Dear School Age Families,

Dear School Age Families, Thank you for choosing the Philadelphia Freedom Valley YMCA Phoenixville Branch for your family s School Age Child Care needs. Our program supports children s success and developmental growth through emphasizing the physical, mental, and spiritual needs, while also concentrating on the YMCA core values of caring, honesty, respect and responsibility. Please see below for important information about registration for the 2017-2018 school year. Important Registration Reminders: All tuition payments will be due in monthly installments. Should you need to make special arrangements or have questions regarding payment methods, please contact Kristin Whitehead at 610-933-5861 X2351 for further assistance. The YMCA is a membership-based organization, and we are excited to have your child join us as a member! You can find membership information on page 3 of this packet. For more information about membership, please contact Membership Services at 610-933-5861. For information on additional membership options, please contact Kelly Handy at 610-933-5861 X2370. If you are a member, a non-refundable deposit is required at the time of registration, which will count as your June 2017 payment. The YMCA also offers Financial Assistance to all families with a demonstrated financial need. Families must first apply for subsidized child care through CCIS (www.compass.state.pa.us ) and attach the letter from CCIS to your registration. If you opt for the non-member membership option, a non-refundable registration fee is required at the time of registration. This payment is $100. A current physical is required within 30 days of registration. It must have been completed within one calendar year of registration. This is a state regulation and we are required by law to have a current appraisal on file. You will be asked during the school year to present an update form as it expires. Our program begins on the first day of school; please refer to your school district s calendar. Your payment is due by the first day of each month. You can sign up for auto pay and your credit card, debit card, or checking account can be automatically drafted each month. You can also pay online by credit card, debit card, or by cash or check at the front desk of the YMCA. No payments will be accepted at the school sites. If you elect to sign up for Auto Pay, please complete an auto draft authorization form with Membership Services. Online Account Management. Make payments online and view balances paid and due. Visit www.philaymca.org, look at top right corner and click on My Account. Sign in with your email address and password. Your registration is not complete, and your child is unable to start in the program until you receive confirmation from the SACC office. Please allow a minimum of 5 business days for processing. Phoenixville YMCA 400 E. Pothouse Road Phoenixville, PA 19460 P 610-933-5861 F 610-935-1827 www.philaymca.org

Program Information: All of our School Age Child Care sites are licensed by the Pennsylvania Department of Human Services (formerly Department of Public Welfare), and participate in Pennsylvania s Quality Assurance Program, Keystone STARS. Keystone STARS is a high quality initiative for early care and learning programs. The program evaluates each school site yearly for high quality, such as cleanliness, health and safety, professionalism, and teaching materials by the staff. Program Locations: Phoenixville School District Sites: Barkley Elementary Door off playground/ Third Ave o Younger siblings at the ELC may be bussed to Barkley for Before and After Care, Must request transportation from/to the YMCA for Before and After Care through PASD Schuylkill Elementary GYMNASIUM DOOR o Younger siblings at the ELC may be bussed to Schuylkill for Before and After Care, Must request transportation from/to the YMCA for Before and After Care through PASD Renaissance Academy- YMCA SACC Multipurpose Room o Must request transportation to the YMCA for After Care through PASD Phoenixville Middle School- YMCA SACC Multipurpose Room o Must request transportation to the YMCA for After Care through PASD Manavon - YMCA SACC Multipurpose Room o Must request transportation from/to the YMCA for Before and After Care through PASD Early Learning Center YMCA SACC Multipurpose Room o Must request transportation from/to the YMCA for Before and After Care through PASD Sincerely, Again, we thank you for selecting the Phoenixville YMCA for your child s school age child care needs. If at any time you have questions about our program, please do not hesitate to reach out to me at the contact information below. Julie Szerenyi School Age Director/Camp Director jszerenyi@philaymca.org 484-921-5857 Website: www.philaymca.org

