Club 56 Birth Date Child s First and Last Name Club 56 Birth Date Child s First and Last Name Club 56 Birth Date Address City State Zip *Parent/Guardian First and Last Name *Parent/Guardian First and Last Name Home Phone Cell Phone Work Phone Cell Phone Provider Company Home Phone Cell Phone Work Phone Cell Phone Provider Company By providing the cell phone provider you authorize Kids Club to send urgent alerts via text. Parent/Guardian Address Parent/Guardian Address TITLE 20 Recipients Only I am currently receiving assistance through Title 20. I understand that I must have authorization approved by DHHS prior to enrolling. I also understand that I am responsible for the full tuition if Title 20 expires. I understand that I am responsible for registration fees and summer activity fees if I do not have an authorization in place prior to registration. I understand copays will be deducted on the last deduction date of the month following care. See deduction calendar for dates. Page 1 of 2 Updated 07/2018

2 Kids Club School Year Registration Kids Club school year program runs from Aug 14, 2018 May 23, 2019 Registering for School Year (must check one) No Yes - If yes, please complete areas below. Aug 14, 2018 May 23, 2019 Site Attending: Annual School Year Registration Fee $25.00 per child x = $ *A non-refundable activity fee is due per child at time of registration. All activity fees that are not paid at the time of enrollment will be deducted from your required current TE account at the time your registration is processed. A $12.50 per child reinstatement fee will be assessed if withdrawing and returning within the same session. Parent/Guardian is a PLCS Employee Payment Agreement School year tuition payments will be deducted bi-weekly from your required Tuition Express (TE) account. See deduction calendar for payment deduction dates. Choose only one enrollment option: Both AM & PM care includes all Out of School Days & Snow Days: $ per child AM only care: $92.50 per child* PM only care: $ per child* Only Out of School Days & Snow Days: $33 per day/per child * The AM only or PM only care programs will be billed for Out of School Days and Snow Days attended at a separate rate of $33/day. Out of school days will be billed on the deduction date following the date of the Out of School day. Snow days will be billed on the next most reasonable deduction date. Sign-up is required in advance for all options for Out of School Day care. Please retain copies of all Kids Club registration paperwork for your reference as these are your enrollment and payment agreements. Parent/Guardian Signature: (Signature required) Page 2 of 2

3 Connecting Great Schools to a Caring Community. Registration Form All information contained in this document is required by Nebraska Department of Health & Human Services, Division of Public Health, Licensure Unit, and Children s Services Licensing Program. Please complete all information. Enrollment Date: Withdraw Date: Pre-Registration Checklist Before registering your child into the Kids Club program please review the following checklist. By initialing you are stating that you understand and agree to each statement. I understand that Kids Club is a group childcare program and does not provide individual childcare. My child is between the grades of Kindergarten and 6 th grade. My child is toilet trained (non-diapered) & able to constantly meet all toileting needs independently. My child is able to move independently to and from the toilet in the restroom. My child has independent eating skills. My child has independent dressing skills (remove and/or put on coat or boots, re-dress self after restroom use). My child has independent hygiene skills (washing hands or face). My child can adhere to the discipline policy and the indoor/outdoor rules My child does NOT meet the above requirements and I am requesting an individualized assessment Revised 1/2018

4 Child Information: Name: Last First Middle Birth Date: Age: Sex: Site: Current Grade Level: Are there any activities in which your child may not participate? Yes No If yes, please explain: Parent/Guardian Information: Mother s Name: Father s Name: Address: Address: City, State, Zip City, State, Zip: Phone: Home: Phone: Home: Cell: Cell: Employer: Employer: Work Phone: Work Phone: Employer Address: Employer Address: Child resides with: Court Documentation is required for proof of non-parental rights Emergency Contacts & Authorized Pick-up Please list at least two, other than parent(s) or guardian(s). Addresses are required for emergency contacts. Name: Home# Cell# Relation Address: Name: Home# Cell# Relation Address: Name: Home# Cell# Relation Address: Revised 1/2018

