LEAD MIDDLE AFTER SCHOOL REGISTRATION CHECKLIST

Transcription

1 1 LEAD MIDDLE AFTER SCHOOL REGISTRATION CHECKLIST Become a Member of the Stamford YMCA, if not already a Member. ALL LEAD Middle Students MUST be a member before enrolling in the after-school program(consult the Front Desk for more information) 2. Completed and signed registration forms 3. Copy of your child s most recent Physical and Immunization Records 4. Completed and signed Administration of Medication forms (if applicable) 5. Financial Assistance: Applications available upon request 6. $100 first months payment (non-negotiable) Bring this completed packet along with the associated fees to the: Stamford Family YMCA 10 Bell Street Stamford, Connecticut (203)

2 2 PROGRAM DETAILS Days of Operation Monday Friday Daily Hours: 2pm-6pm Extended Hours: 2pm-7pm Monthly Fees: $100 per month (additional $10 a month for extended care) Early Release The LEAD Academy will open at 11:45am for early release days (following Stamford Public Schools Calendar). Staff will be on hand early to receive students. Snow Days If Stamford Public Schools closes due to the snow, LEAD Academy will NOT operate. Please watch your local news channels. Absences There will be no pro-rates or adjustments to your monthly fee if your child is absent unless it is due to a sickness or other medical injury. If this is the case, a doctor s note will need to be given to the Youth & Family Director. Explanation of Additional Fees: Vacation Camp Days Vacation camp is offered during school vacation (following Stamford Public Schools calendar). The fee per day for LEAD Academy students is $25 per day. All fees are due upon registration. Late Pick Up Fee An additional fee of $5.00 per 5 minutes, per child will be charged to participants picked up after normal care or extended care has ended. This fee will be applied to your next scheduled monthly payment.

3 3 PAYMENT FORM Draft Authorization Member/ Participant Name: Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Child s Name: I would like to have my remaining balance automatically drafted from my: Checking Account (Please attach a voided check) Routing Number: Account Number: Bank Name: Name of Account Holder: Credit/ Debit Card VISA MasterCard AMEX Discover Credit Card Issuer: Credit Card Number: Expiration Date: Name of Account Holder: All drafts will be taken on the 15 th of every month. Please be sure your preferred billing method has been entered into our system by a staff member at our Membership Desk. Please Initial: I understand that this draft will remain in effect until all payments have been made for 2015/2016 after school program or until two weeks after the Youth & Family Director has received an or written letter requesting withdrawal from the program. I understand that any errors must be identified no later than 60 days from the posted bank or credit statement date. I understand should my bank or credit card issuer for any reason, not honor my draft, I am still responsible for that payment, plus $28.00 service charge applied by the YMCA. This is in addition to any service fee my bank may charge. I understand that after one month of any unpaid balance, my child will be removed from current and future after school program sessions until the balance is paid in full. Parent/Guardian Signature: Date:

4 4 Stamford Family YMCA LEAD Middle After-School Program 10 Bell Street Stamford, CT Registration Form Registration Information: Today s Date: Male or Female Student s Last Name First Circle One Name of School Student s Date of Birth Grade Home Address City State Zip Code / Mother s/guardian s Name Home Phone Number Cell Phone/ Work Phone Mother s work address City State Zip Code Mother s address / Father s/guardian s Name Home Phone Number Cell Phone / Work Phone Father s work address City State Zip Code Father s address

5 5 EMERGENCY CONTACT INFORMATION Please list below at least three emergency contacts other than yourself or your spouse that we would be able to contact in the case of an emergency: 1. Name Relationship Home Address Home Phone Cell Phone Work Phone 2. Name Relationship Home Address Home Phone Cell Phone Work Phone 3. Name Relationship Home Address Home Phone Cell Phone Work Phone Parent Statement of Understanding I understand that the YMCA staff and volunteers are prohibited from babysitting or transporting children in their personal vehicles at any time outside of the YMCA program(s). I understand that I am not to leave my child at the Stamford Family YMCA unless a YMCA staff is there to receive and supervise my child. I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick-up my child must be either listed with the Stamford Family YMCA or other arrangements must be made to inform the Youth & Family Director as soon as possible. I understand that the Stamford Family YMCA and its child care employees are mandated by state law to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. Parent/Guardian Signature: Date:

6 6 MEDICAL INFORMATION Does your child have any allergies or intolerance to food, medication, etc.? If so, please specify: Does your child have any chronic physical problems, pertinent developmental information, or any special accommodations needed? If so, please specify: Does your child take medications on doctor s orders? If so, please specify: *Note: If center is to administer medications, an authorization of medication form MUST be filled out by both the physician and parent/guardian and given to the Youth & Family Director to keep on file Emergency Medical Authorization I give the Stamford Family YMCA permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member of the Stamford Family YMCA. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I give permission to the physician selected by the center to hospitalize, secure proper treatment (injections, anesthesia, or surgery) for my child as named above and will be responsible for all medical expenses. I understand that the provider will make every effort to contact me/and or my designated emergency contacts in the case of an emergency. Parent/Guardian Signature: Date:

7 7 ACADEMIC RELEASE FORM Student s Name: Address: City: State: Zip: Home Phone: School: Grade: School Address (if applicable): City: State: Zip: School Telephone: Homeroom Teacher s Name: Social Worker s Name: Social Worker s Phone Number: Does your child have any specific learning disabilities? If so, please specify: Does your child need extra help in any particular subject? If so, please specify: Authorization to Access Academic Records I have agreed to grant permission to the LEAD Academy Program to access my child s academic records. The LEAD Program will have access throughout the school year for the purpose of monitoring my child s academic progress. Parent/ Guardian Signature: Date:

8 8 AUTHORIZATION/ PERMISSION SLIP FORM I give permission for my child to attend the afterschool program and to participate in all activities. I also give permission for my child to participate in all field trips organized by the afterschool program via transportation by bus to/from school or the Stamford Family YMCA, Monday through Friday. Parent/ Guardian Signature: Date: Photography Release I hereby consent to and authorize the use and reproduction by the Stamford Family YMCA of any and all photographs and videos which might be or have been taken during the program of my child, for the purpose of telling the program story and promoting the message of the program. Parent/ Guardian Signature: Date:

9 9 DISCIPLINARY AND BEHAVIOR MANAGEMENT POLICY The LEAD Academy program has a discipline policy that each student is to adhere to. Step 1: Talk to the child about the behavior or action that is causing the problem Step 2: Asked to take a break from the activity Step 3: Loss of privileges Step 4: Visit with the Youth & Family Director Step 5: Parent/guardian will be informed of the disciplinary problems via telephone conference or inperson meeting After 3 Write-Ups: A conference will be held between the Youth & Family Director, Senior Programs Director, and the parent/guardian After 5 Write-Ups: A child may be suspended for a week and possible expulsion from the after school program Fighting and Bullying Child will be suspended from the program for a day. The Stamford Family YMCA has a zero tolerance for bullying. Assaulting/Threatening YMCA Staff Child will be suspended from the program for two days (possible expulsion depending upon the severity) Stealing Expulsion from the program The YMCA requires the support of the parent/guardian in encouraging appropriate behavior of their child. The YMCA staff will strive to provide a safe and fun environment for all program participants; however, the YMCA will not allow children who continually display disruptive behavior to hinder the safety or enjoyment of others. Parent/Guardian Signature: Date: