Summer Child Care Program Registration Packet WEST VALLEY

Transcription

INTENTIONALLY
AWESOME!
Summer Child Care Program
Registration Packet
WEST VALLEY FAMILY YMCA
Welcome to the YMCA!
The YMCA is a charitable 501(c)(3) non-profit
community organization. We’re here for Youth
Development, Healthy Living and Social Responsibility.
Our Strength is in Community.
WHO SHOULD COMPLETE
THIS PACKET?
• Parents of children entering grades K-5 who
plan to attend our Summer Child Care
Programs at one of our licensed child care
locations: Pomelo Community Charter
Elementary (197408524), Woodlake Avenue
Elementary (191200082), Bay Laurel
Elementary (191231094) or Vanalden
Elementary (191226194).
• Parents of children entering grades 6-8 who
plan to attend our Good Times Programs at one
of our licensed child care locations: Pomelo
Community Charter Elementary (197408524),
Woodlake Avenue Elementary (191200082) or
Vanalden Elementary (191226194).
SWIM
LESSONS!
Included at no extra
charge for
participants
entering K-2!
PREVIEW DAY!
Come out and see
what Summer Child
Care is all about.
May 14
10 am – 12 pm
NEW!
Tired of
handwriting? Our
Registration Packet
now comes in a
Smart Form version
CONTENTS OF THIS REGISTRATION PACKET
PLEASE SIGN AND COMPLETE ALL PAGES.
We apologize in advance that some of the page are asking for repeat information. Our programs
are state licensed; therefore this packet has both forms required by California Community Care
Licensing and forms required by the YMCA of Metropolitan Los Angeles / West Valley Family
YMCA. Some forms may seem exactly the same and may ask for the exact same information.
Please complete all forms in their entirety.
THIS CHECKLIST IS FOR OFFICE USE ONLY
Child Care Welcome Letter – Is this the right program for your child?
YMCA – Allow us to reintroduce ourselves! / Opportunity to Give Back!
Registration Options
Payment Authorization Form
Child Care Registration Form
Multijurisdictional Authorization & Release For Medical & Dental Treatment
Swimming & Aquatic Survey
Identification & Emergency Information (License 700)
Admissions Agreement
Child’s Preadmission Health History – Parent Report (License 702)
Consent for Emergency Medical Treatment (License 627)
Notification of Parent’s Right (License 995)
Personal Rights (License 613A)
Receipt of Parent Handbook / Acceptance of Policies and Procedures
Release and Waiver of Liability and Indemnity Agreement
Photo and Video / Audio Recording Release
Subsidized Child Care Agreement Form (Only for families enrolling with CCRC funding)
“Getting to Know Your Child and Family” Questionnaire
Positive Discipline Policy
The Y: Here for the Community
ADDITIONAL FORMS NOT IN THIS REGISTRATION PACKET, BUT AVAILABLE BY REQUEST IF APPLICABLE
TO YOUR CHILD: To receive an copy of any of the forms listed below, please email Christopher Jefferson, Senior
Program Director of Child Care at [email protected]
Parent Request and Consent for YMCA to Administer Prescription Medication Form
Nebulizer Care Consent/Verification– for children who use inhalers (License 9166)
YMCA Diabetes / Insulin – Release and Waiver of Liability Form
YMCA EpiPen Consent Release Form
YMCA Parent Declination of Sunscreen for Child Form
First-time children enrolling in a licensed child care or Summer Child Care Program may not start the same day they sign-up for the
program. First-time children must wait two (2) days and 48 hours before they can begin a program at a licensed center. The 48 hour
clock is weekday, business days only; Friday enrollments will be approved for a Tuesday start date and Monday enrollments will be
approved for a Wednesday start date, and so on and so forth. This is for first time enrolled children only. Returning children may
start right away without the wait period. The best way to avoid this is to sign-up well in advance so that enrollment is approved well
before the start of the program you have enrolled. The YMCA does not prorate for wait periods.
OFFICE USE ONLY
This packet has been reviewed by a Program Director:
Yes
No
Program Director Signature:
_____________________________________
Approved Start Date for Child:
_____________________________________
Date: ___________
PLEASE READ THIS LETTER BEFORE ENROLLING YOUR CHILD
IS THE WEST VALLEY YMCA CHILD CARE PROGRAM A GOOD FIT FOR MY CHILD?
OVERVIEW:
The West Valley YMCA’s Licensed School-Age Child Care Programs and Summer Child Care Programs
are group child care programs, with an average daily ratio of 1 qualified child care teacher for every 14 school-age
children. Our license is issued by the California Department of Social Services Community Care Licensing Division,
which approves, issues, maintains and regulates licensed care facilities (child care, family child care homes, senior care
facilities, etc.). Under Title 22, we are not permitted to allow a child care teacher to supervise more than 14 children.
At some sites, due to the way in which the program is set up, children may be cared for on a daily basis in smaller
groups of 1 adult for every 12 or 13 children, however, this is not typical.
WHAT IS GROUP CARE? The West Valley YMCA follows the Personal Care Group (PCG) system established by the
YMCA of Metropolitan Los Angeles. The PCG system is designed to keep your child safe and supervised at all times
through continuous 15-minute headcounts, internal sign-in and out forms, absence verifications, travel logs and documentation. Each child in our
program is assigned to a Personal Care Group, which, for the most part, they will remain in during the duration of the day, session or school-year. In
their PCG, they will typically be assigned to one child care teacher who will provide the majority of their care for the day and ensure that their personal
rights (License form 613A) are never violated. Typically, your child will engage in the day’s activities, meal and snack time, group time and team time
with the child care teacher assigned as their personal care giver within their personal care groups. At the YMCA, we do not provide one-to-one adult-tochild services. We also do not provide care is groups smaller than 10-14 children --- typically your child’s PCG will consists of 12-14 children total.
ONE-TO-ONE SERVICES: Families with children who may require one-to-one services (such as families with children who have a one-to-one aide
while the child is at school during the school day) must set-up an appointment with the Senior Program Director of Child Care to determine the level of
the child’s needs and better understand the strategies and techniques needed to help the child be successful in the Y program. The Y will do our best to
meet the needs of the child but families need to understand that our program may not be the right fit for their child. The Y will provide resources to the
families as appropriate.
TAKE A TOUR BEFORE YOU ENROLL: First time enrollees / families who are interested in the YMCA Child Care Programs are STRONGLY encouraged
to visit the center and observe the program PRIOR to registering. At the center, site staff will provide a tour, answer questions, and share about the
program philosophy, general schedule of activities, staffing structure and qualifications, and the group-centered nature of the program, including
teacher to child ratios. Please make an appointment by contacting the Child Care Center directly. We unfortunately cannot accept walk-ins
for tours. Children MUST accompany parent(s) to the tour. We want to meet you and your child.
THE 48 HOUR RULE: The West Valley YMCA has a “two (2) business days of 48 hours” policy for first-time enrollees. If your child is a first-time
enrollee in our programs, the child may not start until we have received a complete registration packet, program fees have been paid and after two (2)
business days of 48 hours has passed. This will give us time to review your registration packet. First time enrollees, please enroll in advance so that
your registration is approved prior to the start of a program, session or school year. Please be sure to also schedule an appointment so that you can
tour the facility and introduce your child to the center staff and director. Friday enrollments will be approved for a Tuesday start date and Monday
enrollments will be approved for a Wednesday start date, and so on and so forth. Returning children and families may start right away and may also
start a program on the same day that they re-register. This includes families who continuously attend only our Summer Child Care Programs.
UPDATED! TRIAL PERIOD: After a family enrolls in our program and pays the registration fee and the enrollment fees (either for the first month of
before / after school care or for their first session of summer child care or a seasonal weekly program) the family may qualify for a trial period. Families
may qualify for a trial period if they are enrolling a child or children for the very first time into our program. “Our program” is defined as before / after
school care or any seasonal child care program on a weekly session schedule. For before and after school care, the trial period is three (3) school
days. For any seasonal child care program on a weekly session schedule (such a summer child care or seasonal programs), the trial period is one (1)
program day. For the three (3) day trial period and for the one (1) day trial period, some restrictions do apply. During the trial period, the family and /
or the Y will can make a determination as to whether or not the YMCA is able to meet the child’s individual needs and interests. The Y staff will work in
partnership with families to address any issues or concerns with the child. If the Y is unable to meet the child’s needs or interests, or if the child
becomes a danger to themselves or others, arrangements must be made for the family to find another child care provider or more appropriate program.