5 Family Physician: Family Dentist: In accordance with Nebraska State Law (3) and LB546, all students entering school are required to have all immunizations up to date. Kids Club is a separate entity from the schools. We will need a copy of immunization records for each child. PLEASE ATTACH A COPY OF YOUR CHILD S MOST RECENT IMMUNIZATION RECORDS. Medical Conditions/Special Accommodations My child has / does not have (circle one) a medical condition, special need, special accommodation or medication. Current health status or any health problems caregiver should know: Medication, if any: (Please complete separate Medication Administration Form and return with medication to your Site Director.) List any allergies and/or intolerance to food, insect bites, or stings, or other factors that result in a medical reaction. Please give clear instructions in the event of an exposure of the factor: Special Concerns: (Glasses, Hearing Aid, Crutches, etc.) In the event I cannot be reached to make arrangements for a medical emergency, I hereby give my consent to Kids Club to contact Doctor (name of physician) (phone) (address) (city) and, if necessary, take my child to the following doctor(s), clinics, or hospital. Signature of Parent/Guardian Date Permission Statements: (Please Read, Initial and Sign) I give permission for my child to participate in supervised activities away from the Kids Club site. I understand that I will be given a schedule in advance of any activities off the premises. I give permission for Kids Club to transport or arrange for transportation of my child. I understand staff will abide by Nebraska laws at all times. I give permission for my child to be photographed for educational or promotional purposes for Kids Club and Papillion-La Vista Schools Foundation publicity. I understand I must provide sunscreen. I give permission for Kids Club Staff to apply sunscreen on my child. Signature of Parent/Guardian Date Revised 1/2018

6 Additional Statements: Please read and initial the following statements. I understand that I am required to give a 2 week notice for any change in status of my enrollment, via a Status Change Form to either change enrollment options or withdrawal my child. Refunds will not be issued if this procedure is not followed. I agree to the payment terms based on my child s registered enrollment category. I further agree to pay for childcare through the required Tuition Express automatic payment program with ACH or credit card. Tuition will be deducted from my account on a bi-weekly cycle. I also understand that tuition is based on enrollment, not attendance. I have received a copy of my current registration form / payment agreement. The deduction calendar can also be found on the Papillion La Vista Schools website. I understand that my deduction amount will remain the same if Kids Club is closed or school is not in session. I understand Out-of-School Days and Snow Days for AM and PM Only billing options, will be in addition to my regular deduction amount. I also understand I will be billed for these days when I pre-register my child to attend regardless of actual attendance. I hereby agree to accept full responsibility for fees and tuition for my child to attend the Papillion-La Vista Kids Club program. In the event that Kids Club receives notification from your financial institution that your tuition deduction is being returned for any reason, a $30.00 fee will be assessed to your account. If Kids Club receives notification that a payment is being returned, you will be responsible to make the payment (cash/credit card/money order) immediately. If payment is not paid at the Foundation Office, the amount will be added to your next scheduled deduction. If two consecutive payments are returned, your child may be removed from the program until your account is paid in full. I understand that Kids Club is owned and operated by Papillion-La Vista Schools Foundation. I understand that as a benefit for your child s care, information may be shared between 2 organizations; Papillion-La Vista Schools Foundation and Papillion La Vista Community Schools. I acknowledge that I will read the Parent Handbook. A copy is located on the Papillion-La Vista Foundation website. A paper copy can be provided upon request. I understand I may be required to provide a sack lunch for my child Title 20: I understand in the event I receive assistance through Title 20, a Tuition Express form is required to be on file with the office and all payment policies apply. Title 20 must follow the same registration guidelines. Title 20 may pay a ONE-TIME registration fee, and will pay summer activity fees annually if you request it from them. Any registration fee thereafter is the responsibility of the parent/guardian. Parent/guardian is responsible for all co-pays, if applicable. All co-pays will be deducted monthly. The payment is deducted the last deduction date of the month following care. By signing this form I agree to abide by all of the policies and procedures for the Papillion-La Vista Schools Foundation Kids Club Program. Parent/Guardian Signature Relationship to Child Date Revised 1/2018

7 Automated Payment Processing Safe Convenient Easy We are excited to offer the safety, convenience and ease of Tuition Express a payment processing system that allows secure, on-time tuition and fee payments to be made from either your bank account or credit card. ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD This form is required for registration. COMPLETE ONE SECTION ONLY SECTION A (Credit Card) - Visa, Master Card, and Discover Child's School (initial) I (we) hereby authorize Papillion-La Vista Schools Foundation Kids Club to initiate credit card charges to the below-referenced credit card account (Section A) OR, initiate debit entries to my (our) checking or savings account, indicated below (Section B). To properly affect the cancellation of this agreement I (we) are required to give 10 days written notice. Credit union members: please contact your credit union to verify account and routing numbers for your automatic payments. It is my (our) responsibility to update my (our) card/account information immediately if there are changes. A $30 fee will be charged to my (our) account if not updated at least 72 hours in advance of a deduction. Cardholder Name Phone # Cardholder Address City State Zip Credit or Debit Card Number Expiration Date Cardholder Signature Date SECTION B (Bank Account) Your Name Phone # Address City State Zip Bank or Credit Union Name Bank or Credit Union Address City State Zip Routing Transit Number (see sample below) Account Number (see sample below) Checking Savings Authorized Signature Date SAMPLE CHECK 242 W. Grant St. Papillion, NE plvschoolsfoundation.org (office) (fax)

