WYCKOFF FAMILY YMCA School Age Child Care

WYCKOFF FAMILY YMCA
School Age Child Care
September 2014 – June 2015
Dear Parents:
Welcome to the Wyckoff Y School Age Child Care Program. The Wyckoff Y staff will do
everything to ensure that your child is provided with a safe, fun and nurturing
environment each day.
Please return the following to the Wyckoff Family YMCA at 691 Wyckoff Avenue,
Wyckoff, New Jersey 07481:
Registration Packet
E-mail Address
Transportation Form (if needed)
Signed Parent Contract
Completed and signed Tuition Payment Agreement
$40 non-refundable registration fee (per family)
$100 June tuition deposit (non-refundable)
A current Wyckoff Y Membership is also needed
You will receive:
Confirmation e-mail once registration is processed
Parent Handbook
Payment coupons available upon request
Please note that any incomplete forms will delay the registration process. Early
enrollment is necessary in order for your child to begin on the first day of school in
September. The enrollment deadline is July 31st, but does not guarantee availability.
When enrolling during the school year please allow five (5) business days from the
receipt of the registration paperwork until your child may begin the program.
Please be sure to encourage open communication with your child’s school and the
Wyckoff Y. Notify the school that your child is participating in the Wyckoff Y’s School
Age Child Care Program. If your child attends extra-curricular activities after school,
inform the Wyckoff Y and the school office so that your child is properly accounted for
at all times.
If you have any questions please speak with the Site Supervisor or contact the Wyckoff
Y directly at (201)891-2081.
Wyckoff Family YMCA
School Age Child Care Program
Monthly Tuition Information: 2014–2015

Sibling Incentive: A 25% reduction will be applied to the lesser tuition for those families
having more than one child participating in Wyckoff Y’s child care programs.

4:30pm Pick-Up Incentive: A 35% reduction will be applied to the After Care rate when a
child is picked up no later than 4:30pm.

Incentives cannot be combined.

Financial Assistance is available through the efforts of the Wyckoff Family YMCA and its
supporters. Please complete a Financial Assistance application and submit it with your
registration for the School Age Child Care Program. All applications must be received in
our office by July 31st. Applications are available at the front desk or our website
www.wyckoffymca.org

All registration forms must be returned with a $100 June tuition deposit and the
$40 registration fee. A current membership is needed to participate in the
program. If you do not currently have a family membership, complete the Basic
Membership form included in this packet. You must then pay the Basic
Membership fee by September 1st.

