Registration school year for (LCPS) (After School 3-6PM) Optional Care Days Offered (7:00am-6pm) Open for all local counties

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1 ZION CHRISTIAN CHILDREN S CENTER AFTERSCHOOL & OPTIONAL CARE PROGRAM Zion United Methodist Church ~1674 Zion Rd. Troy, VA (434) ~afterschool@zionumcva.org Registration school year for (LCPS) (After School 3-6PM) Optional Care Days Offered (7:00am-6pm) Open for all local counties *Please note, it is your responsibility to make arrangements with the school system for your child to be dropped off at ZCCC. Child s Full Name Name Used Date of Birth Gender Street Address City/State/Zip Home Phone Child Lives With: Mother Father Other: Marital Status of Parents: Married Single Divorced Separated Deceased Mother s Name Mother s Occupation Mother s Business Address Work Phone Cell Phone Father s Name Father s Occupation Father s Business Address Work Phone Cell Phone

2 List any information we may need to know about your child. (medication, allergies, food restrictions, developmental concerns): Emergency Situations/Alternate Pick-Up: In case of emergency or sudden illness the parents are the first to be contacted. In the instance that we are unable to reach the parents, we ask that you please list the names of local people that would assume responsibility for your child. Picture identification will be required for student release. If someone other than the listed persons is to pick-up your child you must send a written note. Name: Relation: Phone #1: Phone #2: Name: Relation: Phone #1: Phone #2: Name: Relation: Phone #1: Phone #2: Zion CCC After School and Optional Care Inclement Weather Policy: We will be open to receive students off the school bus in the event of early school closings. We will make all possible attempts to remain open during inclement weather conditions and subsequent days county schools are closed depending on roadway and weather conditions. In the event that there is a power outage at Zion UMC due to any reason, all After School and Optional Care Programs will be closed. All parents or caregivers will be notified of any closing, or delays to the Zion CCC After School program or Optional Care program via and our One Call System. Parent signature: Medical Release: I grant the staff to Zion Christian Children s Center and Zion United Methodist Church permission to seek medical treatment for my child in case of emergency. Physicians Name: Phone: Parent Signature: Date: Photography/Video Release: I grant permission for Zion Christian Children s Center to take video or photograph recordings of my child. I understand that they may be used for promotion, marketing, advertising or training purposes. The video/photograph footage will not violate the rights of any organization or person. I release Zion Christian Children s Center and Zion United Methodist Church from any and all present and future claims for compensation. Parent Signature I DO NOT grant permission for Zion Christian Children s Center to take video or photograph recordings of my child. For use of for promotion, marketing, advertising or training purposes.

3 ZION CHRISTIAN CHILDREN S CENTER AFTERSCHOOL PROGRAM Tuition for attendance in the After School Zion Christian Children s Center is as follows. Please check the days and option your child will be attending. After School $20.00 yearly registration fee Full-Time (Kindergarten-6th Grade) 4 days or above $50.00 a week/ per child Part- Time (Kindergarten -6 th Grade) 3 Days or Below $ a Week per child Unexpected Drop Off Rate (without 2 week advanced notice) $15.00 a /day per child Please select all the days your child will be attending on a regular basis: Monday Tuesday Wednesday Thursday Friday Please select a payment option that best suits you: Weekly Monthly Children that are scheduled to attend the program and are not present due to illness or vacation, etc. are still expected to pay for the week of absence. Payments must be made the previous weeks of care. You will receive a payment reminder via and attached to your child s sign out form. If the payment is not paid by the date specified you will be notified and your child must be picked up immediately and cannot return until the payment is made. There will be no refunds on tuition paid. Checks should be made payable to Zion CCC Afterschool and should be given by an adult to the After School Coordinator, teacher or placed in the gray payment box. Tuition money will not be accepted from children. Receipts can also be given upon request. Children should be picked up no later than 6pm each day. Parents that arrive after 6:10pm will be charged a fee of $1/minute until the child is picked up. By signing below you agree to all of the above. Parent Printed Name Parent/Guardian Signature Date

4 ZION CHRISTIAN CHILDREN S CENTER OPTIONAL CARE PROGRAM Tuition and Calendar ZCCC is offering an Optional Care Program on Various days the Louisa County School & Fluvanna Co. Systems are closed. We will be open from 7am-6pm (unless otherwise stated below) ZCCC After School Student Fee: $20.00 per day/ per child $15.00 for each additional sibling Non ZCCC student registered Fee: $10.00 registration fee $25.00 per day/ per child $20.00 for each additional sibling Tuition for Optional Care Days must be paid separate from normal after school payments. Tuition is due 2 weeks in advance of the scheduled days. Checks should be made out to ZCCC Optional Care. All Afterschool Polices apply. LOUISA CO. Optional Care days available school year: (If LCPS School Calendar changes we will change accordantly) October: Open Monday the 15 th November: Open Tuesday 6 th, Closed the 22 nd for Thanksgiving Day Open Friday 23 rd December: Open Friday 21 st (1pm LCPS dismissal), Open Monday 24 th Christmas Eve (closing at 3pm) Closed 25th Christmas day (Merry Christmas) Open: Wednesday 26 th Friday 28 th Open Monday 31 st. till 6pm January: Closed Tuesday 1 st New Years Day Open Wednesday 2 nd - Friday 4 th Open Monday 21 st February: Continued next page