8 Receipt of Parent Information Brochure Child Care Program Name: Enrolled Child(ren) s names: Parent/Guardian Names: Parent/Guardian Signature; Date: Sign, date and return to your Child Care provider before your child(ren) begin care. Your Child Care provider must retain this Receipt on site for review. Contact Information for Child Care Licensing The following information may be of help in gathering information about Child Care Licensing and includes a mailing address, phone numbers and websites. For questions regarding Child Care Licensing: (toll free) Child Care Licensing Department of Health and Human Services PO Box Lincoln, NE dhhs.ne.gov/publichealth/pages/crl_childcare_ childcareindex.aspx Review or request a roster of Licensed Child Care Providers: dhhs.ne.gov/publichealth/documents/ ChildCareRoster.pdf Phone: Additional Resources These resources may be of additional interest to you. Child Abuse/Neglect Hotline Child and Adult Care Food Program: Nebraska Dept of Health and Human Services dhhs.ne.gov Child Care Subsidy (ACCESS Nebraska) accessnebraska.ne.gov dhhs.ne.gov/pages/reg_t391.aspx Phone: Review or request a copy of Child Care Licensing Regulations: Request copies of Compliance Reviews, the results of Licensing visits to the provider: National Children s Coalition teenzeen.org Child Care Licensing dhhs.ne.gov/publichealth/pages/crl_childcare_ childcareindex.aspx State of Nebraska nebraska.gov Nebraska Immunization dhhs.ne.gov/publichealth/pages/immunization_ index.aspx Douglas, Sarpy, Washington, Cass County All other counties Review Negative Actions: dhhs.ne.gov/publichealth/pages/crl_ monthlydisciplinereports.aspx Make a complaint: dhhs.ne.gov/publichealth/pages/crl_childcare_ complaints.aspx Phone: CRED-PAM-24 Rev. 12/14 (99424) (Previous version should be used) Division of Public Health Parent Information Brochure For Licensed Child Care

9 Complete other side and return to your Child Care Provider Licensed Child Care You have chosen to use a licensed Child Care provider for the care of your child or children. According to Nebraska State law (Neb. Rev. Statute ), the licensing and regulation of Child Care programs exists to protect children and to assist parents in making informed decisions about the enrollment and care of their children in Child Care programs. These licensing and regulatory responsibilities are within the Department of Health and Human Services (DHHS). Nebraska Law requires anyone providing care to four or more children from different families, for compensation, to be licensed. The Types of Licensed Child Care in Nebraska are: Family Child Care Home I Family Child Care Home II Preschool Child Care Center School Age Only Center Roles and Responsibilities of Child Care Licensing The roles and responsibilities of DHHS Child Care Licensing staff are to ensure that programs are providing proper care for and treatment of the children they serve, and that the care and treatment are consistent with the child s physical well-being, safety, and protection. Licensed Child Care programs are encouraged to involve you. We urge you to let your Child Care provider s staff know of any concerns. There may be situations where you believe that the program is not responding to your concerns or may not be meeting state licensing standards. This brochure, which Child Care providers are required to share with you, provides information that might be helpful in those situations. Please complete the receipt section and return it to your Child Care provider. This will be kept with your child s records. Responsibilities of Licensed Child Care Providers Licensed Child Care providers should: Comply with child care regulations for their license type at all times. Obtain and maintain accurate records for children they have in care, such as Enrollment Forms, Parent Information Brochure Receipts, Immunization Records and Medication Administration records. Keep accurate and up-to-date records for their license and staff members. Report changes to Child Care Licensing and complete required paperwork to reflect changes. Allow access to their licensed facility when children are in care at all times to parents, Child Care Licensing representatives and the Fire Marshal. Develop policies and procedures for their programs. Communicate with families their needs and concerns for the children in care. Contact Child Care Licensing with any question or concerns they may have or dhhs.ne.gov/publichealth/pages/crl_ childcare_childcareindex.aspx Expectations of Child Care Consumers As a consumer of Licensed Child Care you should: Read thoroughly all the information your provider gives you. Complete your Child s Record Forms and return to your provider before your child begins care. Review and update these records as needed. Supply your provider with your child s immunization records and keep them updated as needed. Sign and date the receipt of this Parent Information Brochure for Licensed Child Care and return it to your provider before your child begins care. Talk to your Child Care provider regularly to address needs and concerns for your children in care and as a parent. Be informed of the child care regulations. Make sure you know what your licensed child care provider is regulated to do or not do. Contact Child Care Licensing with any questions or concerns you may have or dhhs.ne.gov/publichealth/pages/crl_ childcare_childcareindex.aspx

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