Daily Homework Help Time Outdoor Games Warm & Caring Environment Friendly & Qualified Staff Theme-Based Curriculum Arts & Crafts

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1 GENERAL INFORMATION AFTER SCHOOL After School Programs are provided for youth who attend school in the Town of Amherst. The program operates Monday Friday from 2:00-5:30pm. An Extended Afternoon option from 5:30-6:00pm is available. All programs are accredited through NYS After School Works. Special weekly activities, including cooking, educational games, exercise and group activities are offered through the Amherst Youth & Recreation Department After School Program. Daily Homework Help Time Outdoor Games Warm & Caring Environment Friendly & Qualified Staff Theme-Based Curriculum Arts & Crafts REGISTRATION INFORMATION: DATES June 15 June 19, :00am-5:30pm LOCATION Amherst Youth & Recreation Northtown Center at Amherst 1615 Amherst Manor Drive Williamsville, NY Phone: After School Program Locations and School Districts Served Clearfield Youth Center, 730 Hopkins Rd Jennifer Reed, Program Leader Amherst Youth & Family Center, 1615 Amherst Manor Dr Susan Mohney, Program Leader Harlem Road Youth Center, 4255 Harlem Rd Michele Holmes, Program Leader Williamsville School District Sweet Home School District Amherst School District AMHERST RESIDENT FEES Williamsville Youth & Family Center, 5005 Sheridan Dr Joann Kiefer-Warren, Program Leader Williamsville School District A $15 non-refundable registration fee is required for each family. Fees are applied using a sliding scale, based upon the family s most recent federal tax return (1040). Family applies to both husband and wife, even if filing separately. An optional Extended Day Program (5:30-6:00pm) is available for an additional $1 per day per child. Please bring with you a copy of your most recent federal income tax form along with appropriate registration fee. Program fees are based on a sliding scale and family income applies to both husband and wife, even if filing separately. NON-RESIDENT FEES* Non-residents are students who live outside of Amherst town boundaries, yet attend school within the Sweet Home, Williamsville or Amherst school districts. Registration fee: $25 per family First priority given to Amherst residents. Priority 1 families currently enrolled; Priority 2-Dual/Single working parents; Priority 3-Parent/guardian at home. Questions? Contact: Amherst Youth & Recreation Dept Amherst Manor Drive Williamsville, NY Phone: FOR REGISTRATION FORMS VISIT:

2 TO BE ELIGIBLE Registration is open to all Town of Amherst residents and non-residents whose children attend an Amherst, Williamsville or Sweet Home School District area school. Applicants must be between the ages of 5-11 years or starting Kindergarten in September Selection for this program will be based according to the following priorities: 1). Children currently enrolled in the Afterschool Program and siblings starting. 2). Children of single parent working families, children of dual working parent families. 3). All other applicants (Town resident and non-residents). Town residents will receive priority over non-residents. Amherst Resident Program Fees: Fees are applied using a sliding scale, based upon the family s most recent federal tax return (1040). Family applies to both husband and wife, even if filing separately. An optional Extended Day Program (5:30-6:00pm) is available for an additional $1.00 per day per child. All resident applicants will be placed in an income category (Step see chart below) based upon their family s most recent federal tax return. STEP INCOME # OF CHILDREN ENROLLED (DAILY FEE) A $0-$29,999 $7.25 $13.00 $14.00 $15.00 B $30,000-$49,000 $9.00 $17.00 $18.00 $19.00 C $50,000-74,999 $10.75 $20.00 $21.00 $22.00 D $75,000 and over $12.50 $24.00 $25.00 $26.00 Scholarship assistance is available for those who qualify. Non-Resident Program Fees: Daily Fee: $15.00 per child; Extended Day Program: $5.00 per day/child. (Non-residents are students who live outside of Amherst town boundaries, yet attend school within the Sweet Home, Williamsville or Amherst school districts). Daily Fees & Payments: All applicants will be charged per day according to the sliding scale fee and the first payment will be due in full, on or before, August 7, Subsequent fees will be assessed on a monthly basis with payment, in full, due by the 15th of the month preceding attendance. Credit Days: Credit days can be used for illness, personal time, etc. only if you call in before 2:00pm on the day in question. You are entitled up to the maximum allowances noted below and will not receive compensation for unused credits at the end of the school year. **If your child is absent and our program is notified by 2:00pm, you will receive credit as follows: Days enrolled per week = Daily credit(s) per school year For more information, call the Amherst Youth & Recreation office at !

3 CHILD S FULL NAME CHILD S HOME ADDRESS ZIPCODE PHONE AMHERST YOUTH & RECREATION AFTER SCHOOL REGISTRATION INFORMATION SEX M F Birth DATE OF Registration WHAT SCHOOL DOES THE CHILD ATTEND? (FOR OFFICE USE) STEP PRIORITY Child s Source of Medical Care/Primary Care Physician s Name: Child s Source of Dental Care/Dentist s Name: Name of Medical Care Facility/Hospital: EMERGENCY DATA RELATIONSHIP PARENT/ GUARDIAN CONTACT NAME NAME OF PERSON APPLYING FOR CHILD Parent Guardian ADDRESS OF PERSON APPLYING FOR CHILD ADDRESS WHO DOES THE CHILD LIVE WITH? Any information that will assist us when working with your child (diet, habits, etc.): Both Parents Mother Father Guardian TELEPHONE NUMBER & ADDRESS (DURING HOURS OF CHILD CARE PROVIDED) Telephone Number: Telephone Number: Telephone Number: ZIPCODE Other (specify) Other Telephone Number (Check type) Pager Cell Other Pager Cell Other Pager Cell Other Cell Pager Other Does your child receive special services (IEP, 504, speech, OT, PT) Medications: Allergies: AGREEMENT I consent to the enrollment of the child listed above in this facility and have been advised of the policies regarding administration of medication, fees, transportation and the services provided by the facility and the Office of Children and Family Services regulations. I give consent for this child to take part in field trips or excursions away from the facility under proper supervision. I agree that in the case of accident or injury, emergency medical care may be given in the event the person(s) designated above cannot be reached. I have provided special information on my child s special needs (medications, allergies, diet, medical information) to assist the facility in caring for this child. I agree to review and update this information whenever a change occurs and/or at least every six months. I will provide a most recent copy of my 1040 tax form or I will be placed at the highest step of the sliding scale fee for the program(s). SIGNATURE OF PARENT OR PERSON(S) LEGALLY RESPONSIBLE DATE FOR OFFICE USE ONLY DATE ILLNESS ACCIDENT (describe injuries)

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6 AFTER SCHOOL PROGRAM Please indicate PROGRAM SITE: I would like to register my child, for the afterschool program on the following days: 5:30pm pick-up 6:00pm Extended Day (additional charge) Monday Tuesday Wednesday Thursday Friday Please indicate below which program/s your child attended/attends: Recess Camp (February/April) 2015 After School Program Summer Camp 2015 Amherst Youth & Family Center (Sweet Home School District) Clearfield Youth Center (Williamsville School District) Harlem Road Youth Center (Amherst School District) Williamsville Youth Center (Williamsville School District) Dear Parent/Guardian: We are seeking your cooperation in helping us to provide an additional safeguard regarding the pick-up of your child(ren) at the end of each program day. This will authorize only certain individuals to pickup you children. Your children will not be released to anyone not listed below. You (or any authorized individual listed below) will be asked to sign out your child before they will be released. It will be necessary for you to get out of your vehicle and get your child at a designeated pick-up point. Staff may request photo ID to verify the identity of person(s) authorized to pick-up your child. In case of emergency where a pick-up will be made by someone not on the list, you must call the program leader to tell them who will make the pick-up and that individual must present proper photo identification. Thank you for your cooperation. Sincerely, Amherst Youth & Recreation Program Staff Please list those authorized to pick-up your child from the program (please include yourself). (please print clearly) Name of Child: Name (First/Last) Relationship to Child PARENT/ GUARDIAN Phone/Pager/Cell

7 PARENT/ GUARDIAN INITIALS PARENTAL RESPONSIBILITY CONTRACT 1. I, the undersigned, certify that my registered child has my permission to take part in the program conducted by the Amherst Youth & Recreation Dept. I allow my child to participate in all walking and bussed field trips. In consideration of the acceptance and enrollment of my child in the program, I do hereby expressly waive any claim for injuries sustained by said child participating in the program. I have read the parent handbook available online. 2. I understand this is a well child program. I will not send my child to the program if they are ill. 3. I understand that I cannot send my child on an unregistered attendance day without prior approval from the Program Leader. 4. I agree to allow Amherst Youth Program staff to use insect sting swabs and sunscreen on my child if necessary. (See program staff for more information.) 5. I understand that the Amherst Youth Program promotes healthy lifestyles. I will not send my child(ren) to the program with clothing or gear reflecting inappropriate messages regarding smoking, drinking, sexuality, etc. 6. I understand that this program follows the Amherst/Sweet Home/Williamsville Public Elementary School District calendars. 7. I understand that it is my responsibility to make bussing arrangements with the appropriate School District office and submit that information to the appropriate office. 8. If my child, for any reason, cannot attend or will be late to the program on a given day for which he/she is registered, I will contact the After School Child Care Program by 2:00pm (10am on early dismissal days) to inform them of this. Failing to do so will result in the following procedures: The first and second time this occurs, a phone call will be made to one of the responsible parties listed on the registration form and I will be informed that failing to call may result in my child s loss of After School Child Care Program services. The third time this occurs, I will receive written notification that my child will no longer be able to participate in the After School Child Care Program. 9. The custodial parent(s) MUST submit a list of those persons authorized to pick-up their child(ren) from the after school child care and/ or recess camp program(s). Photo ID must be provided by those individuals authorized to pick-up your child(ren). 10. I will take all steps necessary to insure that any/all individuals authorized to pick-up my son/daughter will be drug/alcohol free and will conduct themselves in a courteous/respectful manner when they arrive on site. 11. I realize that picking-up my child(ren) by 5:30pm (or 6:00pm I enrolled in the Extended Program) is an important responsibility on my part and that failing to do so will result in the following procedure: A $5.00 fee per child will be assessed for every 15 minutes a child remains at program past 6:00pm (ex. 6:01-6:15pm-$5.00 per child; 6:16-6:30pm-$10.00 per child). The first and second time this occurs, I will be informed that failing to pick-up my child on time may result in my child s loss of program services. The third time this occurs, I will receive written notification that my child will no longer be able to participate in the program. 12. The Amherst Youth & Recreation Dept. has my permission to use photos, videos and audio recording or other likenesses taken of my child(ren) for the purpose of publicizing its programs and activities. 13. I agree to release my contact information to the Amherst Youth Foundation (partner to the Amherst Youth & Recreation Dept.). This information may be used for needs assessments, marketing and providing information about fundraising events or activities the Foundation may be sponsoring on behalf of Amherst Youth & Recreation and/or this program. AFTER SCHOOL PROGRAM PAYMENT AGREEMENT POLICY: 14. Payments are due on or before the 15th of the month preceding services. 15. Any payments received after the 15th of the month will incur a $15 late charge. 16. If payment due remains unpaid by the last day of the month in which it is due, parent/guardian agrees to withdraw the child from the program as of the first day of the following month. 17. A child who is withdrawn from the program for non-payment can re-register for services (if space is available) by paying: 1) An additional $15 registration fee; 2) Payment for all days of service to be used within that month prior to the first day of attendance and 3) Payment of any/all outstanding balances due for previous service. REFUND POLICY: No refunds will be given for program(s). I, the undersigned have read, understand and accept the conditions by which I must abide and which are contained in the Parental Responsibility Contract and Program Handbook. Failure to comply may result in loss of program privileges. SIGNATURE OF PARENT OR PERSON(S) LEGALLY RESPONSIBLE DATE

8 (FOR OFFICE USE ONLY) AFTER SCHOOL CHILDCARE CHECKLIST Child s Name 1. A. Is your child between the ages of 5-11 years? B. Registration Fee paid? ($15.00 resident; $25 non-resident) YES NO 2. Most recent 1040 tax form? (NO W-2 s accepted) 3. Extended Day Option (5:30pm-6:00pm) 4. Forms to be completed and/or signed: A. Registration Form B. Parent Responsibility Contract C. Payment Agreement Policy D. N.Y.S. Income Eligibility 5. Non-resident?** Does this child attend a Sweet Home, Amherst or Williamsville School? If yes, which school? 6. Where did you hear about our program? Program & Services Guide Listing Already attend Youth Program Friend/Relative Child s School Newspaper Other please specify: Please indicate PROGRAM SITE: Amherst Youth & Family Center (Sweet Home School District) Clearfield Youth Center (Williamsville School District) Harlem Road Youth Center (Amherst School District) Williamsville Youth Center (Williamsville School District) 7. Additional comments: Income Step ** Priority Date: Accepted by: **Place at Step D (Top Level) if application has no tax form DO NOT ACCEPT INCOMPLETE APPLICATIONS

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