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YMCA Camp Bernie
327 Turkey Top Road
Port Murray, New Jersey 07865
Parent’s Name _______________________________ Child’s Name ___________________
This agreement establishes the terms under which YMCA Camp Bernie Advantage Before/After School
Program will provide childcare.
1)
I have received, read and agree to the Advantage Before/After School Program’s policies and
procedures and all guidelines set forth in the Parent Information Packet.
2) I will submit a $25.00 YMCA membership fee with my completed enrollment form along with payment
for September. I will be billed monthly thereafter.
3) I am responsible for monthly payments that will be due by the 25th of the previous month and that all
late payments are subject to a late fee charge of $10.00. Failure to make payment may jeopardize my
child’s slot in the program and may result in suspension or termination from the program.
4) There will be a $25.00 processing charge for any returned checks.
5) I will notify YMCA Camp Bernie in writing of any changes (names, phone numbers, etc…) in contact
information, either personal or for emergency contacts.
6) I agree to provide YMCA Camp Bernie with one (1) week written notice of any enrollment change or
withdrawal from the program, and understand that no refunds are possible after the first (1st) of the
month.
7) I understand that it is required by law that I, or an authorized adult individual, must escort my child into
the program in the morning and sign my child in on the designated form. It is also understood that it is
required by law that I, or an authorized adult individual, must sign out my child in the afternoon on the
designated form.
8) I understand that the after school program ends at 6 pm. Parents, or authorized individuals, picking up
after 6 pm may be charged $5.00 for every five minutes they are late and this charge will be billed
directly to me. Habitual lateness may result in dismissal from the program.
9) I agree to notify YMCA Camp Bernie if my child will be absent from the program on any given day.
Notification can be in the form of a note to the Site Director or by calling the YMCA Camp Bernie office
at least 3 hours prior to the program start time.I understand that there will be no before or after school
programs on days the school district closes due to emergencies or inclement weather and there will be
no after school care on days the school district closes early due to emergencies or inclement weather
and no before school on days the school district has delays due to emergencies or inclement weather.
Unfortunately, there will be no monetary credit for these missed days.
Failure to comply is a breach of contract and may jeopardize my child’s space in the program.
Parent Signature ____________________________________________Date ______________
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Child’s Name ______________________________
Birth Date_____________Male [ ] Female [ ]
Home Address _____________________________
Grade as of Fall ’10 _______________________
________________________________________
Phone (H) _______________________________
City _______________________ Zip _________
Email ____________________________________
Mother/Guardian Name ____________________
Father/Guardian Name ________________________
Home Address (if different) __________________
Home Address (if different) _____________________
________________________________________
____________________________________________
Phone (Home) ___________________________
Phone (Home) ________________________________
Employer _______________________________
Employer ____________________________________
Address ________________________________
Address _____________________________________
________________________________________
____________________________________________
Phone (Work) ____________________________
Phone (Work) ________________________________
Phone (Cell) _____________________________
Phone (Cell) __________________________________
Work Days & Hours _______________________
Work Days & Hours ___________________________
Email ___________________________________
Email _______________________________________
Authorization/Emergency Contact Information
I/we permit the following individuals to pick-up my/our child(ren) from the YMCA Camp Bernie Advantage
Before/After School program and to be contacted in an emergency, in the event that I/we are not available. In
my/our absence, the persons listed are authorized to make decisions concerning my child(ren). We require at
least 2 emergency contacts.
Name__________________________________________ Relationship ________________________
Home Phone
Work Phone
______
2. Name
Home Phone
___________
Relationship _______________________
Work Phone
Cell Phone ________________________
3. Name
Home Phone
Cell Phone
Relationship________________________
Work Phone
_____
Cell Phone ________________________
Identification is required at time of pick-up. You may write in other authorized pick-up persons.
The following person(s) are NOT permitted to pick up my child(ren)
Name
Relationship
_______________________________
Name
Relationship ______________________________________
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MONTHLY TUITION SCHEDULE
Before School Program (7—8:45 am)
5 days per week
$130/month
4 days per week
$115/month
3 days per week
$95/month
2 days per week
$75/month
Drop In:
Before School $10/day
After School Program (3 – 6 pm)
$260/month
$220/month
$180/month
$140/month
After School $20/day
Half Day $30/day
*5% discount available to families with multiple children enrolled in full-time (5 days/week)
care.
A one-time YMCA membership fee of $25.00 is due with your enrollment.