2017-2018 School-Age Child Care Registration Form Check School Site: Barkley Schuylkill Early Learning Center @ YMCA Renaissance @ YMCA Middle School @ YMCA Manavon @ YMCA Child s Name: Birthdate: Circle: M or F Grade (In Fall): Address: City: Zip: Mother s Name/Guardian: Home Phone: Cell Phone: E-Mail Address: Father s Name/Guardian: Home Phone: Cell Phone: E-Mail Address: Persons to whom child may be released: ; ; ; ; YMCA Membership Options Please choose from one of the membership options below. Either membership will allow your child to participate in the school age programs. Membership Non-Member Your child will have access to only the Child Care program and Y programs at the program member rate. No recreational privileges at the Y. Youth Full Privilege Member* Includes recreational privileges at the Y (while accompanied by full member over the age of 18). You will also receive reduced program fees, including summer camp. *Children must be age 12 in order to use the Y without adult supervision. Children under the age of 12 must be accompanied by a Full Privilege Y member to use the Y for recreational privileges. Family Full Privilege/Single Parent Membership Includes recreational privileges at the Y, reduced program fees and camp tuition, free Child Watch while using the Y, and free adult group exercise classes for the entire family. Fee $100 per year (Registration) $26 per month $101 per month (Family) $87 per month (Single Parent) If your family needs help with membership fees, the Y offers financial assistance. We believe that everyone in our community should have the opportunity to experience YMCA programs and services. In fact, 1 in 4 Y member s benefits from the Y s Financial Assistance Program. Our Financial Assistance Program is central to our mission. The Y also partners with several insurance companies. Check with your insurance provider to see if you qualify for a free membership. If you have any questions concerning financial assistance or insurance memberships, please contact Alicia Broomall @ 610-933-5861 X2314 or abroomall@philaymca.org.

Child Care Options Check one of the following options. All fees are based on a monthly schedule and are due the first day of the month. Late payments will be assessed a $25.00 late fee. Prices listed may be subject to revision. You are registering for 9 ½ months of care. There will be 9 equal monthly payments and 1 half month payment (due at registration) which is considered to be June s payment. **Also note that a $1.00/minute late fee will be assessed for any pick-up after 6:30pm** Choose your options carefully. The plan that you choose will be your arrangement for the school year. Start Date: Your registration is not complete, and your child is unable to start in the program until you receive confirmation from the SACC office. Please allow a minimum of 5 business days for processing. Program Options Basic AM Program (7:00am school opening) Provides daily before school care, including delayed openings. (DOES NOT include early dismissals, school holidays and snow days) NOT AVAILABLE FOR MIDDLE SCHOOL/RENAISSANCE Monthly Tuition Fee $150.00 $75 Deposit* Basic PM Program (School dismissal 6:30pm) Provides daily after school care, including early dismissals. (DOES NOT include delayed openings, school holidays and snow days) $335.00 $167.00 Deposit* Basic AM/PM Program (7:00am school opening and school dismissal 6:30pm) Provides daily before and after school care, including delayed openings and early dismissals. (DOES NOT include school holidays and snow days) NOT AVAILABLE FOR MIDDLE SCHOOL/RENAISSANCE $450.00 $225.00 Deposit* Y-Day/Holiday Care Insurance Provides daily care during school closures at the YMCA branch. Be sure to check out website to ensure the building is open on schedule depending on the weather situation. THIS FEE IS IN ADDITION TO THE MONTHLY OPTION YOU CHOSE ABOVE! Separate Registration Required, Contact Welcome Center for Dates. $90 per month. Registration will include all insurance days. *Deposits are non-refundable and non-transferable. This deposit will be used as your June 2018 payment. This payment is due at the time of registration. Early registration is highly encouraged. I would like to contribute an additional $3.00 $5.00 $10.00 to my monthly tuition rate for Annual Campaign, for financial assistance to help others in need in my community thrive at the YMCA. I, the parent/guardian, have read and understand the payment procedures and policies. I understand that my child will not be allowed to attend the program if payment has not been received by the YMCA prior to my child attending care. I understand that my child will be evaluated periodically and the results will be shared with me. I agree to update the emergency contact/parent consent form and agreement form information whenever changes occur or every six months. Parent/Guardian Signature: Date: Parent/Guardian Signature (6 months): Date: Operator Signature: Date: I would like my tuition to be automatically deducted: Yes No Account Ending in Parent/Guardian Signature: Date:

School Age Child Care Registration Checklist Registration Form (completely filled out with ALL information) Choose membership option o Visit the Phoenixville YMCA Welcome Center to activate your child s membership or join online. Choose care option ½ Month Payment Registration Form ½ Month Payment Made Fee Agreement Emergency Contact Form To be updated every 6 months Please include all applicable information Ensure that there are parent signatures in all appropriate spots Authorization for Emergency Hospital or Medical Treatment Form School Age Authorization Form Non-Discrimination in Services Form Parent/Guardian Email Communication Form Allergy and Dietary Restriction Form Allergy Action Plan & Treatment Authorization Form (as needed/provided by parent) Child Health Assessment Due to YMCA Child Care program within 30 days of enrollment. Must be updated yearly program specific. School Age Getting to Know You Third Party Subsidy Form (CCIS or Other) (if applicable) Release Form (CCIS if applicable) Behavior Management Plan Request for Modifications/Auxiliary Aids and Services (if applicable)

Fee Agreement 55 PA CODE CHAPTERS 3270.123 & 181 (c); 3280.123 & 181 (C); 3290.123 & 181 (c) Child s Name FEE AMOUNT PER/ MONTH Day Payment Made Services to be provided as part of care: Snack/ Homework Assistance / Recreational Play Field Trips (where applicable) Child s Arrival Time Child s Departure Time Late Payment Fee $25.00 Late pick up fee $1.00 per minute Extra Service to be provided at an additional fee if applicable Person(s) to Whom Child may be Released Name Address Phone # I, the parent/guardian: Care Provider Received complete written program information at the time of enrollment {3270.121,3280.121,3290.121} Agree to update the emergency contact/parental consent form information whenever changes occur or every 6 months at a minimum. {3270.124, 3290.124} Signature Parent or Guardian Date Signature Operator Date Date of Child s Admission Date of Child s Withdrawal

Child s Name Emergency Contact/Parental Consent Form 55 PA Code Chapters 3270.124 (a) (b); 3270.181 & 182; 3280.124 (a) (b); 3280.181 & 182; 3290.124 (a) (b); 3290.181 & 182 Child s Gender Male Female Birthdate Home Address Email Address Mother s Name/Legal Guardian Home Phone Home Address Cell Phone Business Name Business Phone Father s Name/Legal Guardian Home Phone Home Address Cell Phone Business Name Business Phone Emergency Contact Person (s) - Name 1). Phone Number when child is in care 2). Person(s) to Whom Child may be released Name/Address Name: Address: Phone Number when child is in care Phone Number Name: Address: Phone Number Name of Child s Physician/Medical Care Provider Phone Number Address Special Disabilities (if any) Allergies (including medicine reaction) Medical or Dietary Information Necessary in an Emergency Situation Medication/Special Conditions Additional Information on Special Needs of Child Health Insurance Coverage for Child or Medical Assistance Benefits Policy Number (Required) PARENT S SIGNATURE REQUIRED FOR EACH ITEM BELOW TO INDICATE Obtaining Emergency Medical Care PARENTAL CONSENT Administration of Minor First Aid Procedures Transportation by the Facility Signature of Parent/Guardian Date

Authorization for Emergency Hospital or Medical Treatment In case of an emergency due to illness or accident, when it is thought advisable to have immediate medical attention for my child, I hereby authorize The Philadelphia Freedom Valley YMCA Phoenixville School Age Child Care program to send my child to the nearest hospital (usually Phoenixville Area Hospital). I agree to meet the teacher at the hospital as soon as possible after being notified. I understand that I must bear all expenses involved, including those uncured to transport my child to the hospital. In the event of a minor injury, I authorize The Philadelphia Freedom Valley YMCA Phoenixville School Age Child Care program to administer minor First Aid to my child. Parent/Guardian Signature: Date: Relationship to Child: Name of Child:

