1 Welcome to the Waltham YMCA Out of School Time Program, I am pleased to welcome you and your family to our out of school time programs for the school year. We are delighted to be serving the Waltham community with after school programs that build character, develop leadership, foster growth in social and academic skills, and most importantly provides hours of fun and friendship for kids. The YMCA after school program will focus its curriculum on building healthy life styles by offering activities that support mind, body, and spirit. Program participants will have opportunities to make friends, explore interests, run, play, develop new skills, and engage in critical thinking. Our IPLAY program encourages physical activity for children each afternoon, ensures minimal screen time, and provides daily snacks that include a fruit or a vegetable. Each month there will be a curriculum theme, social skill emphasis, and community service project. Participants will complete an interest survey at the beginning of the school year and the results of this survey will influence the development of special enrichment clubs. Some clubs will be offered to all grade levels while others are planned for a particular grade level. There will also be opportunities for family members to participate in special family night events throughout the year. As a member of our after school program you are also eligible to attend our vacation day programs which run on most days that school is closed. Our vacation day programs are located at the Waltham YMCA and include the use of the YMCA facility (gyms, pool, and field). Attached you will find a schedule of what days we will not be offering vacation programs this school year. Our after school program also runs at the schools when there is a half day. The half day programs begin at dismissal time and proceed as they normally do until 6:00PM. Your children are only eligible for vacation and half day programs on the days of the week that they are enrolled in the after school program, if additional care days are needed please contact me. The YMCA is for youth development, healthy living, and social responsibility. Our out of school time programs work in partnership with schools and parents to build developmental assets in young people to help them prepare for a healthy and happy life. I hope that your family has a great experience with our YMCA program. Best Regards, Keri Person Youth Enrichment Director YMCA OF GREATER BOSTON WALTHAM YMCA 725 Lexington St., Waltham MA (Office) (Fax)
2 Enrollment Form FOR OFFICE USE ONLY Initial Start Date: Branch: Location: Age at Admission: Child s Name CHILD INFORMATION Nickname Date of Birth Gender Age Grade Home Address Phone DESCRIPTION OF CHILD (Required by the MA Department of Early Education and Care) Eye Color Hair Color Skin Color Primary Language Ethnic Origin Height Weight Identifying Marks PARENT/GUARDIAN INFORMATION Parent/Guardian Name Parent/Guardian Name Relationship to Child Primary Language Relationship to Child Primary Language Home Address Home Address City Zip City Zip Home Telephone Cell Home Telephone Cell Address Occupation Address Occupation Business Address Business Address City Zip City Zip Work Hours Work Phone Work Hours Work Phone Child s School SCHOOL INFORMATION School Office Phone School Address Dismissal Time Does your child have an I.E.P.? (Individual Education Plan) Yes No SERVICE AGREEMENT I wish to enroll my child in the YMCA of Greater Boston s Child Care Program for the following schedule: Monday Tuesday Wednesday Thursday Friday Arrive: Arrive: Arrive: Arrive: Arrive: Depart: Depart: Depart: Depart: Depart: Enclosed is the annual membership fee (where applicable) in the amount of $ and a non-refundable deposit applied to my child s first week s tuition in the amount of $. Tuition is based on a weekly fee. The rate will be same regardless of snow days, school vacations, half days and holidays. I have read and understand all policy and tuition information and agree to comply. Families are responsible for keeping their vouchers current and will be required to pay the full tuition fee if the voucher expires. Parent/Guardian Signature: Date:
3 Emergency Contacts and Pick-up Authorization EMERGENCY CONTACTS* Child s Name: Please list three additional individuals to be contacted in an emergency and non-emergency, if you cannot be reached. Please note that persons listed as Emergency Contacts are automatically authorized to pick up your child from the program. Name Relationship Home Phone Work Phone Cellular Phone Address Name Relationship Home Phone Work Phone Cellular Phone Address Name Relationship Home Phone Work Phone Cellular Phone Address PICK-UP AUTHORIZATION Please list below individuals who are authorized to pick up your child from the program, but would not be contacted in case of emergency. (For example: coach, neighbor, etc.) Name Relationship Home Phone Work Phone Cellular Phone Address Name Relationship Home Phone Work Phone Cellular Phone Address Parent/Guardian Signature: Date: *Biological parents and legal guardians listed on enrollment forms are automatically authorized to pick up your child unless the program is given a copy of a current court ordered custody agreement or restraining order. All individuals authorized to pick up your child from the program must be at least 16 years of age. A license or other positive proof of identification must be shown at pick-up time. If you wish to change, add, or delete any of these authorizations, you must do so in writing. Please note below any special instructions regarding these individuals.
4 Authorization and Consent Form Child s Name: Date: PROMOTIONAL RELEASE I hereby grant consent and authorize the use of photographs, slides, videotapes and film of my child participating in YMCA activities for commercial and art purposes in any medium of advertising, communication, publication or publicity that will promote YMCA programs and services, and/or recognition of participants. I understand that the YMCA is a non-profit organization. Parent/Guardian Signature: Yes No SUPPORT STAFF CONSENT YMCA programs have support staff that consist of resource advisors, family support specialists, and social service staff. In addition, student interns and/or volunteers may work within the program. I give permission for my child to interact with these support staff. Parent/Guardian Signature: Yes No OFF-SITE ACTIVITIES I hereby grant consent for my child to (Check all that apply) utilize local YMCA facilities take walks in local neighborhoods and to parks within a mile radius of the center ride in a baby carriage in local neighborhoods (group day care only) visit the following designated off-site activities/locations: (List of sites visited regularly by children within the program) I understand that any other activity destinations or field trips will require my written permission. Parent/Guardian Signature: Yes No WADING/SWIMMING CONSENT I hereby grant consent for my child to participate in wading/swimming activities in life guarded locations, including at the YMCA. My child may also engage in sprinkler play under YMCA staff supervision. Parent/Guardian Signature: Yes No
5 Arrival and Departure Verification Form BEFORE SCHOOL/AM ARRIVAL Child s Name: My child will arrive at the YMCA program by: Public Transportation Describe: Walking (check one) Supervised Unsupervised Parent/Family/Guardian Drop-Off Other Please Specify: N/A Arrival Time: BEFORE SCHOOL/AM DEPARTURE My child will depart the YMCA program to attend school by: Public School Bus (check one) Supervised Bus Stop Unsupervised Bus Stop YMCA Bus or Van (check one) Supervised walk into school Unsupervised walk into school Public Transportation Describe: Walking (check one) Supervised Unsupervised Other Please Specify: N/A Departure Time: AFTER SCHOOL/EARLY CHILDHOOD-ARRIVAL My child will arrive at the YMCA program by: Public School Bus (check one) Supervised walk into program Unsupervised walk into program YMCA Bus or Van (check one) Supervised walk into program Unsupervised walk into program Public Transportation Describe: Walking (check one) Supervised Unsupervised Parent/Authorized Release Drop-Off Other Please Specify: N/A Arrival Time: AFTER SCHOOL/EARLY CHILDHOOD-DEPARTURE My child will depart the YMCA program by: YMCA Bus or Van (available for families in slots approved for transportation) Supervised walk into home Unsupervised walk into home Public Transportation Describe: Walking (check one) Supervised Unsupervised Parent/Authorized Release Pick-Up Other Please Specify: N/A Departure Time: Parent/Guardian Signature: Date:
6 Registration and Service Agreement YMCA Location Program Site Program Age Group: Infant Toddler Preschool School-Age (Check all that apply) Before School After School Child s Name Date of Birth Grade Parent/Guardian Primary phone # Address address Start Date SERVICE AGREEMENT This Agreement is made between the YMCA of Greater Boston Child Care Program at the YMCA and for the care of Location/site Parent/Guardian on the following days: Child s Name (Before School) Monday Tuesday Wednesday Thursday Friday (After School) Monday Tuesday Wednesday Thursday Friday Your weekly fee is $. Tuition is based on the number of days per week your child is scheduled to attend the program. Please note that parents are responsible to pay for holidays if their child is scheduled for that day. Payment is due one week in advance of services provided. For School Age programs, the weekly rate reflects a blended or average daily cost of providing programming. Snow days, vacation weeks, and early school releases when hours are longer, as well as holidays when the center is closed, are factored in to the rate. In addition, the parent agrees to the following: 1. To be liable for payment for the child s scheduled day, even if the child is absent from the program for any reason. There are no refunds or credits toward another day. Parent agrees to pay for any extra days used. 2. To pay the late payment fee when tuition is past due. 3. To provide the program with all the necessary forms in the intake packet including a physical examination form for your child or for school age verification of that information on file at school. 4. Agree to notify the program of any changes in my enrollment packet i.e. address, phone number, work address or number, etc. or any major events or situations that may affect best practices needed for my child.
7 5. To contact the program if the child is going to be absent (8:30 am for Infant, Toddler, Preschool Programs and 12:00 noon for Afterschool Programs). 6. To abide by the guidelines stated in the Parent Handbook. 7. To have my child in care no longer than 10 hours per day. 8. To pick up children at the program on time. 9. To pay $1.00 per minute, per child, when I, or someone I have designated, is late picking up my child or has left my child in care longer than 10 hours that day. 10. To be responsible for keeping my voucher current and pay the full tuition fee if the voucher expires. 11. To keep my child s YMCA membership current through the end of the program. 12. Be responsible for any and all personal property brought to the program and encourage my child to respect all policies related to those items. Parent Initials YMCA of Greater Boston Child Care Program agrees to: 1. Uphold the Department of Early Education and Care State Regulations and Department of Public Health regulations for all child care and summer camp programs. 2. Provide nutritious snacks /meals each day, dependent on the length of the day. 3. Employ trained, qualified staff. 4. Provide well-supervised social, educational, and recreational activities in a safe, nurturing environment. 5. Uphold the YMCA of Greater Boston s policies and procedures. 6. Provide advance notice of field trips and obtain written permission for trips that take place to locations not listed on the Off-Site Activities list in the enrollment packet. 7. Notify the parent if a child does not arrive at a site and no previous notice has been given. 8. Keep all information about children and families in confidential files, to be released only with permission of the parent. 9. Hold parent meetings at least 4 times per year and agree to engage in open communication with families. 10. Provide parent with a weekly statement of tuition due and notices of tuition that is past due. After reading the YMCA of Greater Boston Family Handbook and reviewing the highlighted policies, we agree to the conditions of this contract. I understand the YMCA reserves the right to amend this agreement upon written notification. Parent/Guardian Signature Date Intake Workers Signature Date For office use only: Applicable Subsidy: (please circle) Voucher EEC ACCESS Other Please specify YMCA Membership expiration date: Member Number
8 Release of Information I hereby authorize the staff from Waltham YMCA s Stanley Afterschool Program and the staff professionals of the YMCA of Greater Boston to release and share information on my child, including, but not limited to attendance, report cards, IEPs, progress reports and behavior charts. It is my understanding that the content of all records will remain confidential and will be used to enhance my child s academic performance and overall afterschool/summer experience. No school records may be released to any other person or agency without by full permission. Also, I will have the option of inviting afterschool staff members to attend in-school conferences and to meet with school teachers and/or staff members to discuss my student s progress per my request. Child s Name: PARENT SIGNATURE: DATE:
9 Out of School Time All Day Programs, Closures, and Vacation Camp We will offer an all day program at the YMCA from 8am-6pm on the following days: Monday, Sept. 17 Thursday, Sept. 29 Tuesday, Nov. 8 Friday, Nov.11 Wednesday, Nov. 23 Friday, April 6 Vacation Camps 8am-6pm December Vacation Camp Monday, Dec. 24-Friday, Dec. 28 We are open until 1 pm on Dec. 24 and closed the 25 th Februaury Vacation Camp Tuesday, Feb. 19-Friday, Feb. 22 April Vacation Camp Tuesday, April. 16-Friday, April 19 We are closed Monday, April. 15 th The Out of School Time Program will be closed on the following days: Monday, Sept. 3 Tuesday, Sept. 4 Monday, Oct. 8 Thursday, Nov. 22 Friday, Nov. 23 Tuesday, Dec. 25 Tuesday, Jan. 1 Monday, Jan. 21 Monday, Feb. 18 Monday, April 15 Monday, May 27 Friday, June TBD Please Note: Vacation day and all day programs are held at the Waltham YMCA at 725 Lexington St. Drop off time is between 8:00-9:00AM. Participants in the before school program may begin drop off at 7:30AM. Pick-up is any time up until 6:00PM. Your child may only attend on days they are regularly scheduled to attend the OST Program. Prior registration is required but there is no additional fee except for our vacation week field trip programs. Registration and program information will be available at your child s OST site two weeks before the scheduled all day or vacation week program.
10 Monthly Program Themes September June 2013 September Teamwork October Nutty about Nature November Fiction December Celebrations Around the World January Imagination February History March Culture and Languages April Healthy Planet May Mad Science June Healthy Kids
11 School Year Welcome Out of School Time Families! Thank you for registering your child for our Out of School Time Program. Enclosed are the required health, emergency and developmental forms that we will need prior to the start of the school year. Please take a few moments to fill them out and return them to our Waltham YMCA Main Building (725 Lexington Street, Waltham, MA 02452). I am also enclosing an auto pay form for your convenience and we recommend that you use this easy payment method for your after-school care program. We can charge your bank or credit card on a weekly, biweekly or monthly basis. If you opt not to use this system, your payments will need to be via mail or in person to the Waltham YMCA. Our after school care personnel are not allowed to collect payments at the school sites. For those of you that are new to our program, I would like to let you know that we will put bills in your family mailbox each Monday, for the following week (i.e. bills on September 10 th are for service dates of September 17-21). It is your responsibility to make sure that payments are received on a weekly basis, unless otherwise arranged (i.e. bi-weekly or monthly payments). Please note if you do not have a family membership, you are required to purchase an annual youth program pass for your child/ren to utilize our child care programs. A youth program pass for September is $ A one-week deposit and program pass fees are due with your application for our program. Once again, welcome to the Waltham YMCA Out of School Time Program. As a youth program pass member, your child will receive discounts on all of our in-house programs as well and has access to our free swim pool time and open gym time. We look forward to seeing you and hope that you have a wonderful year. Please feel free to contact me at any time with questions or concerns. Thank you, Amanda Persampieri OST Billing and Registration Coordinator (office) (fax)
12 Waltham YMCA Out of School Time Program Rates for the School Year After School Program: This program is offered Monday-Friday at the Waltham Elementary School from 3:00PM- 6:00PM. Children must be picked up any time before or at 6:00PM. Program fee includes school early release hours between 1:00PM-6:00PM on days in which your child is registered to attend and school releases early. Program fee includes numerous school closing dates in which an all day program is available for children at the Waltham YMCA on Lexington Street between the hours of 8:00AM-6:00PM. Please see the Waltham YMCA closure list to verify days in which our out of school time programs are closed. Program fees are based on the number of days your child attends the program and are due on a weekly basis. One Day Two Day Three Day Four Day Five Day $40.00 $67.00 $83.00 $97.00 $ Before School Program: Currently there is only a before school program at the Fitzgerald Elementary School The program begins at 7:30AM and continues until the start of the school day. Children can be dropped off at the program at any time beginning at 7:30AM. The program runs Monday-Friday and you are required to participate in a minimum of two days a week. The before school program does not run on days in which school opens late due to inclement weather. Program fees are based on the number of days your child attends the program and are due on a weekly basis. If you are interested in having a before school program at another program site besides the Fitzgerald School, please contact the YMCA to be placed on a waiting list. The YMCA would need a minimum of 10 children registered to attend the program daily in order to start a before school program. Two Day Three Day Four Day Five Day $22.00 $30.00 $36.00 $45.00 If you need are in need of financial assistance please complete our Access Scholarship application located on the last page of the out of school time program registration packet.