First month’s payment in full is due with your completed enrollment form.
Please check the day(s) of the week and program you need care for on a monthly basis.
If you anticipate using the drop in service, please check that box.
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YMCA Camp Bernie Advantage Before/After School Program
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Parent’s Name _______________________________ Child’s Name_________________________________
General Health History: Check “Yes” or “No” for each statement.
Has/does your child:
Ever been hospitalized?
[ ] Yes [ ] No
Ever had surgery?
Have recurrent/chronic illness [ ] Yes [ ] No
Had a recent infectious disease?
Had a recent injury
[ ] Yes [ ] No
Have diabetes?
Had seizures?
[ ] Yes [ ] No
Had headaches?
Had fainting or dizziness?
[ ] Yes [ ] No
Had asthma/shortness of breath?
Please explain “Yes” answers in the space below, noting the number of the questions.
[
[
[
[
[
] Yes
] Yes
] Yes
] Yes
] Yes
[
[
[
[
[
] No
] No
] No
] No
] No
Allergies: [ ] No known allergies [ ] Is allergic to [ ] Food [ ] Medicine [ ] Environment (stings, hay fever, etc…)
Please describe below what your child is allergic to and the reaction seen
Mental, Emotional and Social Health: Check “Yes” or “No” for each statement.
Has your child:
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)
Ever been treated for emotional or behavioral difficulties or an eating disorder?
During the past 12 months, seen a professional to address mental/emotional health concerns?
Had a significant life event that continues to affect the child’s life?
[
[
[
[
] Yes [
] Yes [
] Yes [
] Yes [
] No
] No
] No
] No
(History of abuse, death of a loved one, family change, adoption, survived a disaster, others)
Please explain “Yes” answers in the space below, noting the number of the questions. Also please tell us anything that
you wish to that may help us gain a better understanding of your child.
Medical Insurance Information:
Include a copy of your insurance card. Please copy both sides if applicable.
Insurance Carrier ________________________________________
Policy Number __________________________
Subscriber’s Name _______________________________________
Subscriber ID# __________________________
Family Physician _________________________________________
Phone # _______________________________
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the student to whom it pertains. The person described has the
permission to participate in all program activities except as noted. I give permission to the medical personnel selected by the Program
Director to order x-rays, routine tests, transportation and treatment related to the health of my child for both routine health care and in
emergency situations. If I cannot be reached in an emergency, I give my permission to the medical personnel selected by the Program
Director to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the child named above. I understand
that I will be responsible for payment of all medical bills. I understand the information on this form will be shared on a “need to know”
basis with program staff. I give permission to photocopy this form. In addition, the program has permission to obtain a copy of my
child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health
status.
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I, ____________________________________________, give permission to the Advantage Program staff to
administer the following prescription medicine to ________________________________________________
in accordance with the directions provided by the doctor and parent. Prescription medicine must be in the
original container with the complete pharmacy label attached. Non-prescription medicine must be in its’
original container. All medication must be accompanied by a doctor’s note indicating dosage and when to be
administered. The parent or healthcare professional designated by the parent must instruct the staff on the
proper use and administration of the medication. Please indicate if the child has permission to self administer
medication with the oversight of the Advantage Program staff. The medication must be given to the Site
Director and not left in the possession of the child.
Name of medication: _______________________________________________________________________
Dosage to be given: _______________________________________________________________________
Time to be given: _________________________________________________________________________
To be self administered with the supervision of the Advantage Program staff?
[
] Yes [
] No
Any special reactions to be aware of or any other information needed? _______________________________
________________________________________________________________________________________
________________________________________________________________________________________
Name of medication: _______________________________________________________________________
Dosage to be given: _______________________________________________________________________
Time to be given: _________________________________________________________________________
To be self administered with the supervision of the Advantage Program staff?
[
] Yes [
] No
Any special reactions to be aware of or any other information needed? _______________________________
________________________________________________________________________________________
________________________________________________________________________________________
Parent Signature ___________________________________________________ Date _________________
,
1
Among the many activities available to children in the Advantage Program, homework help/study time is
provided on a daily basis where staff will be available to assist children on a one on one basis. Rather than
assigning your child to this time, we request that parents inform us if this is a priority for their child. Discussion
of this between the parent(s) and child is encouraged so that there is an understanding at the start between all
the parties involved. Please be advised that the homework help time is determined by the Site Director and
may consist of two scheduled times with ½ hour increments. Advantage staff will encourage and assist your
child in completion of work; however it is the responsibility of the child to take advantage of the time and
support that is offered.