If this determination is made by the Y or the family, the Y will immediate terminate the child’s services and the parent will receive a full-refund of all
enrollment fees paid, with the exception of the required registration fee, which will not be refunded. This type of refund is called a “child care trial
period refund”. To qualify for a child care trial period refund, the family must request the refund within the applicable timeframe. For before / after
school, the trial period is three (3) school days. The refund must be requested within 5 calendars days after the child’s third day of care. In addition to
this, the refund must be requested within two weeks of the child’s first day, regardless of if they attended a second or third day. If the child attends the
program for a fourth day, the family is disqualified from receiving a child care trial period refund. For any seasonal child care program on a weekly
session schedule, the period is one (1) program day. The refund must be requested within 3 calendars days after the child first day of care. In addition
to this, the refund must be requested within one week of the child’s first day. Refunds will only be considered for approval if they are within the
appropriate, above listed, qualifying timeframes. Any requests outside of the qualifying timeframe will be denied. If approved and if a child care trial
period refund is issued, the entire family is disqualified from requesting a second child care trial period refund indefinitely, including if they re-enroll into
our programs in the future. This disqualification extends to all current and future members of the household, including younger siblings to the original
child who qualified for the refund. If a child is enrolled in any of our seasonal child care programs that are on a weekly schedule and the
child begins that program on a day where there are only three program days left in the week (for example, a Wednesday) the child and
the family is automatically disqualified from requesting or receiving any type of refund, including the trial period refund. Similarly, the
child care trial period refund does not apply to any single one-day or single two-day program of any type (before / after school, any
seasonal child care program on a weekly schedule, full-day single care, etc.). Similarly, if a child is enrolled in a before /after school
program and the child begins that program on a day where there are only three program days left in the month (for example, the March
29, 2016), the family is automatically disqualified from requesting or receiving any type of refund, including the trial period refund.
For a complete list of our policies and procedures, including the Y’s policies on children with special needs, please see our Summer Child Care Parent
Handbook. By signing below, you acknowledge that you have read and understood the information listed above and wish to continue with enrollment:
Parent/Guardian
Signature:
Parent Name (Please print)
Name of Child being
enrolled in YMCA program:
Date
ALLOW US TO REINTRODUCE OURSELVES
Our Cause Defines Us
We know that lasting personal and social change comes about when we all work together. That’s why, at the Y, strengthening
community is our cause. Every day, we work side-by-side with our neighbors to make sure that everyone, regardless of age, income
or background, has the opportunity to learn, grow and thrive.
Our Strength is in Community
•
The Y is a nonprofit like no other. That’s because in 10,000 neighborhoods across the nation, we have the presence and
partnerships to not just promise, but deliver, positive change.
•
The Y is community centered. For nearly 160 years, we’ve been listening and responding to our communities.
•
The Y brings people together. We connect people of all ages and backgrounds to bridge the gaps in community needs.
•
The Y nurtures potential. We believe that everyone should have the opportunity to learn, grow and thrive.
•
The Y has local presence and global reach. We mobilize local communities to effect lasting, meaningful change.
Our Impact is Felt Every Day
With a mission to put Christian principles into practice through programs that build a healthy spirit, mind and body for all, our impact
is felt when an individual makes a healthy choice, when a mentor inspires a child and when a community comes together for the
common good.
The YMCA in the United States
Today, the Y engages more than 10,000 neighborhoods across the U.S. As the nation’s leading nonprofit committed to helping
people and communities to learn, grow and thrive, our contributions are both far-reaching and intimate—from influencing our
nation’s culture during times of profound social change to the individual support we provide an adult learning to read. By nurturing
the potential of every child and teen, improving the nation’s health and well-being, and supporting and serving our neighbors, the Y
ensures that everyone has the opportunity to become healthier, more confident, connected and secure.
Opportunities for All
The Y is for everyone. Our programs, services and initiatives: enable kids to realize their potential, prepare teens for college, offer
ways for families to have fun together, empower people to be healthier in spirit, mind and body, prepare people for employment,
welcome and embrace newcomers and help foster a nationwide service ethic. And that's just the beginning.
Parents, did you know that funds raised through our Community Support Campaign helps us to provide scholarships and assistance
for families who are not able to afford to come to the Y? Would you like to donate to our Community Support Campaign to keep
program fees affordable to all and to provide these valuable scholarships? The Y and the community are grateful for your generosity.
The Y is a 501(c)(3) charitable non-profit. Tax ID: 95-1644052 A $50 donation will help to make summer child care more
affordable for one family
MAKE A DONATION TO THE Y TODAY!
CHECK ONE
Yes
I would like to make a one-time $50 donation to the YMCA to support Youth Development and Child Care Programs. Please charge my
credit card on file ending with ______ (last 4 digits). If I do not have a credit card on file, I will provide one to the YMCA
Welcome Center.
Yes
I would like to make a $50 donation over time to the YMCA to support Youth Development and Child Care Programs. Please split my
donation into 5 payments of $10 per month for 5 months beginning (enter a month here): ____________ (preferred billing is $10 a
month, for 5 consecutive months, beginning May, June or July 2016. Debits will offer on the 1st of the month). Please charge my
credit card on file ending with ______ (last 4 digits). If I do not have a credit card on file, I will provide one to the YMCA
Welcome Center.
Yes
I would like to make a donation to the YMCA to support Youth Development and Child Care Programs in the following amount:
__________. Please charge my credit card on file ending with ______ last 4 digits. If I do not have a credit card on file, I will
provide one to the YMCA Welcome Center.
Yes
I would like to make a donation to the YMCA to support Youth Development and Child Care Programs in the following amount:
__________. I would like to give the donation immediately using cash or check.
No
I have already made a donation to the Y Annual Support Campaign for 2016
No
Not at this time
You can support the Y’s Youth Development and Child Care programs in more ways than you may know. Call me or email me and ask me about our Annual 10k Race and 2k Family Fun Run this Fall and how you can support the Y and
improve your health too!
Christopher Jefferson | [email protected] | 818 668 2611
PROGRAM OPTIONS – SUMMER CHILD CARE PROGRAM
STEP 1: REGISTRATION INFORMATION – COMPLETE ONE FORM, PER CHILD
BASIC INFORMATION
Child’s Name
T-Shirt Size:
(Please indicate Youth or Adult)
1 - Select One
STEP 2: ENROLLMENT INFORMATION
REGISTRATION & ENROLLMENT:
Child Care is for kids entering K-5th grade & Good Times is for kids entering 6th-9th grade
WOODLAKE ELEMENTARY
Weekly
Sessions
POMELO ELEMENTARY
VANALDEN ELEMENTARY
23231 Hatteras Street,
Woodland Hills, CA 91367
M-F, 7 am – 6 pm (closed Mon., July 4)
818 643 0065 | License #191200082
7633 March Avenue,
West Hills, CA 91304
818 665 9794 | License #197408524
19019 Delano Street,
Reseda, CA 91335
818 996 8564 | License #191226194
K-5: $175/session | 6-9: $195/session
This site offers child care for grades K-5
This site offers Good Times for grades 6-9
BAY LAUREL ELEMENTARY
24740 Paseo Primario,
Calabasas, CA 91302
M-F, 7 am – 6:30 pm
(closed Mon., July 4)
818 223 9528 | License #191231094
K-5: $175/session
Session 1
6/13–6/17
□Child Care (K-5) □Good Times (6-9)
□Child Care (K-5)
Session 2
6/20-6/24
□Child Care (K-5)
Session 3
6/27-7/1
□Child Care (K-5)
Session 4
7/5-7/8
□Child Care (K-5)
Session 5
7/11-7/15
□Child Care (K-5)
Session 6
7/18-7/22
□Child Care (K-5)
Session 7
7/25-7/29
□Child Care (K-5)
Session 8
8/1-8/5
□Child Care (K-5)
Session 9
8/8-8/12
□Child Care (K-5)
Session 10
8/15-8/19
/////////////////////////////
/////////////////////////////
/////////////////////////////
□Child Care (K-5)
STEP 3: SET-UP PAYMENT
PAYMENT OPTIONS
Option 1: Pay up front today – You may pay upfront today for all sessions you have checked-off above.
Option 2: Automatic Payment Plan – You may set-up an automatic payment plan using a credit or checking account. Sessions fees will be drafted at
12:01 am on each of the draft date & deadline for cancellations or changes listed below. Each session has a draft date & deadline for cancellations or
changes, which is one week prior to the start of the each session. Please complete Payment Authorization form and see the Draft date &
deadline for cancellations or changes schedule below.
Weekly Session
Dates
Draft Date & Deadline for
Weekly Sessions
Dates
Draft Date & Deadline for
1-5
Cancellations / Changes
6-10
Cancellations / Changes
Session 1
June 6
Session 6
July 11
June 13 – June 17
July 18 – July 22
Session 2
June 20 – June 24
June 13
Session 7
July 25 – July 29
Session 3
June 27 – July 1
June 20
Session 8
August 1 – August 5
July 18
July 25
Session 4
July 5 – July 8 (4 days)
June 27
Session 9
August 1
Session 5
July 11 – July 15
July 5
Session 10
August 8
STEP 4: PAY YOUR REGISTRATION FEE
$50 REGISTRATION FEE, PER CHILD
DUE TODAY: $50 Registration fee per child (this fee is non-discountable)
You are only required to pay the $50 registration fee once per summer. This covers your registration fee for all summer 2016 Child Care and Day Camp
activities (Summer Child Care Program, Day Camp at the Y and Good Times).
STEP 5: SIGN & VERIFY By signing below, you verify that you have read and understood this complete document:
REMINDERS ON SOME IMPORTANT POLICIES & PROCEDURES:
1.
2.
3.
4.
5.
6.
Please be sure to check your schedule to ensure that you are choosing the correct sessions.
Please be sure to double check your school and school district calendar so that you are not selecting sessions when your school is still in session. Our schedule is in-line with both LAUSD and
LVUSD school districts.
We no longer accept reservations without a full payment. Please pay upfront for all sessions today, or set-up an automatic draft payment plan. If you are not prepared to pay today or do not
wish to set-up a payment plan, then we cannot accept your registration today and you may sign-up session-by-session (week-to-week) if spaces are available. We cannot reserve spaces in
program without either a full payment or a payment plan set-up (via draft).
All requests for cancellations & refunds must be submitted by the 10:00pm on the payment draft date & deadline for cancellations or changes for each session requested. You must submit a
refund request form. Refunds will not be given after the payment draft day for each session. For each session, the payment draft date & deadline for cancellations or changes is the same deadline
to request a refund.
I understand that session 4 is only 4 days (closed Monday, July 4) and that the fee for this session is NOT prorated due to the shortened session.
This is not a full list of policies, procedures and guidelines. For a complete list, please see our 2016 Summer Child Care Program Parent Handbook.
By signing below, I verify that I have read and understood this complete document. Additionally, if I have selected an Automatic Payment Plan option (listed above), I hereby authorize the YMCA to
charge my credit card or I authorize my financial institution to honor preauthorized debit entries by the YMCA, on a weekly basis for payments as indicated above. When my financial institution honors
such debits by charging my account, this shall constitute my receipt for payment.
Parent/Guardian
Signature:
Date
For YMCA staff use only
______________________________________________________________
Account Number
___________________________________ _________________________
Date
Staff Initials
PAYMENT AUTHORIZATION FORM
YMCA OF METROPOLITAN LOS ANGELES
MEMBER INFORMATION
_____________________________________________________________________________________________________________________________________________________________
Legal name (include middle initial)
________________________________________________________________________________________
Address
_____________
Apt.
( __________ ) __________________________________________
Phone
_________________________________________________________________ _________
City
State
_________________________
Zip code
PAYMENT AUTHORIZATION
STEP 1:
Date of First Draft: _________________________________________
(See Column 2 and Column 4 to determine date of first draft. This must correlate with the draft date of the first
session you are pre-registering for)
STEP 2:
Rate per week:
_________________________________________
(Please list the full price per session or the discounted price per session, if you have a discount)
AUTOMATIC PAYMENT SCHEDULE: DRAFT DATE
1
2
3
DRAFT DATE
WEEKLY SESSIONS
WEEKLY SESSIONS
S1: June 13 – June 17
June 6
S6: July 18 – July 22
S2: June 20 – June 24
June 13
S3: June 27 – July 1
June 20
S8: Aug 1 – Aug 5
June 27
S9: Aug 8 – Aug12
July 5
S10: Aug15 – Aug19
4
DRAFT DATE
July 11
July 18
July 25
August 1
August 8
STEP 3:
Read this: Your account will be debited or charged based on the payment option you choose below. You will be debited or charged based on the sessions
that you pre-registered for on the draft due dates for each of those sessions. (The draft will be deducted the Monday prior to the start of each session at 12:01 am).
STEP 4:
Select ONE of the two payment options below and provide the requested information.
PAYMENT OPTION 1
PAYMENT OPTION 2
Automatic funds transfer (Attach a voided check.)
Type of account:
Checking
Savings
Recurring credit card or debit charge
Type of account:
Visa
MC
Amex
Discover
_________________________________________________________________________________
Name on the account registration (print)
_________________________________________________________________________________
Name as it appears on the credit card (print)
_____________________________________________ _________________________________
Account number
Routing number
_____________________________________________ _________________________________
Credit card number
Expiration date
I hereby authorize my financial institution to honor preauthorized debit entries by
the YMCA on my account for weekly program payments. When my financial
institution honors such debits by charging my account, this shall constitute my
receipt for payment.
I hereby authorize the YMCA to charge my credit card on a weekly basis for
payments as indicated above. When my financial institution honors such debits
by charging my account, this shall constitute my receipt for payment.
_______________________________________ _______________________________________
Member initial
Payee initial
______________________________________ _______________________________________
Member initial
Payee initial
YMCA OF METROPOLITAN LOS ANGELES FINANCIAL POLICIES
I further agree to the following conditions (Please read and sign below.):
• I understand that the weekly program session fee charges or debits will be charged to the above listed account, based on the program sessions that I selected on
the Program Options form. I will be charged one week prior to the start of each program session that I have selected. The frequency and occurrence of my visits
or my child’s visits to the YMCA or its programs has no bearing on my weekly program session fees, charges or debits.
• I understand that the weekly program session fee charges and debits will be charged to the above listed account, based on the program sessions that I selected
on the Program Options form, until I give written notice to charge or cancel a weekly program session.
• I understand that I must give the YMCA written notice on or prior to the Draft Date & Deadline for Cancellations or Changes for each weekly program session
and by 10:00 pm. Written notice may be submitted in-person or by e-mail. I understand that at the time of my request for a cancellation, exit or change, I may
be asked by a YMCA employee to complete a YMCA Exit, Change and / or Cancellation form and I will be given a deadline by the YMCA employee to return the
form. Failure to notify the YMCA of a cancellation, exit or change prior to the Draft Date & Deadline for Cancellations or Changes or failure to return the YMCA
Exit, Change or Cancellation form within the requested timeframe, will make the subsequent draft non-refundable. Any outstanding balances will be due at the
time of the cancellation. I am liable for any fees that the YMCA may incur in its effort to collect any remaining balance due.
• I understand that I must inform the YMCA 15 days in advance of any changes to my name, address, telephone number or payment information. Failure to provide the
YMCA with current information may result in non-refundable fees. I am personally responsible for any payments not processed by my financial institution and/or
the YMCA.
• I understand that it is my responsibility to bring any billing discrepancies to the YMCA’s attention within 60 days after they first appear on my financial statements.
After 60 days, I waive my right to dispute such discrepancies.
• I understand/authorize a $10.00 NSF or collection of fees will/to be charged to me for any declined or returned monthly dues. Such non-sufficient fees will be the maximum
amount allowed by law and will include applicable taxes.
____________________________________________________________________________________________________________________________________________
Signature
__________________________________________________
Date
CHILD CARE REGISTRATION FORM
BASIC INFORMATION
CHILD’S NAME
SEX
BIRTH DATE
(M/D/Y)
HOME ADDRESS
(Include City And Zip Code)
TELEPHONE
(
)
NAME OF SCHOOL CHILD
IS CURRENTLY ATTENDING:
CURRENT
GRADE:
1ST ADULT’S NAME
HOME PHONE
(
)
MOBILE NUMBER
(
)
HOME ADDRESS
WORK NUMBER
(
)
(If Different From Child)
E-MAIL ADDRESS:
EMPLOYER NAME /
ADDRESS
DRIVER’S LICENSE #
2ND ADULT’S NAME
HOME PHONE
(
)
STATE OF
ISSUE:
(ID Purposes)
MOBILE NUMBER
(
)
HOME ADDRESS
WORK NUMBER
(
)
(If Different From Child)
E-MAIL ADDRESS
EMPLOYER NAME /
ADDRESS
DRIVER’S LICENSE #
(ID Purposes)
STATE OF
ISSUE:
SIGN IN / OUT – EMERGENCY CONTACT INFORMATION
SIGN IN AND OUT AUTHORIZATION: The following individuals have my unrestricted permission to sign the above
named child out from the YMCA program and should be contacted in an emergency when I cannot be reached. Please
notify your Site Child Care Director in advance in writing if an individual not listed will be picking up your child. (minimum
of two names required)
ADDITIONAL PERSONS WHO MAY BE CALLED IN EMERGENCY
NAME
PHONE# 1
ADDRESS
RELATIONSHIP
TO CHILD
Pick-Up
□
□
□
□
Emergency
□
□
□
□
Restricted PICK-UP : The Following individuals are RESTRICTED from signing out my child due to a courtissued restraining order (A certified copy of the official documentation must be kept in the child’s YMCA file)
Name
Name
Name
Name
CCIS/Cal-Works families MUST provide:
Case #:
Name of Case Manager:
Telephone number:
CHILD’S HEALTH STATEMENT:
I, the undersigned, understand that at a YMCA day camp, Summer Child Care Programs and before / after school program,
physical activity is a regular part of the daily scheduled activities. To the best of my knowledge, my child is in excellent
physical health and has no restrictions (except what is listed in this packet under “special consideration”) from strenuous
activity. IF I have any questions regarding my child’s health, I understand that it is my obligation to seek professional
medical advice and to inform the YMCA of any restrictions on my child’s activities. I understand that the YMCA is a group
child care program with one adult teacher assigned to ever group of 14 children. The YMCA does not provide any one-toone assistance services.