5 LOUISA Optional Care days available school year: (If LCPS School Calendar changes we will change accordingly) March: April: Open Monday 1 st - 5 th May: Open Friday 24 th (LCPS 11am Dismissal) By signing below you agree to all of the above Optional Care Information for Louisa Schools: Parent / Guardian signature Date

6 FLUVANNA Co. Optional Care days offered available school year: October: Monday 8 th (Fluvanna only) November: Closed the 22 nd for Thanksgiving Open Friday 23 rd December: Open Monday 24 th Christmas Eve (closing at 3pm) Closed 25th Christmas day (Merry Christmas) Open: Tuesday 26 th Friday 28 th Open Monday 31 st. till 6pm January: Closed January 1 st New Years Day Open Wednesday 2 nd - Friday 4 th Open Monday 21 st Continued next page: February: March: Open Friday 29 th (Fluvanna only) April: Open Monday 1 st - 5 th By signing below you agree to all of the above Optional Care Information for Fluvanna Schools: Parent / Guardian signature Date

7 ZCCC After School and Optional Care Policy Communicable Diseases Policy: 1. If it is observed that a child is ill, or becomes ill or injured in our care, we will separate him/her from the other children and notify parents/guardians immediately. The child must be picked up within one hour of our call. 2. He/she may NOT return until 24 hours after the temperature returns to normal. We may require a doctor s release note in order for your child to return to the program at our discretion. 3. The parent or guardian agrees to notify ZCCC staff within 24 hours or the next business day after their child, or any many member of their household, has developed a reportable communicable disease. Life threatening diseases must be reported immediately. 4. Tuition will still be collected for absences due to illness. Transportation Policy: Zion Christian Children s Center, a ministry of Zion United Methodist Church, may be transporting children to and from field trips. During transporting, all drivers will hold a valid driver s license and all vehicles will be insured and registered. Parents/Guardians will always be notified of field trip dates and will be required to sign a permission slip. While being transported, ZCCC and all of its affiliates, including drivers and counselors, will take precautions before, during and after transporting ZCCC staff and affiliates will not be held responsible in the case of an accident or emergency. In the case of an accident, if deemed necessary by the EMS officials, the specified child/ren will be transported to the nearest hospital to be examined, in which, parents/guardians will be notified at this time. Electronic Device Possession Policy: The children are allowed to bring electronic devices (GameBoy, DS, Ipad etc) for personal use during Drop Off and Cool Down times only and must not share or distribute any of their games to another student. In the case that this does occur I will not hold ZUMC or any of its counselors responsible for loss. If a child refuses to abide by these rules their privilege to use electronics will be revoked and they can no longer bring their devices. Parent Statement of Understanding By signing below I acknowledge that I have read and agreed to the following: 1. I understand the aforementioned policies and tuition agreement and agree that myself and my child will follow these guidelines. 2. I recognize that the staff of Zion Christian Children s Center will do their best to ensure a safe experience. I understand that accidents may occur from my child s participation in activities. I agree to assume these risks. I release Zion Christian Children s Center, it s staff and volunteers, from all liability based on any damage, loss or injury. Child s Name Date Parent/Guardian Signature

8 Please Keep this page for your Records ZION CHRISTIAN CHILDREN S CENTER Louisa Co. Optional Care days available school year: (If LCPS School Calendar changes we will change accordingly) October: Open Monday the 15 th November: Open Tuesday 6 th, Open Friday 23 rd Closed the 22 nd for Thanksgiving December: Open Friday 21 st (1pm LCPS dismissal), Open Monday 24 th Christmas Eve (Closing at 3pm) Closed 25th Christmas day (Merry Christmas) Open: Tuesday 26 th Friday 28 th Open Monday 31 st. till 6pm January: Closed January 1 st New Years Day Open Wednesday 2 nd - Friday 4 th Open Monday 21 st February: March: April: Open Monday 1 st - 5 th May: Open Friday 24 th (LCPS 11am Dismissal)

9 Please Keep for your Records FLUVANNA Co. Optional Care days offered available school year: October: Monday 8 th (Fluvanna only) November: Closed the 22 nd for Thanksgiving Open Friday 23 rd December: Open Monday 24 th Christmas Eve (closing at 3pm) Closed 25th Christmas day (Merry Christmas) Open: Tuesday 26 th Friday 28 th Open Monday 31 st.till 6pm January: Closed January 1 st New Years Day Open Wednesday 2 nd - Friday 4 th Open Monday 21 st February: March: Open Friday 29 th (Fluvanna only) April: Open Monday 1 st - Friday 5 th