School Age Authorization Form Please sign all spaces and fill in your child s name for those activities you authorize. Transportation and Planned Field Trips/Unscheduled Walking Trips I,, the parent/legal guardian of, who is my minor child, hereby give permission for my child to be transported to and from off-site locations and attend planned scheduled field trips. I agree that they may be transported by the YMCA Bus, rented van, or a private bus company on said trips. I also give permission for my child to go for unscheduled walking trips. Unscheduled Emergency Evacuation I,, the parent/legal guardian of, who is my minor child, hereby give permission for my child to be transported in the event of inclement weather or for the purpose of emergency evacuation. Photo Release I,, the parent/legal guardian of, who is my minor child, hereby give permission for my child s image, photograph, or other reproduction to be taken without reimbursement for the sole purpose of advertising YMCA programs. Swimming I,, the parent/legal guardian of, who is my minor child, hereby give permission for my child to participate in recreational/instructional swimming as part of the YMCA Holiday Care program. My child s swimming ability is that of a (check one) non swimmer or swimmer. I understand that my child will be taking part in recreational swim time. Lost or Broken Item I,, the parent/legal guardian of, who is my minor child, hereby agree to be aware that my child s toys, games, electronics, and/or any other items of value are not to be brought to YMCA school age programs. I am aware that the YMCA will not be held responsible for lost, broken, or stolen items brought from home to school age program.

Philadelphia Freedom Valley YMCA Nondiscrimination Policy The Philadelphia Freedom Valley YMCA ( YMCA ) embraces values and beliefs which support and reflect the inclusion and appreciation of all individuals, regardless of race, color, physical or mental disability (including use of a guide dog, hearing dog, or service dog), religion, creed, sex, pregnancy, childbirth or related medical conditions, sexual orientation or affectational orientation, gender identity or expression, national origin, ancestry, nationality, age, veteran status, uniform service member status, genetic information, atypical hereditary cellular or blood trait, marital status, domestic partnership status, civil union status, familial status, or any other protected class under federal, state, or local law. We are proud to be an equal opportunity employer and provider of services to the community. Nondiscrimination in the Provision of Services to Persons with Disabilities As a place of public accommodation, the YMCA is proud to serve a diverse community of individuals, including those with disabilities. The YMCA will work with prospective and current participants with disabilities, and/or their parents/guardians, to ensure that individuals with disabilities are offered full and equal enjoyment to the YMCA s goods, services, facilities, privileges, advantages and accommodations. The YMCA does not discriminate in the provision of services to individuals with disabilities, including children with diabetes, in any YMCA programs including, but not limited to, childcare, camps, before and after-school programs, classes and recreational programs. Accordingly, the YMCA will not exclude individuals with disabilities from enrollment. The YMCA also will not impose or apply eligibility criteria that tend to screen out or screen out individuals with disabilities. Prospective or current participants with disabilities, and/or their parents/guardians, may, at any time, request modifications to the YMCA s policies, practices and procedures and/or request auxiliary aids or services. Reasonable modifications and auxiliary aids and services can be wide-ranging. A few examples include: working with children who have diabetes to administer the necessary care they need, allowing a program participant to have a service animal, and providing sign language interpreters. All requests for modifications or for auxiliary aids and services should be directed to the applicable Program Director, the Branch ADA Compliance Officer or the Association Office ADA Compliance Officer. Program Directors may be reached in person or by calling the Branch s main telephone number and asking for the Program Director. Contact information for Branch ADA Compliance Officers is located at https://philaymca.org under the About Us tab. The Association Office ADA Compliance Officer, Bertram L. Lawson II, may be reached at blawson@philaymca.org or at 215.963.3731. The YMCA will work with prospective or current participants in our programs, and/or their parents/guardians, to promptly address all requests for modifications to the YMCA s policies, practices and procedures and/or for auxiliary aids or services and to determine what reasonable modifications and/or auxiliary aids and services are available. Our goal is to ensure that all participants in our programs with disabilities have access to the full and equal enjoyment of all YMCA programs. Accordingly, the YMCA conducts individualized assessments on the specific facts of each request and will not apply a general prohibition against providing particular types of reasonable modifications. The YMCA will make reasonable modifications for individuals with disabilities, including children with diabetes, unless the request for modification amounts to a fundamental alteration of the applicable YMCA program. Similarly, the YMCA will provide auxiliary aids and services for individuals with disabilities, unless the request for the auxiliary aids or services creates an undue burden or amounts to a fundamental alteration of the applicable YMCA program. The YMCA prohibits retaliation against any individual for exercising their rights to request and/or receive a modification to the YMCA s policies, practices and procedures or auxiliary aids and services. The YMCA further prohibits retaliation against any individual who in good faith participates in any investigation or proceeding related to a request for modification to the YMCA s policies, practices and procedures or auxiliary aids and services.