Parent/Guardian
Date
Signature:
MULTIJURISDICTIONAL AUTHORIZATION & RELEASE
FOR MEDICAL AND DENTAL TREATMENT
CHILD’S NAME
(Last name, First name)
SEX
BIRTH DATE
(M/D/Y)
PARENT’S NAME
I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the YMCA
Program. I hereby grant permission for my child to leave the YMCA Program premises under the supervision of a staff
member for neighborhood walks or field trips in authorized vehicles. I hereby grant permission for my child to be
included in evaluation and pictures connected with YMCA Program.
The undersigned, as the parent(s) or legal guardian(s) of the above-named person, (the “minor”) authorize YMCA of
Metropolitan Los Angeles and its employees, directors and adult volunteers (collectively “YMCA”) to consent to any
x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively “dental care”) to be rendered
to the minor by a dentist licensed under the law of the State or other jurisdiction in which dental care is sought. For
the purpose of medical care or dental care obtained outside of California, this authorization is given with the intent that
any consent given pursuant to this authorization shall be the consent of each of the undersigned.
The undersigned understand and agree that YMCA shall not be legally or financially liable for any bill or medical expense
incurred, or for any cause of action or claim arising from any medical care or dental care provided, or the lack of medical
care or dental care. The undersigned hereby agree to indemnity, defend and hold YMCA harmless from any claim made
by or on behalf of minor’s heirs or parents or guardian arising out of any medical care or dental care provided.
NOTE: The YMCA requests that if the minor is in the custody of both of their parents or more than one legal
guardian, both or all sign this authorization. The YMCA understands that the minor is in the custody only of the
person(s) who have signed this authorization.
If for religious reasons you cannot sign this, you must provide a Written statement from parent(s) or authorized
representative exempting child from medical assessment, immunizations, and treatment because of adherence to a
religious faith that practices healing by prayer or other spiritual means; or physician's statement that immunization is
not indicated and the YMCA branch must be contacted for a legal waiver, which must be signed for attendance.
Emergency Medical Informaition (This information is required)
PHYSICIAN OR DENTIST TO BE CALLED IN EMERGENCY
MEDICAL INSURANCE COMPANY:
POLICY NUMBER:
EXPIRATION:
Parent/Guardian
Signature:
Date
Parent/Guardian
Signature:
Date
SUNSCREEN UTILIZATION PERMISSION FORM
The YMCA requires written approval or instructions from parents prior to administering non-prescription medication to
children in summer child care. Sunscreen is considered a non-prescription medication. As the parent or
guardian of the above child, I give permission for the staff at the YMCA programs, to provide a sunscreen product of
SPF 30 or higher, especially during the months of April-September. I understand the YMCA staff will not be applying
the sunscreen on my child.
Check one:
In the event that I forget to send sunscreen with my child on a particular day, I approve of the YMCA to provide
my child with sunscreen of SPF 30 or higher.
Please do not provide my child with sunscreen, I will provide my child with specific type of sunscreen
The YMCA has a limited supply of sunscreen available at the child care site to provide to children on days when they may forget their personal
sunscreen bottles. Parents/Guardians are required to send Sunscreen each day with their child.
Parent/Guardian
Signature:
Date
SWIMMING AND AQUATIC SURVEY
CHILD’S NAME
Does your child know how to swim:
SEX
Yes
BIRTH DATE
(M/D/Y)
No
How would you describe your child’s swim ability? Is your child comfortable in water?
Is your child currently enrolled in swim lessons at the YMCA or has your child ever been enrolled in swim
lessons at the YMCA?
If yes, what is your child’s current level or what was there level when they stopped attending lessons at the
YMCA?
Your child may be required to have a swim test prior to the start of the program. Have you read the
information about swim testing in the Parent Handbook or the Summer Program Guide for Summer Child Care
Programs/Day Camp?
If your child does require a swim test based on the criteria listed in our Parent Handbook and/or Summer
Program Guide for Summer Child Care Programs/Day Camp, have you read the available dates and selected a
date to attend? Please note: Swim testing is every Saturday in May, June and July from 12:00 pm to 2:00
pm. There are no appointments for Swim Testing. You just need to show up on one of the swim testing dates
(every Saturday in May, June and July) during the swim testing time (12:00 pm – 2:00 pm) with your child in
their swim attire.
Please read the parent handbook for more details on swim testing, as not all children are required
to have a swim test. This summer, we will be offering Swim Lessons as a part of the program for
children entering grades K-2 in the fall. This is an included benefit in our camp program and
offered at no extra charge to you.
Parent/Guardian
Signature:
Date
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
ADDRESS
NUMBER
MIDDLE
FIRST
SEX
TELEPHONE
(
STREET
FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME
CITY
LAST
STATE
MIDDLE
ZIP
FIRST
BUSINESS TELEPHONE
(
HOME ADDRESS
NUMBER
STREET
CITY
STATE
ZIP
LAST
MIDDLE
FIRST
NUMBER
STREET
CITY
STATE
ZIP
LAST NAME
MIDDLE
FIRST
)
HOME TELEPHONE
(
PERSON RESPONSIBLE FOR CHILD
)
BUSINESS TELEPHONE
(
HOME ADDRESS
)
HOME TELEPHONE
(
MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME
)
BIRTHDATE
)
HOME TELEPHONE
BUSINESS TELEPHONE
(
(
)
)
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY
ADDRESS
NAME
TELEPHONE
RELATIONSHIP
PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN
ADDRESS
MEDICAL PLAN AND NUMBER
DENTIST
ADDRESS
MEDICAL PLAN AND NUMBER
TELEPHONE
(
)
TELEPHONE
(
)
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?
■
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
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE
DATE OF ADMISSION
LIC 700 (8/08)(CONFIDENTIAL)
DATE LEFT
ADMISSIONS AGREEMENT
Admissions Agreement – Page 1 of 2
ACKNOWLEDGEMENT/AGREEMENT – As the parent or legal guardian of the above named child I understand agree
to and/or acknowledge the following:
A. I acknowledge that I have received a copy of the YMCA 2016 Summer Child Care Program Handbook and will
comply with the policies set forth. I further acknowledge that I have received copies of the following
documents required by the State of California Community Care Licensing: “Parents Right (LIC 995)”,
“Personal Rights (LIC 613A)”, “Parent Handbook”, “Fee Schedule Page”, “Caregiver Background
Check Process (LIC 995E) and “Acknowledgment of Receipt of Licensing Reports” if applicable.
Some of these documents are located in this registration packet, while others are located in the Parent
Handbook.
B. Field trips, either by walking or in YMCA vehicles or chartered buses are a part of the Child Care program
activities. No additional permission slips will be required.
C. Authorization for the YMCA to take photographs, videos, motion pictures and /or sound recordings of the child
care participant of members of the participant’s family. I further grant the YMCA permission to use the
photographs video, motion pictures or sound recordings in its general publicity materials. See attached
waiver.
D. The YMCA staff and volunteers are not allowed to babysit or transport children at any time outside of the
YMCA program (The YMCA will take immediate staff and volunteer disciplinary action if a violation occurs).
Staff are not permitted, under any circumstances, to transport children in their personal vehicles.
E.
That I am not allowed to leave my child at the YMCA program center unless a YMCA staff is there to receive
and supervise my child.
F.
That should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for
the child’s safety, staff may have no recourse but to contact the police. (Please do not put staff in a position
where they have to make this judgment call.)
G. That the YMCA is mandated by state law to report any suspected child abuse or neglect to the appropriate
authorities for investigation.
H. That per Department of Social Services, Community Care Licensing, Title 22 regulations, and my child’s file is
available for review by the Department of Social Services and representatives from these agencies may
interview my child without prior parental/guardian permission. In addition Law Enforcement personnel may
request the information listed in your file and may interview your child if necessary.
I.
If your child is suspended from the program due to behavioral / discipline issues, you have exactly 30 minutes
to pick-up your child from the program center; the child can be picked up by either a parent or a parent’s
designee (designee listed on the enrollment form authorized for pick-up). Furthermore, an additional day of
suspension will be added for every 30-minute period that the child is not picked-up from the site. An
additional day of suspension will be added at the 31st minute and an additional day will be added every 30minutes thereafter, for a maximum of up 3 additional days. Parents will not receive reimbursement, credit or
refund for these missed days, including the missed days of the original suspension. It is important for parents
to pick-up their child immediately if suspended due to discipline issues. Our goal is to provide your child with
a stimulating environment that keeps them engaged in positive behavior. Unfortunately, some severe
discipline issues can arise throughout the day that require immediate parent intervention and possibly a
suspension from the program for any set amount of days.
