June 15, 2015 Dear Parents/Guardians: Welcme t the Ott Family YMCA Afterschl Prgram fr schl year 2015-2016. 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 www.tucsnymca.rg. YMCA OF SOUTHERN ARIZONA Ott Family YMCA 401 S Prudence Rad, Tucsn AZ 85710 P 520 885 2317 F 520 885 6667 www.tucsnymca.rg
OTT FAMILY YMCA AFTERSCHOOL PROGRAM REGISTRATION 2015-2016 PARENT/GUARDIAN #1 (Payment Cntact/Primary Payer) First: Last: Hme Phne: Address: City: State: Zip: Cell Phne: Wrk Phne: Email: PARENT/GUARDIAN #2 First: Last: Hme Phne: Address: City: State: Zip: Cell Phne: Wrk Phne: Email: 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 885-2317 3 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
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 2015-2016 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 2015-2016 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
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 R9-5-304.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):
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: www.azdhs.gv/phs/immun/index.htm r cntact the Arizna Immunizatin Prgram Office at (602)364-3630. 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)
Arizna Department f Health Services Bureau f Child Care Licensing Travel Permissin Frm R9-3-408.A.1.a-e R9-5-517.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: R9-3-408.B.1. - Maintain a cpy f the written permissin fr 12 mnths after the date f the last trip. R9-5-517.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)