Registration is not considered active until payment and completed paperwork
are processed.
School Age Child Care Program
Office Use Only
Date_________________
Registration Form (2014-2015)
Child’s Name:
Male: 
Start Date____________
School:
Female: 
Grade in 9/14:
Birth Date:
Parent’s Name:
Parent’s Name:
Email:
Email:
Address:
Address:
Town:
Zip:
Town:
Zip:
Place of Employment:
Place of Employment:
Business Address:
Business Address:
Home Phone:
Home Phone:
Work Phone:
Work Phone:
Cell Phone:
Cell Phone:
Does your child have a sibling enrolled in any Wyckoff Y Day Care or SACC programs as of September
2014? If yes, please indicate name(s)
Are there any custodial limitations? Yes No (If yes, parent must attach a current copy of court documents).
These documents must be delivered to the Wyckoff Y Business Office prior to child’s scheduled start date in the
program.
Emergency Contacts/Authorized Pick-Up Please list adults (18 yrs. of age or older)*, other than
parents, who can pick up your child if you are delayed or if there is an emergency. A valid phone number must be
provided for each emergency contact.
Emergency Contact/Authorized Pick-up*
(other than parents)
Phone Number
Relationship
Full Name
Full Name
Full Name
Full Name
* Siblings under the age of 18 will not be allowed to pick up the child.
=======================================================================
Enrollment Selection
Before School
Care
KEP AM
KEP PM
M T W TH F
M T W TH F
M T W TH F
(Circle Days)
(Circle Days)
(Circle Days)
KinderKrew
3-2
HoHoKus Kinder
Extended
After School Care
M/T or R/F
M T W TH F
M T W TH F
(Circle Days)
(Circle Days)
(Circle Days)
 I will pick up my child by 4:30 and receive a 35% discount from the After Care rate.
For staff:
Fee $______________ Discount $ _________________ Total tuition to be paid $ ________________
School Age Child Care Program
Registration Form
Child’s Name: ____________________________________ Date: _______________
Yes No I permit the Wyckoff Y to print or display any photographs of my child in YMCA publications, on
the Wyckoff Family YMCA website and/or press releases. (Child’s name or identifiers will not be used)
PLEASE INITIAL AND SIGN BELOW:
______I give permission to the Wyckoff Y staff to communicate with my child’s school and teachers regarding
my child.
_______In case of a medical emergency, I authorize the Wyckoff Y to initiate emergency care in the event that I
cannot be reached.
_______I have received and read the Department of Children and Families Office of Licensing Information to
Parents Statement. (Included within this packet)
_______I give my child permission to participate in the School Age Child Care Program. In consideration for
accepting my child in the School Age Child Care Program, I agree on behalf of my child to hold the Wyckoff
Family YMCA and its agents and employees harmless against any loss or injury of any kind as a result of my
child’s activities while participating in this program.
Parent/Guardian Signature: _______________________________________ Date: _________________
Administration of Medicine / Medical Information
The Wyckoff Y staff will NOT administer over-the-counter medications to children without written permission
from a physician which specifies the recommended dosage for your child’s age and size. Students may NOT
carry their own or other medication to the program. A medication permission form must be completed in order
for the Wyckoff Y staff to administer any medication.
(This form has been included in the packet for you convenience).
In order to best care for your child, our staff must be aware of any medical, physical or special needs
your child has, including but not limited to the following.
Diabetes
Seizures
Asthma Allergies: ___________________________________
Chronic Condition ________________________ Activity Restriction _________________
Surgery & Other Health Issues _________________________________________________
Behavioral Condition ________________________________________________________
List any other medical conditions, special needs or physical limitations we should be aware of:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
________________________________
(A doctor’s note must accompany the registration listing restrictions and/or limitations)
When your child is ill, parent will be called immediately to pick him or her up from program
Wyckoff Family YMCA
Medication Permission Form
691 Wyckoff Avenue
Wyckoff, NJ 07481
Individual Medication Record
(201)-891-2081 Fax: (201)-891-3519
The Wyckoff Family YMCA After Care Program shall administer medications for children only after receipt of written approval
from the parent(s). Any prescription medication for a child shall be:
1) Prescribed in the name of and specifically for the child.
2) Stored in its prescription container, which has been labeled with the child’s name, the name of the medication, the date it
was prescribed or updated, and directions for its administration.
The center shall limit the dispensing of non-prescription over-the-counter medication to the following types of medicines:
antihistamines/decongestants, acetaminophens (Tylenol), cough suppressants and topical ointments. The center may permit
dispensing of non-prescription medication other than those listed above if the child’s physician authorizes in writing. This is in
compliance with state and federal laws.
Child’s Name:________________________________________________________________
Name of medication:_____________________________________________________________________
___ Prescription
(in original bottle)
___ Non-Prescription
(in original container)
Condition for administering medicine: _______________________________________________
Amount to be administered:____________________________________________________________
Times to be administered: ________________________________________________________
Refrigeration necessary: ___ Yes
___ No
Possible adverse reactions: _______________________________________________________
Staff member authorized to administer medication: _____________________________________
__________________
Date
_________________________________________________
Parent/Guardian Signature
Date and Time Administered
Adverse Reactions Observed
Y Staff signature
School Age Child Care Program Parent Contract
Please read contract carefully.
I understand that I am enrolling my child,
agree to the following:
into the Wyckoff Y SACC program and
1. Tuition:
I have signed and completed the TUITION PAYMENT AGREEMENT. I agree to pay monthly installments by cash, check,
money order OR automatic credit card draft (MasterCard, Visa or American Express) based on the number of contracted
days my child attends the program. Monthly payments will remain constant regardless of holidays or break weeks from
school. Multi-Child Discount (25%) applies when enrolling a second child in our Wyckoff Y’s SACC program.
a.
b.
c.
Monthly cash, check or money order payments are due by the 1st of each month. Payments should be mailed to: Wyckoff
Family YMCA, 691 Wyckoff Avenue, Wyckoff, NJ 07481. Payments may also be dropped off at the Wyckoff Y’s Business
Office. Site supervisors and assistants are not permitted to accept payments.
Automatic credit card draft payments will be processed monthly. If my credit card tuition payment is declined in any
given month, the subsequent month will be charged the declined amount. Returned checks incur a $20.00 bank
processing fee.
For updated information about your account and your monthly tuition rate you can access your account online. For
instructions see the Parent Handbook.
2. Schedule Changes:
I understand that days must be consistent each week for the month. I will notify the Wyckoff Y office of any changes to my
child’s attendance schedule or withdrawal from the program no later than the 15th of the previous month. You will be
notified of approval of your requested change once your request for Schedule Change Form is received. This form can
be downloaded from the Wyckoff Y’s website by going to Forms, Links, and Schedules. DAY-TO-DAY CHANGES ARE NOT
ACCEPTABLE and NO SWITCHING OF DAYS IS PERMITTED.
3. School Holidays:
The Wyckoff Y offers a full schedule of fun when school is closed for most holidays and/or snow days. Hours of care are
7:30am–6:00pm. Each day’s activities relate to a theme. Cooking, crafts and contests complete the day. You may choose
to sign your child up for one or all of the days. The fee is $45.00 per day per child enrolled.
4. Child Release/Pick Up:
The School Age Child Care staff will be responsible for my child from arrival through pick-up and will request proper
identification at pick-up. I understand that my child will not be released to an adult Suspected to be under the influence
of drugs or alcohol. Children must be physically signed in for Before Care and signed out at the end of After Care by an
authorized adult (18 years of age or older) for the safety and accountability of each child.
As I have designated on my child’s registration form, I will pick up my child by 4:30pm or 6:00pm. A late charge of $25.00
for every 15-minute interval may be assessed if I do not comply with my contracted hours.
5. Credit/Refund Policy:
I understand that I am responsible for full tuition payment regardless of any absences from the program. The June deposit
is non-refundable, and will only be applied to June’s tuition. There will be no credit given for contracted days lost due to
my child’s absence, holidays, or emergency closings. There will be no refunds for mid-month withdrawals. Payment is
based on ten equal payments regardless of school days in any month.
6. Emergency Closing:
I understand that if the school closes early due to inclement weather while in session, there will be NO After Care
Program. It is my responsibility to pick my child up from school at the school’s deemed closing time. If there is a
delayed opening, I understand that there will be NO Before Care Program. If the schools close for the day, there will be
no care for the entire day and there will be no tuition adjustments made.
7. Termination Policy:
The Wyckoff Y staff may recommend withdrawal of any child if a proper adjustment to the program is not made in a
reasonable length of time. The following steps will be taken before the termination of a child’s enrollment:




Verbal discussion with the parent regarding the situation.
Written Incident Report signed by the parent for the file.
An agreement between the parent and Wyckoff Y of a suitable timeframe to resolve the situation.
If the situation is not resolved a termination of the child from the program may be required.
I agree to adhere to the above School Age Child Care Program policies and give my child permission to participate in this program.
Date_________________________________
Signature __________________________________________
TUITION PAYMENT AGREEMENT
Date:
Child’s Name:
Program:
_
Monthly School Age Child Care costs are based on 180 days of school divided by
10 equal payments. Tuition is paid September – June and payment is due the
first week each month. No invoices will be sent, however you can access your
information online (see our instructions for online account access included in
the Parent Handbook). Tuition payments may not be given to Site Supervisors or
staff members.
Please check and sign items 1 OR 2 and provide credit card information below:
1._____ I agree to pay monthly tuition by cash, check or money order. In the event that
my cash, check or money order payment is not received by the 15th of the month, I
hereby authorize the Wyckoff Family YMCA to automatically charge the credit card
designated below (MasterCard, Visa or American Express) for the monthly School Age
Child Care tuition.
Signature
2. _____ I agree to pay my monthly tuition by an automatic credit card draft. I hereby
authorize the Wyckoff Family YMCA to automatically draft the following credit card
(MasterCard, Visa or American Express) on a monthly basis for the School Age Child
Care tuition amount.
Signature
___________________________________________________________________________
Credit Card: Visa
/ Mastercard
Credit Card #:
Credit Card Expiration Date:
Name as it appears on credit card:
Credit Card Billing Address:
Credit Card Billing Zip Code:
/
American Express (circle one)
CID #:
**Please note credit card information will be encrypted in our payment system and the credit card portion of this document will be
shredded and disposed of properly.
Wyckoff Family YMCA
School Age Child Care Program
Transportation Authorization Form
Dear Parents;
In accordance with our licensing requirements, parents are asked to sign the release below
granting the Wyckoff Y permission to transport your child to and/or from school during the 20142015 school year.
I hereby, give permission to the Wyckoff Family YMCA to transport my child. I also agree on
behalf of my child to hold the Wyckoff Family YMCA and its agents and employees harmless
against any loss or injury of any kind as a result of my child’s activities while participating in this
program.
My child, ________________________________ requires transportation to and/or from
____________________________________ (school) to the Wyckoff Family YMCA, 691 Wyckoff
Avenue, Wyckoff, New Jersey for the School Age Child Care Program. I understand that if my
child will be absent on any scheduled day, it is my responsibility to contact the Wyckoff Y at
(201) 891-2081 and report the absence as early in the day as possible.
Please check which applies:
____From your school to the Wyckoff Y.
____From the Wyckoff Y to school.
Signed: ____________________________________________________ (Parent/Guardian Signature)
Date: ___________________________
In addition, if your child is enrolled in program classes (swim, dance, sports etc.) and requires
transportation to their class from any School Age Child Care Program, an additional
transportation form must be completed at the time of program class registration.
Please access this Program Transportation Form from our website at:
http://www.wyckoffymca.org/wp-content/uploads/2011/04/Transport-Form3.pdf
Wyckoff Family YMCA
Basic Membership
Basic Member’s Name:
___
Address:
____
_____
City:
___ State:
Phone:
__ D.O.B.
ZIP:
_____
__ Sex:
____
_____
M
F
Business Phone:___________________________________________
Email Address:____________________________________________
Emergency Contact Name and Phone:
_________________________________________________________________
All membership fees are indicative of your support of this association and its
mission, and are therefore non-refundable.
___I consent to allow the Wyckoff YMCA to take photographs of my
child which may be used as part of activities or promotional materials.
___No photographs of my child may be taken.
Annual Membership Fee: $70
Paid:__________________________
(Check # and Date)
In consideration of my membership (including my family and all guests) to participate in
activities at the Wyckoff Family YMCA, I, for myself, my heirs, executors and administrators,
hereby release and forever discharge the Wyckoff Family YMCA and all representatives and
personnel from all liabilities, actions, claims, demands, damages, costs and expenses, which
may now or in the future have against them or any of them arising out of my participation
at the above mentioned Wyckoff Family YMCA including, but not limited to, all injuries that
may be suffered by me.
Signature:
_________
Date:
_____
(Parent’s signature if under 18)
For office use only
Date:___________
Rec: ___________