J.
That the YMCA may terminate my child’s enrollment for any of the following reasons:
•
Emergency names and phone numbers are incorrect.
•
Parent is late picking up child after program center closes.
•
Non-payment, late payment or ATS reject of fees.
•
Failure to adhere to the sign in and out policy.
•
Failure to notify the YMCA that the child is absent.
•
Child leaving the program center without authorized permission.
•
Behavior that is continually disruptive or dangerous to others and/or self.
Admissions Agreement – Page 2 of 2
•
(Continued from letter J) Behavior that is disruptive to property and/or refusal to replace said property.
•
Any single incident that is deemed by the program center director to be dangerous, harmful or disruptive.
•
Harassment, violent behavior or threat of such behaviors against a staff person or other member by
parent/guardian or persons associated to the child (family member, family friend, etc.).
K. That program participation requires that my account is in good standing with all balances up to current. This
includes program fees and membership dues (if applicable). Non-payment of program fees and / or
membership dues (if you are a facility member) will result in my child not being allowed to participate in the
program and could result in legal referral with the additional costs to myself, until the balance is paid and
current. I further understand that there is an administrative processing fee for any payment returned by my
bank or credit account.
L.
The YMCA and the staff employed by the YMCA will not become involved in custodial disputes between
parent/guardian. If YMCA documents are requested, the court must request them. The staff’s responsibility is
to provide a safe environment for children.
M. I understand I am required to give 15 days’ written notice when terminating my child from YMCA child care
programs. If 15 days is not provided I will not receive a refund or credit and I will be billed or charged as
regularly scheduled. Registration Fees are non-refundable.
N. Pick-Up of Child from Child Care Center: I understand and agree that in the event my child is not called
for by closing, the Child Care Center will immediately make every attempt to contact me, or other persons
authorized by me to take my child from the center. If I or my authorized individual cannot be located, or if
satisfactory arrangements for calling for the child cannot be made, that the office will continue to try to locate
me or another designed person; but if those efforts are unsuccessful within a reasonable period of time (one
hour), the appropriate law enforcement and welfare authorities will be contacted, and my child may be
released to the custody of those welfare authorities as a possible ward of the Juvenile Court. I hereby release
the YMCA, its employees and agents, from all liability for any damage sustained by my child or by me which
results directly or indirectly from the procedure outline above. I further agree that if this procedure must be
utilized because I fail to pick-up my child on time from the center, or because any person designated by me
fails to pick up my child on time from the center, I will indemnify and hold the YMCA Child Care Center
harmless for any damage sustained by my child. I hereby release the YMCA, its employees and agents from
all liability and responsibility for any damaged sustained y my child after closing time. I understand and agree
that if my child is not called for at the designated time, my child and I may be dropped from the program. I
have read the foregoing acknowledgement and release. My signature below indicates that I understand and
agree to it.
O. My child, listed below has my permission to participate in all activities which are a part of the YMCA Child Care
Program. These activities include water play, use of the playground and apparatus, woodworking, cooking,
animal care, messy arts and crafts, adult supervised walks in the immediate neighborhood / community of the
YMCA Child Care Center, field trips and other active play experiences typical in a Child Care Program. I, the
undersigned, hereby release and discharge the YMCA, officers, employees, agents and servants (herein,
collectively referred to as the YMCA). For the purpose of this agreement, liability means all claims, demands,
losses, courses of action, suits or judgments of any kind that I, my heir, executors, administrators or
assignees may have again the YMCA because of any loss or damage to property that results from any cause
other than the negligence of the YMCA. I have no objection to my child being included in photographs, slides
or movies taken in the YMCA which might be used for the purposes of interpreting the Child Care Program. I
understand that college students may be making observations at the YMCA as a part of class assignments and
that any photography or observation will be done only under the supervision of the director. I understand
that the discipline methods use with my child shall include warnings, redirection, denial of privileges and
logical consequences. Continued behavioral issues may warrant a suspension from the program, as outlined
in our Parent Handbook (see Positive Discipline section). I have read, understand and agree to the
stipulations and policies in the child care registration packet and policy handbook and realize that abuse of the
policies may lead to the termination of my child’s enrollment.
My signing below, I acknowledge that I have read and agree to all the statements in this document:
Parent/Guardian
Date
Signature:
Name of Child being
STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
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
TOILET TRAINING STARTED AT
*
BEGAN TALKING AT
*
*
MONTHS
MONTHS
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
DATES
■
■
Poliomyelitis
■
Three-Day Measles
(Rubella)
Ten-Day Measles
(Rubeola)
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
■
DOES CHILD HAVE FREQUENT COLDS?
YES
■
NO
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?
*
WHEN?
DOES CHILD SLEEP DURING THE DAY?
*
DIET PATTERN:
DOES CHILD SLEEP WELL?
*
HOW LONG?
*
BREAKFAST
(What does child usually
eat for these meals?)
*
*
WHAT ARE USUAL EATING HOURS?
BREAKFAST
LUNCH
LUNCH
DINNER
DINNER
ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
IS CHILD TOILET TRAINED?
■
YES
■
IF YES, AT WHAT STAGE:
*
*
NO
ARE BOWEL MOVEMENTS REGULAR?
■
YES
■
*
WHAT IS USUAL TIME?
*
NO
WORD USED FOR URINATION
*
WORD USED FOR “BOWEL MOVEMENT”
*
PARENT’S EVALUATION OF CHILD’S HEALTH
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?
■
YES
■
DOES CHILD USE ANY SPECIAL DEVICE(S):
■
YES
■
IF YES, NAME OF DOCTOR:
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?
■
NO
IF YES, WHAT KIND:
NO
YES
■
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
NO
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME? IF YES, WHAT KIND:
■
YES
■
NO
PARENT’S EVALUATION OF CHILD’S PERSONALITY
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
LIC 702 (8/08) (CONFIDENTIAL)
DATE
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CONSENT FOR EMERGENCY MEDICAL TREATMENTChild 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)
)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
PERSONAL RIGHTS
Child Care Centers
Personal Rights, See Section 101223 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.
Not to be locked in any room, building, or facility premises by day or night.
(6)
(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
6167 Bristol Parkway, Suite 400
CITY
CULVER CITY
ZIP CODE
AREA CODE/TELEPHONE NUMBER
CA
90230
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
LIC 613A (8/08)
(DATE)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
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:
Community Care Licensing LA Northwest Office
Licensing Office Address:
6167 Bristol Parkway, Suite 400, Culver City, CA 90230
Licensing Office Telephone #:
310-337-4333
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 www.meganslaw.ca.gov
LIC 995 (9/08)
(Detach Here - Give Upper Portion to Parents)
A C K N O W L E D G E M E N T OF NOT I F I C AT I O N OF P A R E N T S ’ R I G H T S
(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)
NOTE:
Date
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 www.meganslaw.ca.gov
LIC 995 (9/08)
RECEIPT OF 2016 SUMMER CHILD CARE PROGRAM PARENT HANDBOOK
& ACCEPTANCE OF POLICIES AND PROCEDURES
By signing below, I acknowledge the following:
•
I have received a copy of the 2016 Summer Child Care Program Parent Handbook applicable to the current season and to the program my
child is registered. I have read and understood the contents and information within the 2016 Summer Child Care Program Parent Handbook.
•
I understand that I can sign-up pay for the Summer Child Care Program in one of the following ways:
1.
Pay for the child care sessions upfront and in advance using cash or credit
2.
Reserve sessions for our Summer Child Care Program by setting up an Automatic Payment Plan using my checking/savings or credit
card account.
3.
Walk-in payment session-by-session (week-by-week) without a reservation and without a guarantee of a space.
•
I understand that due to the short turnaround, the YMCA cannot accept checks as a form of payment for the Summer Child Care Program.
The YMCA will accept cash or credit only.
•
I understand that when I sign my child up for the Summer Child Care Program, I am required to pay a $50 registration fee for each child that
I am enrolling in the form of cash or credit. After paying the registration fee, I may register my child for a Summer Child Care Program
session or sessions using one of the following options: (1) pay for the Summer Child Care Program sessions upfront and in advance using
cash or credit or (2) reserve Summer Child Care Program sessions by setting up an Automatic Payment Plan using my checking/saving
account or credit card account. Session fees will be deducted for each session on each payment draft date & deadline for cancellations or
changes (Payment draft date & deadline for cancellations or changes is one week in advance of each session – the draft will happen at 12:01
am on Mondays). I will be subject to a $25 service charge for all returned items due to insufficient funds and my enrollment may be
cancelled. I can re-enroll my child if space is available. Although not recommended, I can pay session-by-session (week-to-week), before,
on or after the payment draft date & deadline for cancellations or changes, in-person, at the YMCA. However, I understand that this method
of paying is not a reservation and is subject to space availability at the time that I make the full payment for a session. There is no preregistration or reservation (saved space) if I choose to pay this way.
Automatic Payment Plan Draft Schedule / Deadline for Cancellations and Changes
Weekly
Dates
Draft Date &
Weekly
Sessions 1-5
Deadline for
Sessions
Cancellations or
6-10
Changes
Session 1
June 13 – June 17
June 6
Session 6
Session 2
June 20 – June 24
June 13
Session 7
Session 3
June 27 – July 1
June 20
Session 8
Session 4
July 5 – July 8 (4 days)
June 27
Session 9
Session 5
July 11 – July 15
July 5
Session 10
Dates
July 18 – July 22
July 25 – July 29
Draft Date &
Deadline for
Cancellations or
Changes
July 11
July 18
July 25
August 1
August 8
•
I understand that there is a $50 non-refundable registration fee due for each child in order to sign-up for the Summer Child Care Programs.
This fee is non-refundable, even if my child never attends our programs. The YMCA will not refund, credit or transfer this fee for any reason.
I understand that the Child Care Department has two annual registration fees per year. There is a $50 registration fee for programs that take
place in the school-year. This fee must be paid annually (once per school year). The school year programs include fall, winter and spring full
day Child Care Program and before / after school programs. I understand that there is a separate $50 registration fee for child care programs
that takes place in the summer. This fee must be paid annually (once every summer). The summer programs includes our Summer Child
Care Program and the Traditional Day Camp at the Y. The two registration fees do not cover each other. Once I pay the registration fee for
summer, I will not have to pay it again during the current season. I will not have to pay it again until next summer. Similarly, for the school
year programs. Once I pay the registration fee for the school year, I will not have to pay it again during that current school year. I will not
have to pay it again until the following school year. I understand that the registration fees are annual and must be paid each year; once a
year for summer and once a year for our school year child care, if I intend to participate. For the school year, I would not need to pay the
registration fee until I enroll in a school year program, such as before / after school or a seasonal full-day program (such as our fall, winter or
spring Child Care Program).
•
I understand that I may cancel my child’s enrollment for any session as long as I request it on or prior to the payment draft date & deadline
for cancellations or changes of the session or sessions I am requesting to be cancelled from. After the payment draft date & deadline for
cancellations or changes, the YMCA will not approve any cancellations from the program. To request a cancellation from a session or sessions
of the Summer Child Care Program, I must request a Summer Child Care/Day Camp Exit & Cancellation Form. I understand that I must
complete and return the form on or before the draft date & deadline for cancellations or changes or draft date & deadline for cancellations or
changes of the session or sessions I am requesting to cancel from. I understand that the YMCA will only approve cancellations requested
before the deadline. If I do not want to cancel, but want to make a change to my enrollment, I understand that I must complete a Summer
Child Care/Day Camp Transfer & Changes Form. I understand that the YMCA will be happy to make any cancellations to my enrollment as
long as I submit the request on or prior to the draft date & deadline for cancellations or changes for the session or sessions I are requesting.
•
I understand that a transfer request is a request for a change to my child’s enrollment that allows me to transfer (or switch) the same child
from one or more week session(s) to another week or other week session(s). This is being offered to me as a convenience, as the YMCA
understands that scheduling conflicts may arise during the summer. I must complete a Summer Child Care/Day Camp Transfer & Changes
Form and identify which session(s) I am transferring from and which session(s) I want to transfer to. Transfers are subject to space
availability at the child care program site I am transferring to. I may make one transfer per summer, per child, for free of charge. I
understand that any additional transfers after the first free transfer is $10 per session, and per child, and that I am responsible to make this
payment to the YMCA along with my request. I understand that the $10 fee is due at the time of the transfer request and is contingent upon
whether or not space is available and the request is made on or prior to the draft date & deadline for cancellations or changes. The deadline
for a transfer request for a specific session or sessions is the same as the draft date & deadline for cancellations or changes (listed on the
chart above). All transfer requests must be submitted by 10:00 pm on or before the draft date & deadline for cancellations or changes for the
session or sessions I am requesting for the YMCA to change.
•
I understand that the YMCA will not issue credits for missed days of program or missed days of a session. The YMCA will not issue credits for
missed days of any session due to the wait period requirements for first time participants. If a refund is approved, I may request it in the
form of a program credit.
•
I understand that I may request a refund for the Summer Child Care Program using the refund request form. I understand that there is a
$25 refund fee for all approved refunds that will be deducted from the total refund amount approved. The $25 refund fee is per session and
per child. If I am requesting a refund for several sessions and it is approved, I will be assessed a $25 refund fee for each session and for each
child. I understand that the refund request form is exactly what it states, a request. Completion of the refund request form does not
guarantee me a refund. The draft date & deadline for cancellations and changes (listed on the chart above) is also the deadline to request a
refund for each session. If I am requesting a refund for a session or sessions and it is after the draft date & deadline for cancellations and
change for that session, I understand that the refund will not be approved under any circumstance. For example, the final payment for
Session 1 is due June 6. June 6 is also the deadline to request a refund or to make changes for Session 1.
•
I understand that in order for the YMCA to be fair to all program participants, only parents who have paid for the program weekly sessions will have their child or children listed
on the weekly session roster. I understand that if I am paying via a draft from their checking, savings or credit account, my child will automatically be on the roster for the session
once my payment has successfully be transferred to the YMCA. I understand that if my draft is declined due to Non-Sufficient-Funds (NSF) or any other account issues, my
child’s enrollment will be cancelled from the roster and the space will be opened for enrollment. I may re-enroll if space is available.
I understand that when a draft payment does not go through, the YMCA Accounting Department will reach out to me or the account holder to obtain payment. I understand that
failure by the YMCA Accounting Department to reach me or the account holder is not an excuse for a non-payment, nor does this reserve me the right to have a reserved space.
The YMCA encourage me to check my accounts weekly to ensure that payments has been successfully processed and that I should contact the YMCA Accounting Department at
the West Valley YMCA to correct any payment issues. I understand that if I am opting to pay session-by-session (week-to-week), via a walk-in payment, my child will not be
added to the roster until the full payment is made.
I understand that the YMCA does not accept reservations or partial payments. In order for my child to be enrolled in the program and on the weekly session roster, a full payment
must be made. I understand that there are no reservations allowed and YMCA cannot save spaces. The only way to guarantee my child’s enrollment is to pay for the sessions in
advance or set-up a weekly draft, if space is available.
•
I understand that the Summer Child Care Program closes each day at a specific time. If I pick up my child late, I will be charged a late pickup fee of $10 for every 15 minute period that I am late in picking up my child, beginning 60 seconds (1 minute) after the program closes.
Unless noted, all YMCA child care program centers close at 6:00 pm. Our Bay Laurel location operates until 6:30 pm on all days of
operation, unless otherwise noted.
•
I understand that during the summer season, the Summer Child Care Program will be closed at all locations on Monday, July 4, 2016.
Although this is a shortened session, the YMCA does not prorate the cost of the session and, if I have selected this session (Session 4), I must
be prepared to pay the full weekly session program fee.
•
I understand that the YMCA does not prorate, issue credits or refunds for missed days of session or late registration. The YMCA is not
responsible for personal schedule conflicts. The YMCA does not prorate for wait periods for first time participants.
•
I understand that the YMCA will not accept deposits, partial payments, or split payments for the Summer Child Care Program 2016. The
YMCA will allow you to register after the payment draft date & deadline for cancellations or changes by walk-in if space is available.
•
I understand that the YMCA reserves the right to combine or cancel programs due to low enrollments.
•
I understand that the YMCA reserves the right to limit the age or grade range for any program.
•
I understand that if my child is involuntarily removed from the program (suspended or expelled) due to behavior problems, I will not receive a
refund, credit or transfer of any kind for any fees paid.
•
I understand that if my child is suspended from the program due to behavioral / discipline issues, I will have exactly 30 minutes to pick-up
my child from the program center; my child can be picked up by either by myself, another parent or my designee (designee listed on the
enrollment form authorized for pick-up). Furthermore, an additional day of suspension will be added for every 30-minute period that my child
is not picked-up from the site. An additional day of suspension will be added at the 31st minute and an additional day will be added every 30minutes thereafter, for a maximum of up 3 additional days. I understand that I will not receive reimbursement, credit or refund for these
missed days, including the missed days of the original suspension. It is important that I pick-up my child immediately if my child is
suspended from the program due to discipline issues. The YMCA’s goal is to provide my child with a stimulating environment that keeps them
engaged in positive behavior. Unfortunately, some severe discipline issues can arise throughout the day that require immediate parent
intervention and possibly a suspension from the program for any set amount of days.
•
I have read and understood the West Valley Family YMCA’s Trial Period policies and procedures listed on the child care welcome letter. I fully
understand all procedures related to the child care trial period refund request.
•
I understand that if I have applied for financial assistance, I must wait until my application is approved before enrolling in any Summer Child
Care Programs. If I enroll before my application for financial assistance is approved, the YMCA cannot go back and adjust / reduce session
fees.
By signing below, I acknowledge that I have read and understood the above statements. If this statement is true, please confirm by signing below:
Parent/Guardian
Signature:
Name of Child being
Date
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of the YMCA (or for my
children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or
participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such
participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as “the
undersigned”) hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or
participating will, inspect and carefully consider such premises and facilities and/or the affiliated program. It is further
warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such
affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such
affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as
being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such
children.
IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT
NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFFSITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:
1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES,
DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, volunteers and agents
(hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal
representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or
demands on account of injury to the person or property or resulting in death of the undersigned or such children
whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or
such children is in, upon, or about the premises or any facilities or equipment therein or participating in any
program affiliated with the YMCA.
2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each
of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or
passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises
or any facilities or equipment therein or participating in any program affiliated with the YMCA.
3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH OR
PROPERTY DAMAGE to the undersigned or such children due to negligence, active or passive, of releasees or
otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or
equipment thereon or participating in any program affiliated with the YMCA.
THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND
INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California
and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal
force and effect.
THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY
AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing
written
agreement
have
been
made.
THIS AGREEMENT DOES NOT APPLY TO LICENSED CHILD CARE SERVICES.
I HAVE READ THIS RELEASE
Date: ___________________________________
___________________________________________
Printed Name
___________________________________________
Signature of Applicant/Guardian
_____________________________________________________________________________________________
Name(s) of Child(ren) in Program and/or YMCA Facility
Revised 5/22/08
PHOTO & VIDEO/AUDIO RECORDING RELEASE
PLEASE PRINT
I ______________________________________________________ am eighteen years of age or older, and if
not, then my Mother/Father/Legal Guardian has also signed below under my signature.
With regard to my participation in activities sponsored by or related to any activity in which I participate in any way
sponsored by the National Council of Young Men’s Christian Associations of the United States of America, and to any
YMCA of the USA Association, including the Young Men’s Christian Association of Metropolitan Los Angeles
(collectively, “YMCA”), I hereby give my permission and consent, now and for all time (without any further
compensation, claim or demand by me) to the YMCA, and to advertising agencies, agents, entities and third parties
collaborating with the YMCA and their representatives, if any, (the “Organizations”) to make, reproduce, edit,
broadcast or rebroadcast any video, film, or digital footage and other sound track recordings, or photo reproductions
of my image or voice in any form, and my narrative account of my experience with YMCA activities (“Materials”) for
publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any
further compensation to me. I may or may not be identified by name in such reproductions. However, I shall not be
stated by name to have endorsed any particular commercial products or commercial services without my express
written permission.
I further agree to the following:
• Any Materials created subject to this Release shall belong to the YMCA as its property, with full right of disposition of
them without my oral or written permission.
• The Materials will not be subject to any obligation of confidentiality and may be shared with and used by the
Organizations, as well as with any third parties as the YMCA may elect.
• The YMCA shall not be liable for any claim arising from the use or disclosure to a third party of any of the Materials.
• The YMCA shall exclusively own all known or later existing rights to the Materials worldwide and shall be entitled to
the unrestricted use of the Materials for any purpose without compensation to me or the provider of the Materials.
AGREEMENT AND CONSENT
I have read and understood the contents of this Release. I agree that my consent to this Release is irrevocable. I
hereby voluntarily release and discharge the YMCA and the Organizations and their representatives from any and all
claims arising out of or relating to or in connection with the uses and reproductions of my image and voice and my
narrative account as described herein. I understand that the term “YMCA” in this Release specifically includes the
YMCA of Metropolitan Los Angeles.
Signature: ____________________________
Date: ____/____/________
Age: ___________________
Email Address: ________________________
Phone: _________________
Cell Phone: _______________
Address: ____________________________________________________________________________________
I am the Mother/Father/Legal Guardian of ___________________________. I have read and understand
PLEASE PRINT
the contents of this Release and hereby voluntarily consent to this Release on behalf of my minor child.
Signature of Mother / Father / Legal Guardian: _____________________________
Date: ___________________
Email Address: ___________________________
Phone: ________________________________
Cell Phone:
_______________________________
Address: ______________________________________________________________________________________
Rev 2014
SUBSIDIZED CHILD CARE AGREEMENT
ONLY COMPLETE IF YOUR FAMILY HAS BEEN APPROVED FOR CHILD CARE SUBSIDY THROUGH A CITY,
COUNTY OR STATE AGENCY.
The West Valley YMCA has partnered with the Child Care Resource Center and other child care subsidizing agencies to
provide free or low cost child care services for our YMCA Before and After School and Summer Child Care Programs to
families who qualify.
The West Valley YMCA is proud to partner with these community based agencies to make our programs accessible to all
families, regardless of their ability to pay the full fee. These partnerships are extremely valuable to us and we are hopeful to
remain connected to these agencies for years to come.
It is important that families not only follow the YMCA guidelines for participation in these subsidy programs, but also the
guidelines of the subsidizing agency. Our partnership is put at risk when families make the choice not to follow the rules or
guidelines.
Effective immediately, the following guidelines and rules will be enforced for all families in our YMCA child care programs who
receive subsidy from an outside agency:
•
•
•
•
•
•
•
•
Agency timesheets must be completed daily.
o
When the child arrives from school, the Y staff will sign the child into the program and notate their time on
the timesheet. The parent or authorized adult will notate the time when the child is picked-up from the
program.
o
When the child arrives to our program from home (such as when we offer full-day child care), the parent or
authorized adult must notate the time on the timesheet at both drop-off and pick-up.
o
This must be completed daily.
Families are not permitted to complete timesheets at the end of the month. The timesheet must be completed
daily (Every day that the child is in the program).
Children are expected to be in the YMCA program every day that the program is in operations and within the
parameters of the option your child is registered within. Pro-longed absences from the child care program may
result in the Y’s refusal to provide child care services and thus, the cancellation of the subsidy contract. Ill children
should not attend program.
Families are required to sign the timesheet on the last day of the month.
Timesheets may never be taken from the YMCA facility under any circumstances.
Timesheets will remain in the site sign-in/sign-out binder at all times.
Both the agency timesheet and the YMCA sign-in/sign-out forms must be completed each day.
Parents are responsible for balances not paid by their subsidizing agency. If your subsidizing agency does not make
a full payment to the YMCA, you will be invoiced for the remaining balance.
Additionally, all families are required to pay the annual registration fees for our programs, as this fee is not covered by your
subsidizing agency.
Families who fail to comply with these guidelines and rules will be removed from the YMCA program. When one family is not
compliant with these guidelines, it places all families receiving subsidy from the same agency at risk. It is vital that families
comply with these guidelines, effective immediately. On the first business day of the month, the YMCA expects to
have a completed timesheet for your child for the previous month, including a signature from the parent. Failure
to have a complete timesheets will result in your removal from the YMCA program. The YMCA is required to audit
and submit timesheets by the deadline. Families with incomplete timesheets hold up the submission of all timesheets for all
child care facilities/programs in the West Valley Family YMCA. It also delays our payments by up to 60 days.
This form must be signed and returned with your registration packet prior to the start of the program. Families who do not
have Subsidized Child Care Contracts on file will be responsible and billed for the full fee to the West Valley Family YMCA.
The YMCA understands that these policies are being strictly enforced. Unfortunately, many families have taken advantage of
these subsidy services and not completed their part of the agreement. It is our desire to continue to partner with these
agencies to provide this service to you. Please continue to do your part so that we can do our part, which is to develop your
youth and help them reach their full potential.
Parent/Guardian
Signature:
Name of Child being
Date
GETTING TO KNOW YOUR CHILD QUESTIONNAIRE
At the Y, we strive to develop the whole child. This includes understanding the children who participate in our
programs and understanding their family. As a part of our registration and enrollment process for all children, we
require all families to complete this questionnaire about their child. The information you provide will help us to best
provide care for your child’s individual needs. This questionnaire is required, as this information is extremely valuable
to your Site Director and Site staff. The information below will provide us with information about your child’s daily
routine, social development, health and family.
CHILD’S NAME
SEX: ✔ M F
BIRTH DATE
(M/D/Y)
Who does your child live with?
Name:
Relationship to child:
Please list all adults, siblings and other
adults and children living in the home
with the child (example, mother, father,
brother, grandparent, etc.)