13 ACCESS Financial Assistance Application Since 1851, the YMCA of Greater Boston has lived its mission to build health of spirit, mind and body for all and to improve the quality of life for children, teens, adults and families throughout Greater Boston. At the Y, strengthening community is our cause. By encouraging youth development, promoting healthy living and fostering social responsibility the Y is positively impacting people and communities. 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. Deeply rooted in our community, it is the mission of the YMCA to make it affordable for all. Membership and programs are available to all regardless of age, income, ability, race or religion. Based on available resources and sliding scale eligibility, the Y will not turn anyone away due to an inability to pay our full fees. Our ACCESS program provides financial assistance based on need through an easy application process. Much of the financial assistance dollars shared are made possible through the generosity of those who contribute to our Annual Reach Out Campaign and United Way support. Financial Assistance Policy The YMCA of Greater Boston will provide financial assistance to qualified applicants through our ACCESS program based on the following: Applicants qualify for assistance based on annual adjusted gross household income and the size of the family. ACCESS assistance is available up to 60% for membership and programs and up to 50% for early education, out-of-school time and camp. Branch Executives have authority, based on extreme need, to make larger assistance grants. ACCESS is reviewed at least annually by the YMCA, from the date of this approved application, or as requested by the YMCA. The applicant must responsible to reapply with current income verification prior to the end date of his/her financial assistance or as requested by the YMCA. The YMCA will send a financial assistance expiration notice 30 days prior to expiration. If the applicant does not re-apply for financial assistance fees will be charged at the full-published rate. The amount of financial assistance being offered is limited only to the overall resources of the YMCA of Greater Boston. All ACCESS financial assistance information is confidential. Application Process Complete ACCESS application Household income from most recent tax return (1040, not W2) social security numbers will be redacted AND One month proof of recent income (paystubs), or other proof of your current combined household income (SSI/SSDI) Other proof of income verification may be required and/or accepted at the discretion of the YMCA, i.e. signed letter from your employer, on your employer s letterhead detailing the weekly income you earn. Notification Process The YMCA will notify applicants via the contact information provided on the ACCESS application. Applicants are expected to update contact information as needed. Please expect to hear from us within 14 days of submitting your complete ACCESS application. Revised
14 ACCESS Scholarship Application Name: Membership Number: Address: City: State: Zip Code: Date of Birth: Phone: Day Evening Cell Phone Your Employer s Name & Address: Financial assistance requested for: Instructional Program Camp Early Education & Out-of-School Time Programs Program Membership Other Spouse s Name: Date of Birth: Spouse s Employer s Name & Address: Your Annual Adjusted Gross Income $ Spouse s Annual Adjusted Gross Income $ Child Support Income $ Other Income (source & amount) Number of Family Members: (proof of family size may be required) 1. Date of Birth / / 4. Date of Birth / / 2. Date of Birth / / 5. Date of Birth / / 3. Date of Birth / / 6. Date of Birth / / List any special circumstances highlighting your reason for need: Yes, I am willing to share my Y story with the YMCA to help support the Annual Reach Out campaign. To qualify for ACCESS you must submit the following documents: Complete ACCESS application Household income from most recent tax return (1040, not W2) social security numbers will be redacted AND One month proof of recent income (paystubs), or other proof of your current combined household income (SSI/SSDI) Other proof of income verification may be required and/or accepted at the discretion of the YMCA, i.e. signed letter from your employer, on your employer s letterhead with the weekly income you earn. The information listed on this form is correct to the best of my knowledge. I understand that the financial assistance granted to me by the YMCA of Greater Boston must be re-applied for annually, from the date of this application, or as requested by the YMCA. I understand it is my responsibility to reapply and that the YMCA will send out a financial assistance expiration notice 30 days prior to expiration. If I do not re-apply for financial assistance my fees will be charged at the full-published rate. Applicant Signature: ************************** FOR OFFICE USE ONLY ************************** Program / Program Membership: Subsidy % Scholarship Code Begin Date Review Date Date: Early Education &Out-of-School Time Programs/Camp Subsidy % Scholarship Code Begin Date Review Date Date mailed/ ed confirmation Date entered in Scholarship Code Approved By: Date: Revised
15 PAYMENTS MADE EASY You may pay for programs, child care or make contributions using our easy AutoPay program. AutoPay allows the YMCA to debit your credit card account for each payment you agree on for the program or activity you select. All you need to do to use AutoPay is complete the following information. Personal Information Your name as it appears on your credit card statement: First Name: MI: Last Name: Your Address as it appears on your credit card account statement: Street: City: State: Zip Code: Your Home and Work Telephone Numbers Home: Work: YMCA Information Your YMCA Member Number: Branch: WALTHAM Name of participant if different form you: Name of Program, Child Care or Contribution Activity: Payment Agreement Payment Frequency: 1= One Payment; W= Weekly; S= Semi-Monthly; M=Monthly; Q = Quarterly **For semi-monthly payment date must begin with 1 st or 15 th of month** Number of Payments: Amount of Each Payment: First Payment Due Date: Last Payment Due Date: Credit Card Type: Account Number: Card Issue: Name of Card: Expiration Date: MMYY (Please notify the YMCA when your expiration date changes) BY CHECKING THIS BOX, I AUTHORIZE THE YMCA TO CONTINUE USING THE CURRENT CREDIT CARD ON FILE FOR PAYMENTS FOR THE SCHOOL YEAR. BY CHECKING THIS BOX, I AUTHORIZE THE YMCA TO USE THIS CREDIT CARD FOR PAYMENT OF YOUTH DEVELOPMENT CLASS (classes such as gymnastics, karate, soccer or other extra-curricular activity) Terms I hereby authorize the YMCA of Greater Boston to charge my credit card account as indicated above for the program, child care or contribution I have selected, for the payments amount and schedule as specified on this form. When the credit card issuer honors the payment my credit card statement will constitute receipt for the payment. Should any payment not be honored by the credit card issuer then it is understood that the payment has not been made and I am responsible for making the payment directly to the YMCA. Date: Signed:
16 Emergency Authorization and Consent Form INSURANCE INFORMATION CHILD S MEDICAL INFORMATION MEDICAL HISTORY Please write NONE if there are none. Child s Name Date of Birth Allergies Reactions Treatment Medical Insurance Company Policy Number Special Disabilities / Needs / Chronic Health Conditions Other Coverage (Include Dental) Current Medications: Yes No Home School Program Emergency Medical/Dietary Information/Religious Restrictions Child s Physician Phone Address Behavioral Issues Child s Dentist Phone Address Other Emergency Health Concerns Documentation of a physical examination, immunization record, and lead screening is on file at my child s school Parent Initials MEDICAL TREATMENT CONSENT I hereby authorize certified staff of the YMCA of Greater Boston to give First Aid and CPR to my child as needed. In the event of an emergency, I hereby authorize the program staff to have my child transported to the nearest medical facility or to and secure necessary medical treatment including, but not limited to: hospitalization, injections, anesthesia and/or surgery. In the event that I cannot be reached, I hereby give permission to the physician attending to my child to secure and administer treatment as necessary. I understand that the staff will make every effort to notify me of the emergency immediately. Parent/Guardian Signature: Date:
17 Authorization and Consent Form Child s Name: Date: PROMOTIONAL RELEASE I hereby grant consent and authorize the use of photographs, slides, videotapes and film of my child participating in YMCA activities for commercial and art purposes in any medium of advertising, communication, publication or publicity that will promote YMCA programs and services, and/or recognition of participants. I understand that the YMCA is a non-profit organization. Parent/Guardian Signature: Yes No SUPPORT STAFF CONSENT YMCA programs have support staff that consist of resource advisors, family support specialists, and social service staff. In addition, student interns and/or volunteers may work within the program. I give permission for my child to interact with these support staff. Parent/Guardian Signature: Yes No OFF-SITE ACTIVITIES I hereby grant consent for my child to (Check all that apply) utilize local YMCA facilities take walks in local neighborhoods and to parks within a mile radius of the center ride in a baby carriage in local neighborhoods (group day care only) visit the following designated off-site activities/locations: (List of sites visited regularly by children within the program) I understand that any other activity destinations or field trips will require my written permission. Parent/Guardian Signature: Yes No WADING/SWIMMING CONSENT I hereby grant consent for my child to participate in wading/swimming activities in life guarded locations, including at the YMCA. My child may also engage in sprinkler play under YMCA staff supervision. Parent/Guardian Signature: Yes No