Please indicate your preference after discussion with child:
[
]
Yes, I would like my child to participate in the designated time to do homework.
[
]
No, I would like my child to determine for his/herself to participate as needed.
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The Ridgewood YMCA conducts its programs with the best interests of all participants in mind. The YMCA
attempts at all times to run programs that are educational, enjoyable and safe. Further, the activities of the
YMCA are designed to further the educational, motivational and charitable objectives of the YMCA.
Nonetheless, participants must understand that some of the activities of the YMCA may involve inherent risks
and hazards for which the YMCA cannot be held responsible. Because of the nature of YMCA activities,
injuries may still result even after reasonable precautions have been taken but it is acknowledged that the
YMCA cannot be held responsible in the event that injury occurs.
The undersigned releases the Ridgewood YMCA of all liabilities in the event that my son/daughter should be
involved in an automobile or bus accident while being transported to and from any program activity on or off
premises, or to the hospital or doctor.
The undersigned represents that it knows of no legal, physical or health reason why he or she or the
participating child (if the participant is a minor) cannot fully participate in the program being registered for.
Finally, by signing below, the undersigned hereby acknowledges that it is understood that The Ridgewood
YMCA is a non-profit corporation, organized exclusively for charitable and educational purposes, and as such,
is immune from liability for the negligence of its agents, servants or employees under N. J. S. A. 2A:53A-7.
The undersigned further gives permission for photographs or videotape of my child to be used for YMCA
promotional materials.
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Unfortunately, there are sometimes reasons we have to expel a child from our program either on a short term
or permanent basis. We want you to know we will do everything possible to work with the family of the
child(ren) in order to prevent this policy from being enforced. The following reasons are reasons we may have
to expel or suspend a child.
Immediate Causes for Expulsion
The child is at risk of causing serious injury to other children or himself/herself
Parent threatens physical or intimidating actions toward staff members
Parent exhibits verbal abuse to staff in front of enrolled children
Parental Actions for Child’s Expulsion
Failure to pay/habitual lateness in payments
Failure to complete required forms
Habitual tardiness when picking up child(ren)
Child’s Actions for Expulsion
Uncontrollable tantrums/angry outbursts
Ongoing verbal or physical abuse to staff or other children
Excessive biting
Proactive Actions That Can Prevent Expulsion
Staff will try to redirect the child from negative behavior
Staff will always use positive methods and language for discipline of children
Staff will praise appropriate behaviors
Staff will consistently apply rules, policies and procedures
Child will be given verbal warnings
Child will be given time to regain control
Child’s disruptive behavior will be documented and maintained in confidentiality
Parent/guardian will receive copies of any written material documenting disruptive behaviors
The Director, program staff and parent/guardian will have a conference to discuss behaviors
Recommendation of evaluation by professional consultation on site
Recommendation of evaluation by local school district child study team
Schedule of Expulsion
With the exception of Immediate Causes for Expulsion, if the above remedial actions do not improve
behaviors, the child’s parent/guardian will be advised in writing with a specific timeframe and behavior
expectations for continued enrollment. This timeframe will be of sufficient time to allow parent/guardian
to seek alternative care in the event that the situation does not improve.
I have read and understand the Advantage Program Expulsion Policy
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Child’s Name _____________________________________________________________________________
Child’s Name _____________________________________________________________________________
Child’s Name _____________________________________________________________________________
Child’s Name _____________________________________________________________________________
Method of Payment:
[
] Visa
[
] MasterCard
[
] Amex
[
] Discover
Card # _____________________________________ Exp. Date: __________
Security Code # _________
Name on Card: ___________________________________________________________________________
Billing Address (if different from Home Address): _________________________________________________
If you would like us to automatically bill your payments to this credit card, please check and sign below. Thank
you.
[
] Please bill my tuition to this credit card each month for the duration of the school year.
[
] Please bill this credit card for additional services (drop-in charges, late pick-up) as needed.
Cardholder’s Signature _______________________________________ Date _________________________
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Dear Parents,
In keeping with New Jersey’s child care center licensing requirements, we are obliged to provide you, as the
parent of a child enrolled at our center, with the enclosed information statement titled “Department of Children
and Families Office of Licensing INFORMATION TO PARENTS”.
The statement highlights, among other things: your right to visit and observe our center at any time without
having to secure prior permission; the center’s obligation to be licensed and to comply with licensing
standards; and the obligation of all citizens to report suspected child abuse/neglect/exploitation to the State’s
Division of Youth and Family Services (DYFS).
Please read the statement and if you have any questions, please do not hesitate to call us.
Please complete and return this portion with your registration.
Name of Child: _____________________________________________________________________
Name of Parent(s): __________________________________________________________________
I have read and received a copy of the Information to Parents statement prepared by the Bureau of Licensing
in the Division of Youth and Family Services (DYFS).
Department of Children and Families Office of Licensing
INFORMATION TO PARENTS
LICENSING INFORMATION
In keeping with New Jersey’s child care center-licensing requirements; we are obliged to provide you, as the
parent of a child enrolled at our center, with this informational statement. The statement highlights, among
other things: your right to visit and observe our center at any time without having to secure prior permission;
the center’s obligation to be licensed and to comply with licensing standards; and the obligation of all citizens
to report suspected child abuse/neglect/exploitation to the State’s Division of Youth and Family Services
(DYFS). Please read this statement carefully and, if you have any questions, feel free to contact YMCA Camp
Bernie at (908) 832-5315.
INFORMATION TO PARENTS
Under provisions of the Manual of Requirements for Child Care Centers (N.J.A.C. 10:122), every licensed child
care center in New Jersey must provide to parents of enrolled children written information on parent visitation
rights, State licensing requirements, child abuse/neglect reporting requirements and other child care matters.
The center must comply with this requirement by reproducing and distributing to parents this written statement,
prepared by the Bureau of Licensing in the Division of Youth and Family Services (DYFS). In keeping with this
requirement, the center must secure every parent’s signature attesting to his/her receipt of the information.
Our center is required by the State Child Care Center Licensing law to be licensed by the Bureau of Licensing
in the New Jersey Division of Youth and Family Services. A copy of our current license must be posted in a
prominent location at our center. Look for it when you’re in the center. To be licensed, our center must comply
with the Manual of Requirements for Child Care Centers (the official licensing regulations). The regulations
cover such areas as: physical environment/life-safety; staff qualifications, supervision, and staff/child ratios;
program activities and equipment; health, food and nutrition; rest and sleep requirements; parent/community
participation; administrative and record keeping requirements; and others.
Our center must have on the premises, a copy of the Manual of Requirements for Child Care Centers and
make it available to interested parents for review. If you would like to review our copy, just ask any staff
member. Parents may secure a copy of the Manual of Requirements by sending a check or money order for $5
made payable to the “Treasurer, State of New Jersey”, and mailing it to: State of New Jersey, Department of
Human Services, Licensing Publication Fees, PO Box 34399, Newark, New Jersey 07189-4399.
We encourage parents to discuss with us any questions or concerns about the policies and program of the
center or the meaning, application or alleged violations of the Manual of Requirements for Child Care Centers.
We will be happy to arrange a convenient opportunity for you to review and discuss these matters with us. If
you suspect our center may be in violation of licensing standards, you are entitled to report them to the Bureau
of Licensing toll-free at: 1-877-667-9845. Of course, we would appreciate your bringing these concerns to our
attention first.
Our center must have a policy concerning the release of children to parents or people authorized by parent(s)
to be responsible for the child. Please discuss with us your plans for your child’s departure from the center.
Our center must have a policy about administering medicine and health care procedures and the management
of communicable diseases. Please talk to us about these policies so we can work together to keep our children
healthy.
Our center must have a policy concerning the expulsion of children from enrollment at the center. Please
review this policy so we can work together to keep your child in our center.
Parents are entitled to review the center’s copy of the Bureau of Licensing’s Inspection/Violation Reports on
the center, which are issued after every State Licensing inspection of our center. If there is a licensing
complaint investigation, you are also entitled to review the Bureau’s Complaint Investigation Summary Report,
as well as, any letter of enforcement or other actions taken against the center during the current licensing
period. Let us know if you wish to review them and we will make them available for your review.
Our center must cooperate with all DYFS inspections/investigations. DYFS staff may interview both staff
members and children. Our center must post its written statement of philosophy on child discipline in a
prominent location and make a copy of it available to parents, upon request. We encourage you to review it
and to discuss with us any questions you may have about it. Our center must post a listing or diagram of those
rooms and areas approved by the Bureau for the children’s use. Please talk to us if you have any questions
about the center’s space.