Describe your child’s personality in 5 words:
What motivates your child?
1.
2.
3.
4.
5.
What makes your child upset?
What are three goals you have for your child
for this year (or this summer)?
We do not celebrate the following holidays:
What is the primary language spoken at
home? Are there any other language spoken?
Does your child know more than one
language?
What responsibilities does your child have at
home? Such as chores, etc.
Please list any fears your child may have
(dogs, vacuum cleaners, etc.):
What comforts your child when he / she is
upset?
What are your child’s interests and hobbies?
What outside activities does your child
participate in?
Does your child have any allergies? Please
list all allergies (food, medication,
environmental, etc.):
Does your child have any health problems
that you believe we should be aware of? Has
their health improved, decline or remained
steady over the past 3 months?
Do you think your child feels good about
himself/herself? Please comment:
1.
2.
3.
What is your child favorite:
How does your child get along with other
children?
Color:
Cartoon:
Treat / Snack:
Toy Brand:
School Subject:
Game:
Does your child have any special needs that
you feel are important for us to know about?
Please describe any recent family events or
major changes in your child’s daily routine
that we should be aware of (death, divorce,
marriage, new siblings, new blended family,
moving, parent change in work schedule,
etc.), if any.
What rules do you have at home that your
child must follow?
Does your child make friends easily?
How does your child react to frustration? How
does your child relax or soothe him or
herself?
How do you deal with discipline issues at
home?
Does your child have a nickname that you
and other family and friends call him or her?
The YMCA is a group child care program with
1 adult staff for every 14 children. How well
will your child function in an environment
with a 1 to 14 teacher to child ratio?
If your child does not live with both parents,
how often do they see their other parent?
What activities do you share or do together
as a family?
How do you feel that the YMCA can best
support your child?
Is there anything else you would like to share
about your child?
Parent/Guardian
Signature:
Name of Child being
Date
POSITIVE DISCIPLINE POLICIES
It is our intent that each child enjoys the activities planned by understanding that she/he is responsible for her/his actions. With
prior knowledge of our basic rules of safety and good conduct, each child is made aware of how to exercise self-discipline. We are
here to assist her/him and to know that we expect her/him to succeed. YMCA house rules and anti-bullying strategies will be
reviewed weekly at the Child care site. We also use positive reinforcement by consistently acknowledging good behavior.
The expectations listed below are the general expectations we have for all of our program participants:
•
Respect for yourself, for others, and for property.
•
Safety first.
•
Speak for yourself/listen attentively.
•
Be responsible for your words and actions.
Philosophy
The YMCA strives to maintain a positive approach to managing children’s behavior at all times. “Discipline” is the process of teaching
self-control and the ability to live within limitations and agreed upon guidelines. The staff and children at each Child care site
establish expected behavior guidelines. Positive behavior is self-rewarding and allows for program activities to run smoothly. When
children choose to behave outside of the guidelines, some consequence is required to avoid future problems. The overall safety of
all children in the program is our highest priority.
Breaking Program Rules
•
If a child is not following the rules, he/she will be reminded of the rules.
•
If the child continues to break the rules, he/she will be asked to leave that area and find another area to play in.
•
If the child still fails to follow the rules, the Teacher will assign an area for the child.
•
If the behavior has not improved by this time, the child will be removed from the group and placed directly beside a Teacher
or staff member.
Threatening the Safety of the Staff and/or Children in the Program
•
If a child threatens the safety or health of anyone in our program by hitting, kicking, biting, pushing, spitting or any other
dangerous act they will receive a verbal warning.
•
If the behavior continues after the verbal warning has been given, the parent will be called to pick the child up within a half
an hour. Credit will not be reimbursed for this day.
•
After returning to program, if the child continues this behavior, the parents will be called to pick the child up within a half an
hour and the child will be suspended for one (1) program day. Credit or refund will not be reimbursed for these days. A
parent conference with the Director will be mandatory at this time.
•
The next time the child is required to be picked up for inappropriate behavior, they will again need to be picked up within a
half an hour and this time the child will be suspended for three (3) program days. Credit or refund will not be reimbursed
for these days.
•
Upon returning to program after a three day suspension and the child’s behavior continues, the parent will be called to pick
their child up within a half an hour and the child will receive his/her final suspension of one program session (5 program
days). Credit or refund will not be reimbursed for these days.
•
After the final suspension, if the inappropriate behavior has not stopped, the parent will be called to pick the child up within
half an hour and the child will be expelled from the program thereafter. There will not be any reimbursements of any kind.
•
Drugs, alcohol, lighters, weapons, electronics, cell phones, animals (dead and alive), and other such items, are not allowed
at the child care center/program.
There are some cases where a child will be sent home and/or suspended on the first violation. This is left to the Director’s discretion.
The Director also reserves the judgment to suspend a child for additional days based on the severity of the incident and the
behavior.
Suspension from Program
If your child is suspended from the program due to behavioral / discipline issues, you have exactly 30 minutes to pick-up your child
from the program center; the child can be picked up by either a parent or a parent’s designee (designee listed on the enrollment
form authorized for pick-up). Furthermore, an additional day of suspension will be added for every 30-minute period that the child is
not picked-up from the site. An additional day of suspension will be added at the 31st minute and an additional day will be added
every 30-minutes thereafter, for a maximum of up 3 additional days. Parents will not receive reimbursement, credit or refund for
these missed days, including the missed days of the original suspension. It is important for parents to pick-up their child
immediately if suspended due to discipline issues. Our goal is to provide your child with a stimulating environment that keeps them
engaged in positive behavior. Unfortunately, some severe discipline issues can arise throughout the day that require immediate
parent intervention and possibly a suspension from the program for any set amount of days.
Parent/Guardian
Signature:
Name of Child being
Date
PHOTO FOR YOUR CHILD’S FILE
At the Y, we want to keep your kid safe and we also want to be prepared for all emergencies.
Along with your registration packet, please submit an up-to-date photo of your child for their file. Children’s photos
and files will be locked away in a file cabinet at the child care site and in an emergency binder that staff can grab-andgo in case of an emergency or evacuation.
THE Y IS HERE FOR THE COMMUNITY
Looking For a great afterschool program? Well, look no further! The Y may be the answer for you! The WEST VALLEY
FAMILY YMCA has EIGHT great programs that might be a perfect fit for your child!
LICENSED CHILD CARE, BEFORE & AFTER SCHOOL
7 LOCATIONS: Vanalden Elementary (Reseda), Pomelo
Community Charter Elementary (Canoga Park / West Hills),
Round Meadow Elementary (Calabasas), Bay Laurel Elementary
(Calabasas), Woodlake Avenue Elementary (Woodland Hills),
Justice Street Elementary (West Hills), Calabash Charter
Academy (Woodland Hills).
Grades K – 5th (Our Calabash sites accept Pre-K and Journeys)
Did you know that we also offer before and after-school care at
7 elementary schools in the West Valley region, in addition to
Summer Child Care Programs? Our before-school and afterschool programs encourage families to play an active role in the
quality experiences that the Y provides for your children!
Our Curriculum provides:
•
Homework time and educational support
•
Weekly educational, recreational and fine arts
enrichment
•
Activities that encourage the families to spend time
together and build stronger relationships
•
Collaboration with community organizations to provide
other enrichment experiences for your child.
Enjoy the benefits of:
•
Safe, quality licensed child care
•
Morning care beginning at 7:00 am (at some locations)
and afterschool care ending at 6:00 pm.
•
Care when school is out of session
•
Options to meet everyone’s budget.
• Financial assistance available for qualify families
WANT TO KNOW MORE?
PLEASE CHECK ONE:
YES! Please send me more
information about your before and
after school programs.
NO…My child already attends a great
before and after school program or
has care during out-of-school time.
Name of before and/or after school
program child is currently attending:
Name of school:
Additional Comments:
AFTER SCHOOL RECREATION AND ENRICHMENT
CLUB PROGRAM
1 LOCATIONS: Haynes Charter for Enriched Studies (West Hills)
Grades K – 5th
Join our after school exempt-recreational enrichment club programs for kindergarten through 5th grade. Our Club
programs offer academics (homework support), enrichment (engaging and meaningful activities) and recreation
(fitness, outdoor activities and social time).
-----------------------------------------------------------------------------------------------------Are our before and after school programs too far for you? Does your child’s school lack high quality before and/or
after school program? Would you like a YMCA before and/or after school program at your school?
TELL US MORE!
What School Does Your Child Attend? _______________________________________________________________
What current programs are being offered? ____________________________________________________________
Principals Name: _________________________ Principals E-mail: ________________________________________
Principal or School’s Contact phone number: __________________________________________________________
Contact information for school’s PTA/Booster Club: _____________________________________________________
Tell us why your school needs a YMCA Before and/or After School Program:

Summer Child Care Program Registration Packet WEST VALLEY

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