Phoenixville YMCA School Age Program Child s Name: Dear Parent/Guardian, In an effort to be able to communicate with parents as frequently and easily as possible, much of the communication is done through e-mail. Please provide the e-mail address of all parents/guardians involved. Please note if you have regular, daily access to e-mail. If you do not, any correspondence that is sent will be printed out and put into your child s school bag. Thank you for your help in improving our communication methods! PARENT/GUARDIAN E-MAIL ADDRESS 1. Name of Parent/Guardian I DO NOT have regular access to e-mail. I do have regular access to e-mail. E-mail address: 2. Name of Parent/Guardian I DO NOT have regular access to e-mail. I do have regular access to e-mail. E-mail address:

Phoenixville YMCA School Age Program ALLERGIES AND DIETARY RESTRICTIONS Child s Name: Date of Birth: Dear Parent/Guardian, Please complete the following form to let us know if your child has any allergies to any food or other substance such as medications, latex, etc. Please also indicate if your child has any other dietary restrictions for reasons other than allergies (religious, vegetarian/vegan, etc.) If your child has an allergy which requires administration of an EPI-PEN, Benadryl, or other medication, please let us know immediately so that we can ensure that the classroom staff is trained in administering the treatment. Please check one box and complete as necessary: At this time, my child does not have any allergies or dietary restrictions. My child has the following allergy(s) or food restriction(s): 1. Name of allergen or restricted food: Reason for restriction: Religious Medical Other (please specify) Please indicate reaction and treatment: 2. Name of allergen or restricted food: Reason for restriction: Religious Medical Other (please specify) Please indicate reaction and treatment: The information on this form is true to the best of my knowledge. I will inform the School Age Child Care office if any of this information changes. Parent/Guardian Signature: Date:

Philadelphia Freedom Valley YMCA Getting to Know You Form Participant s Name: Parents: We can work more effectively with your child at the YMCA this summer if we know as much about him/her as possible. Please help us by filling in the blanks and handing in with the registration packet. Feel free to make an appointment with the Program Director as well. Well-liked nickname: Age at beginning of the program: Birth Date: Living with whom: Others with whom your child resides: Does your child require any modifications in YMCA policies, practices or procedures or auxiliary aids and services in order to allow your child to fully participate in our programs? Yes No If yes, explain. (Our ADA Compliance Officer will follow up with you to discuss any requests.) Does your child require the services of therapeutic support staff (TSS) while at the YMCA? Yes No (If yes, an appointment must be made to meet with the Program Director prior to starting the program to review the YMCA TSS policy). If your child has an IEP, would you like to provide a copy to the Program Director? (Provision of the IEP is up to the discretion of the parents/guardian.) Yes No What areas of your child s life would you hope to see developed by at the YMCA? What do you consider his/her strengths and weaknesses? Does your child have siblings attending YMCA programming at the same time? Yes No If yes, Name (s) & Age(s)