Our center must offer parents of enrolled children ample opportunity to participate in and observe the activities
of the center. Parents wishing to participate in the activities or operations of the center should discuss their
interest with the center director, who can advise them of what opportunities are available. Parents of enrolled
children may visit our center at any time without having to secure prior approval from the director or any staff
member. Please feel free to do so when you can. We welcome visits from our parents.
Our center must inform parents in advance of every field trip, outing, or special event away from the center,
and must obtain prior written consent from parents before taking a child on each such trip. Our center is
required to comply with the New Jersey Law Against Discrimination (LAD), P.L. 1945, c. 169 (N.J.S.A. 10:5-1
et seq.), and the Americans with Disabilities Act (ADA), P.L. 101- 336 (42 U.S.C. 12101 et seq.). Anyone who
believes the center is not in compliance with these laws may contact the Division on Civil Rights in the New
Jersey Department of Law and Public Safety for information about filing an LAD claim at (609) 292-4605 (TTY
users may dial 711 to reach the New Jersey Relay Operator and ask for (609) 292-7701), or may contact the
United States Department of Justice for information about filing an ADA claim at (800) 514-0301 (voice) or
(800) 514-0383 (TTY).
Anyone who has reasonable cause to believe that an enrolled child has been or is being subjected to any form
of hitting, corporal punishment, abusive language, ridicule, harsh, humiliating or frightening treatment, or any
other kind of child abuse, neglect, or exploitation by any adult, whether working at the center or not, is required
by State law to report the concern immediately to the Division of Youth an Family Services’ Office of Child
Abuse Control, Toll-Free at: 1-(800)-792-8610, or to any DYFS District Office. Such reports may be made
anonymously. Parents may secure information about child abuse and neglect by contacting: Community
Education Office, Division of Youth and Family Services, P.O. Box 717, Trenton, New Jersey 08625-0717
STATE LICENSING POLICY ON THE RELEASE OF CHILDREN
Each child may be released only to the child’s parent(s) or persons authorized by the parent(s) to take the child
from the center and to assume responsibility for the child in an emergency if the parent(s) cannot be reached.
If a non-custodial parent has been DENIED ACCESS, or GRANTED LIMITED ACCESS, TO A CHILD BY A
COURT ORDER, the center shall secure documentation to that effect and maintain a copy on file, and comply
with the terms of the court order.
PLEASE KEEP THIS STATEMENT FOR YOUR RECORDS.
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YMCA Camp Bernie
327 Turkey Top Road
Port Murray, New Jersey 07865
908-832-5315
www.campbernieymca.org
OUR PHILOSOPHY
For more than 50 years, YMCA Camp Bernie has provided programs that help children make new
friends, develop new skills and experience innovative, age-appropriate challenges. We build strong
kids so that they can become healthy and productive adults.
1) We provide safe and healthy program experiences with positive role models
2) We offer a wide variety of activities through which children have fun, build confidence, develop
skills and make friends.
3) We teach and live the YMCA values of caring, honesty, respect and responsibility that
encourage cooperation, trust, integrity and accountability.
4) We instill an appreciation of nature through outdoor adventures, discovery and environmental
awareness.
5) We celebrate diversity and respect each other in our community.
ENROLLMENT
Any child in the Lebanon Township School District is eligible to attend the before and/or after school
program. We accept children ages 5-13. Morning kindergarten children can be accommodated by
the before school program, while afternoon kindergarten children can be accommodated by the after
school program.
PROGRAM HOURS AND DAYS
Before School:
Program will operate daily from 7 am until the beginning of the school day. The Before School
program will not operate on delayed opening days or in the event of school closings or delays
for snow days or emergency closures.
After School:
The program will operate daily from school dismissal (either early or regularly scheduled) until
6 pm. There is no additional charge for scheduled early dismissal programs. The After School
program will not operate in the event of school closings or early dismissals for snow days or
emergency closures.
Vacation Camp:
The program will operate at YMCA Camp Bernie facility from 9 am- 4 pm (with before and after
care available) on these specific holidays provided a minimum of five participants are enrolled
in the program.
• Columbus Day 10/11/10
• NJEA Conference 11/4 &11/5/10
• Winter Recess 12/27-12/30/10
• MLK Jr. Day 1/17/11
• Presidents Weekend Friday & Monday 2/18 & 2/20/11
• Spring Recess (excluding Good Friday) 4/18 – 4/21/11 & 4/25/11
Full-time enrolled students will not pay an additional fee to attend Vacation Camp however if
before or after care is required, an additional fee will be charged accordingly.
Vacation Camp will not run on:
• Labor Day
• Thanksgiving, Thanksgiving Friday
• Christmas Eve, Christmas Day
• New Years Eve, New Years Day
• Good Friday
• Memorial Day
SUMMER CARE:
A reduced price will be offered to all full-time enrolled students to attend YMCA Camp Bernie’s
summer day or overnight camps.
DROP IN PROGRAM
Families needing services less frequently or parents who have last minute schedule changes can be
accommodated subject to available space based on licensing. Your child must be registered in the
program for you to use the Drop In service.
You will not be on a monthly billing plan and payment must be made in advance of the service unless
you complete a credit card charge form and indicate automatic billing for additional services. You
must notify the Advantage Program Director at least 1 business day in advance of your child(ren)
attending- i.e. we must know by 3 pm on Thursday if you need care for after school on Friday.
PROGRAM HIGHLIGHTS
The YMCA is the largest child-care provider in the United States, and YMCA Camp Bernie will be
utilizing the wealth of resources for its daily curriculum. Children will be able to participate in daily
interest areas that may include arts and crafts, literacy, health and fitness, indoor and outdoor
physical activities, team-building, and more. Homework Help is offered daily by our professional staff.
Snack time is also provided on a daily basis.
ILLNESS POLICY
Children are not allowed to attend the Advantage Program if they are absent from school. In the
event your child becomes ill during the Advantage Program, you will be contacted by the Advantage
Program Director and he/she may be isolated until you are able to make arrangements for pickup.
Please be sure we have up to date emergency contact numbers.
ABSENCE POLICY
If your child will not be attending their scheduled days for any reason, parents must:
1) Call the Advantage Program Director at 908-832-5315 in advance and leave a message
regarding their attendance or absence
2) Send a note to the School Office so the child’s teacher will be aware if they need to send the
child home on a bus
SCHOOL SPORTS/ACTIVITY POLICY
If your child will be attending an in-school sports program or other in-school activity during the
operation times of the Advantage Program, but still need some time period of care, parents must:
1) Ensure that their child(ren) know to check-in for attendance at the Advantage Program before
going to their activity
2) Send a written note stating that the child has permission to attend activities, and please specify
the dates of the activity, as well as the start and end time of the activity.
3) Ensure that their child(ren) know that they are to return to the Advantage Program immediately
after the conclusion of the activity (if applicable).
While attending the Advantage Program, children will not be permitted to leave the Program or school
premises for any reason UNLESS a parent or authorized person has signed them out.
TELEPHONE
Each program has a telephone with a voice mail message system which can be reached at
908-832-5315. Please use this phone to leave a message after program hours. On site phone
numbers will be distributed prior to the beginning of the program.
BILLING
YMCA Camp Bernie will bill you monthly if you have not signed up for automatic payments, and all
payments are due by the 25th of the month preceding program. September enrollments and
payments are due no later than August 25th. Please send and make checks payable to:
YMCA Camp Bernie
327 Turkey Top Road
Port Murray, NJ 07865
If there are any questions regarding your account, please call 908-832-5315 ext. 15.
FINANCIAL ASSISTANCE AND DONATIONS
The YMCA is a national non-profit charitable organization. We exist and work for everyone; people of
all ages, races, religions, incomes and abilities. We constantly strive to offer assistance to those in
need. If you feel you can help us in our efforts, please do not hesitate to contact us at 908-832-5315
or visit the donation section of our website at www.campbernieymca.org.
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Registration Fee
First Monthly Installment
Health History Form
Homework Agreement
Program Waiver
Photo/Video Waiver
Enrollment Agreement
Enrollment Forms (2)
Licensing Information
Medication Permission Slip
Authorized Pickup Information
Expulsion Policy
Automatic Billing Form (optional, but suggested)
Parent Advisory Committee (optional)
SAVE TIME AND PAPER
ENROLL IN OUR AUTOMATIC BILLING PROGRAM
BE SURE TO COMPLETE THE ENCLOSED AUTOMATIC BILLING FORM
THANK YOU!
ADVANTAGE BEFORE/AFTER SCHOOL PROGRAM
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.

9:30 am studies the Am erican presidents 4:30 pm learns w hat it m

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