Please note any additional information the Program Director should know about your child to better serve your goals for your child. Such information may include, but is not limited to, information about your child s personality, disposition, social skills, and forms of behavior modification used at home as well as hobbies, interests and preferred activities etc. Official Use only: Meeting Date: Attendees:

Philadelphia Freedom Valley YMCA Third Party Subsidy Form (CCIS or Other) Mandatory Family Information Parent s Name: Name of child(ren) covered by Third Party subsidy: 1) 2) 3) Address: City State: Zip: County: Home Phone: Cell: ********************************************************************** Caseworker s Name: Caseworker s Phone: Ext Name of Organization: Address of Organization: City, State, Zip, & County ********************************************************************** Amount of Parent Co-pay: $ Parent s Name (Print): Parent s Signature: Date:

Philadelphia Freedom Valley YMCA Release Form Provider Name Provider ID Provider Phone Number Parent/Caretaker s Name Child(ren) Name I authorize Child Care Information Services (CCIS) of Chester County to disclose information regarding my eligibility status with the Philadelphia Freedom Valley YMCA. Parent/Caretaker Signature Date CCIS Use Only Record # CCW Enrollment Begin Date CCW Enrollment End Date

School Age Child Care Behavior Management Plan YMCA School Age programs provide a safe environment for all children to develop a healthy spirit, mind and body. We believe that children should make their own choices and take responsibility for their actions. Our policy is that behavior management is a function of engaging children in meaningful and stimulating activities which focus on positive role models, in addition to promoting respect for self and others in a climate of acceptance and fairness. Based on the Golden Rule: Treat others as you would want them to treat you. Children will respect the rights and feelings of others and will avoid disruptive behavior that would interfere with program activities. Aggressive behaviors such as hitting, kicking, verbal put-downs, and bullying will not be tolerated. Children will follow all directions given by the program leaders regarding safety procedures and will stay with the group for all scheduled activities. Children will respect the private property of others and will understand that stealing or vandalizing the property of others will not be tolerated. Behavior Management Procedures Step 1: When a problem arises which threatens the health or safety of himself, other children or staff, the staff will take immediate action to stop the behavior and inform the child of the disciplinary action that will be taken. If the severity of the inappropriate behavior warrants, or the child cannot be controlled in the area, it may be necessary to temporarily remove the child from the situation. The Parent/Guardian will be notified and we will work together with the child to correct the inappropriate behavior. Step 2: The YMCA Program Director will call the parent/guardian to discuss the continuing inappropriate behavior. Should the behavior continue the child will be suspended from the program. A conference between site staff, the program director, and the parent/guardian may be scheduled at this time. Step 3: The Program Director will inform the parent/guardian (via phone call) of a three-day suspension for the continuing inappropriate behavior. No care will be provided by the YMCA. The parent/guardian remains responsible for paying all fees for that month. A written letter will be sent home outlining the suspension. Step 4: After a third call from the Program Director has been made, and there have been several unsuccessful attempts to correct the child s behavior, the Program Director will notify the parent/guardian that the child is withdrawn from the YMCA program. Written notification will follow. ***When a child s inappropriate behavior is extremely persistent in that it takes too much attention away from the needs and safety of the other children or the behavior is too violent, the possibility of suspending or dismissing the child from the program may be considered immediately. This decision is an important and difficult one to make. It will be carefully considered and discussed before action is taken. I have read and understand the YMCA School Age Child Care Behavior Management Policy. Parent/Guardian Signature Date

Philadelphia Freedom Valley YMCA Request for Modifications/Auxiliary Aids and Services Case Management Form Section A INITIAL REQUEST FOR MODIFICATION/AUXILIARY AIDS AND SERVICES Prospective or Current Participant: Gender: Date of Birth: Program Registration for: Date Request Received: Branch: Dept.: Person Making the Request (if not the prospective or current participant) and Relation to Prospective or Current Participant : Parent/Guardian or Emergency Contact Name: Address: Home Phone: Cell Phone: Email(s): Nature of Request for Modification to Policies, Practices or Procedures and/or for Auxiliary Aids and Services: