YWCA Programs for Early Learning and School Age Development Enrollment Packet

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1 YWCA Programs for Early Learning and School Age Development Enrollment Packet Child s Name: Early Learning Center Penn Manor School Age Care SDOL School Age Care Penn Manor Wrap Program -FOR OFFICE USE ONLY- Registration Form Contracted Schedule Form Emergency Contact form-must BE COMPLETE Child Health Report Getting to Know Your Child Form Publicity Release Form CACFP Paperwork (Lime Street Location Only) Payment Information: Funded Caseworker: Self-Pay Record Number: - Checked By: Sibling name for discount $ Registration $ Deposit or CCIS Co-pay (Goes toward last week of care with 2 weeks notice) $ First Week Fee (Only when program already started) -FOR OFFICE USE ONLY- Data completed / / By: H.A./Schedule completed / / By: Ledger/Tuition completed / / By: Payment Option $ Key Card YWCA Only Lime Street only (1 st $15.00, 2 nd $7.50) Refunded upon return Tuition Express Automatic (Attach form will be processed once file is entered into Pro-Care) $ Total Tuition Express Online Receipt Number: ( will be sent with Link and Codeonce file is entered into Pro-Care) Cash Check# Money Order# Credit Card # TE # Initials: Date: (Registration fee, and deposit are non-refundable) Start Date: Site Notified: 1

2 110 North Lime Street Lancaster, PA (717) (717) (fax) Registration Form All information must be filled out in order for your child to be enrolled. Start Date Site/Class Name Office use Only Total Days Contracted M T W TH F Weekly Fee: EHS PKC SACC Please Print Child s Full Name Age Birthdate Sex Race Grade Fall 2017 Address Home Phone # Please attach an IEP or IFSP for your child if applicable. Indicate with a check mark one of the following: I am providing a copy of my child s IEP/IFSP I am not providing a copy of my child s IEP/IFSP This is not applicable to my child Primary Guardian Name Home Address Street City State Zip Home Phone # Cell Phone # Business Phone # Guardian Employer/School Employer s/school s Address Street City State Zip Social Security # Date of Birth Annual Household Income: $0-$9999 $10,000-$14,999 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,999 $75,000-above Number of household members: * Information required for YWCA funding source Secondary Guardian Name Home Address Street City State Zip Home Phone # Cell Phone # Business Phone # Secondary Employer/School Employer s Address Street City State Zip Social Security # Date of Birth Person Responsible for Payment (if different from above, list address & phone): Self CCIS Other At the time of enrollment a deposit/co-pay equal to the amount of one contracted week is required; in addition to the Registration and security card fees (for Lime Street Only). The deposit will be credited for the last week of service assuming a two week (14 days) written notice has been given.these fees are non-refundable. Please call Child Care Information Service at (717) for more information on subsidized care. 1. I understand my bill will be sent weekly via- to the address I have provided to the YWCA Lancaster. Please provide the YWCA Lancaster with your current address. If your is changed for any reason please provide the YWCA Lancaster with the new address. It is your responsibility to review all correspondence sent from the YWCA Lancaster. I agree to pay in advance for each week my child is contracted. I understand that payment is due the Thursday before the week service is needed. 2. I understand that there is an annual non-refundable registration fee for all Programs. 3. I understand that all Program fees are based on my contracted schedule. 4. I understand that billing is based on the full time or part time enrollment for which I have contracted and not for actual attendance. I understand I will be billed for the days for which my child is enrolled based on their full time or part time status, even if she/he is absent from the program for any reason including but not limited to illness, vacations, etc. I understand that no fees will be credited to my account if my child is ill or fails to attend. 5. I agree to pay late fees of $1/minute if my child is not picked up by 6:00 pm. I also understand that I may be asked to remove my child from the program if late pick up is habitual. 6. I understand YWCA Lancaster programs cannot exceed staff-child ratios mandated by Department of Human Services. Therefore, unscheduled children will not be accepted. 7. I understand that failure to pay my contracted fees or an unpaid balance will result in my childcare services being interrupted until said balance is addressed. I understand that there is a $25 charge for all returned checks. Checks are to be made payable to YWCA Lancaster. I understand that it is my responsibility to keep statements, receipts or canceled checks for income tax purposes. YWCA Lancaster s Federal ID number is

3 8. All designated individuals understand that my child may not be left on school grounds without supervision. I agree to walk my child into the Program each morning and to be sure a staff member is present before releasing my child. I understand that staff are not prepared to accept my child until 6:30 a.m. I will sign my child in each morning and/or out each evening. Transportation home from the program must be provided by a parent or other designated person. 9. I agree to follow all parking procedures mandated by the school when I drop off and/or pick up my child. I understand that failure to do so may affect my child s enrollment in the program. 10. I understand that all forms required for programs must be completed and on file before my child may attend. These include the registration form and this contract for services. 11. I understand that staff must release children to all parents unless a court order indicating sole custody is provided to the Program Director at YWCA Lancaster. 12. I understand that I need to give written permission allowing staff to release my child to any individual other than the parent/guardian or those persons listed on Emergency contract/parental consent form. 13. I understand that I am responsible for any damages resulting from my child s actions to either YWCA Lancaster or school property. The price of any damaged items will be added to my weekly bill. 14. I understand that no medication is administered unless I fill out the medication log completely. Written instructions from a physician are required for medication administered for ten or more days, or on an as-needed basis. All medication must be in the original prescription bottle. 15. Families who wish to have sunscreen/sunblock at the program must complete a sunscreen form. 16. I agree to support and reinforce Program rules and procedures that concern the health and safety of the children. I understand that I must provide a current Health Appraisal, along with a current vaccination record for my child. I understand that my child may not attend the program with any illness that threatens the health of other children, and that the Health Department regulations governing periods of infection are enforced. I will be asked to pick up my child from the program if he/she has a contagious illness. 17. I understand that all YWCA childcare programs are state licensed programs and that all staff are mandated reporters who are required to report any evidence of suspected abuse to Childline. 18. I waive any claim for bodily injury or property damage against Penn Manor School District, the City of Lancaster, Lancaster Township, Millersville Borough, Conestoga Township, Washington Boro, Manor Township, Martic Township, Pequea Township and the YWCA Lancaster while my child is a participant in a YWCA Lancaster program at any location. 19. In accordance with applicable Federal and State civil rights laws and regulatory requirements, you and your child, as clients of the YWCA Lancaster, have the right: -To be provided services by YWCA Lancaster and to be referred for services at other facilities without regard to your race, color, sexual orientation, religious creed, disability, ancestry, national origin, age or sex. -Program services shall be made accessible to persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to equipment redesign, the provision of aids, and the use of alternative services delivery locations. Structural modifications shall be considered only as a last resort among available methods. -If you feel you have been discriminated against on the basis of your race, color religious creed, disability, ancestry, national origin, age or sex, complaints of discrimination may be filed with any of the following: YWCA Lancaster PA Human Relations Comm. Attention: Deb Sims Harrisburg Regional Office 110 North Lime Street 333 Market Street-8 th Floor Lancaster, PA Harrisburg, PA Department of Human Services Bureau of Equal Opportunity Room 223, Health & Welfare Building P.O. Box 2675 Harrisburg, PA U.S. Department of Health and Human Services Office for Civil Rights Suite 372, Public Ledger Building 150 S. Independence Mall West Philadelphia, PA I understand that I may be asked to withdraw my child if his/her behavior patterns threaten his/her own health and safety or the health and safety of other children. The established discipline procedure will be followed, but severe infractions of the rules may result in immediate dismissal from the program. 21. I will notify the YWCA Lancaster of any change on the Registration Form and will verify by signature that all information is correct semi-annually. 22. I understand that if my CCIS funding is discontinued I am responsible to pay the entire fee. Per CCIS regulations, if I reach 25 days absent from the program, I am responsible to pay the Center the daily rate for each day absent after the first 25 days. Primary Parent/Guardian Signature Date YWCA Lancaster Signature Date Secondary Parent/Guardian Signature (optional) Date Please sign after January 2018 Annual Review I have reviewed my child s registration and made necessary corrections. Parent/Guardian Signature Date 3

4 Financial Information YWCA Lancaster Rates Infant, Young Toddlers, Older Toddlers and Pre School Full-Time Rates Infants Young Toddlers Older Toddlers Pre School $ weekly $ weekly $ weekly $ weekly Pre-K Counts Before and After Care Rates Pre-K Counts (8AM-1PM) Pre-K Counts Only Before Care/ASP Care 6:30AM-8AM & 1PM-6PM Schedule is based on the SDOL school year calendar. $ Weekly No extra charge for No School Day Before & Wrap & After care (6:30AM-9AM), (11:30AM-3:30 PM), (3:30PM-6 PM) Wrap care (11:30AM-3:30 PM) Before & Wrap care (6:30AM-9AM), (11:30AM-3:30 PM) Wrap & After care (11:30AM-3:30 PM), (3:30PM-6 PM) School Year Program (Grade K5) Minimum 2 days 3 Days 4 Days 5 Days $80.00 $ $ $ $68.00 $92.00 $ $ $70.00 $94.00 $ $ $70.00 $94.00 $ $ No extra charge for No School Day or Early Dismissal. Must sign-up for day! No extra charge for No School Day or Early Dismissal. Must sign-up for day! No extra charge for No School Day or Early Dismissal. Must sign-up for day! No extra charge for No School Day or Early Dismissal. Must sign-up for day! 4

5 School Year Program (Grade 1-6th) Before Care (6:30AM-9AM) After Care (3:30PM-6PM) No School Day charge (6:30AM-6PM) $31.00 $41.00 $49.00 $55.00 May not add After school or Early Dismissal day. You must be contracted for the day $31.00 $41.00 $49.00 $55.00 that the Early Dismissal occurs in order to attend. This fee is for those who sign up for NSD on their regularly contracted day of care. Must $20.00 sign-up for day! We cannot accommodate NSD on non-contracted days. BSP(6:30AM-9AM) ASP(3:30PM-6PM) ED(12:30PM-6PM) NSD(6:30AM-6PM) $62.00 $82.00 $98.00 $ All Early dismissal and/or NSD fees for contracted days are included. CCIS Clients CCIS clients will be charged the daily rate for days of absence after the 25 th absence, starting the 26 th day of absence. CCIS Rates Full-time per day Part-time per day Infants $42.00 $35.00 Young Toddlers $38.00 $32.00 Older Toddlers $35.00 $30.00 Pre School/Pre-K Counts $31.00 $26.00 School Age Students BSP/ASP ASP 5

6 Contracted Schedule Form To provide a quality program for your child, program staff must be scheduled appropriately. YWCA staff are scheduled in relation to the number of children attending the program each day. Schedules are established for the school year because we plan and staff for each child s contracted attendance. Parent(s)/Guardian(s) will be given the opportunity to revise the Contracted Schedule Form, if needed, up to two times per school year with a two weeks (14 days) notice before the start of the requested change. All changes must be reviewed for space availability in the program requested and automatic approval should not be assumed. You must contact the SACC Administrative Team at to approve any changes to your contract. Your contracted fees do not change for days absent or if you are on vacation. If you find your child will be absent from our program you will need to contact by 9:00AM. This allows us to notify our staff and the secretaries of the respective schools in a timely manner. If you need to terminate your care, a two week written notice must be submitted to the SACC Administrative Team prior to the last day of attendance. If two weeks notice is not given, you will be charged two week s tuition from the time of withdrawal. I understand my bill will be sent weekly via- to the address I have provided the YWCA Lancaster. I agree to pay in advance for each week my child is contracted. I understand that payment is due the Thursday prior to the following week service. Method of payments: a. Tuition Express is the preferred methodof payment at the YWCA Lancaster. By signing up, your account will always be current and no late charge will be applied to your account. If funds are not available by Friday, you will receive a $25 service charge for non-sufficient funds. b. Tuition Express Online is another payment Parents/Guardians can sign in and make credit card payments manually. To access this option, Parents/Guardians must contact us in order to receive a code to register online. A charge of $2.50 per payment will be affixed to your account to offset the costs associated with processing payments by hand. c. Credit card transactions will be accepted at the front desk between the hours of 8 a.m. - 4.p.m. d. Cash payment and check payments may still be processed at the front desk between 8a.m. 4p.m. e. The drop box is still available to those families wishing to pay with cash or check. If balance is not paid in full weekly, a late payment charge of $10 will be affixed to your account. Please check days your child is to be contracted. Example: If you choose a 2 day minimum, you must identify which two days (example: Monday/Tuesday). Days may not be switched at any time unless you revise your contract. Infant, Toddlers, and Pre-K Counts Students Only Start Date: Time In: Time Out: Total # of days contracted Total Weekly Fee: Sibling name discount: Monday Tuesday Wednesday Thursday Friday EHS EHS EHS EHS EHS BSP/ASP BSP/ASP BSP/ASP BSP/ASP BSP/ASP School Age Students Only Start Date: Total # of days contracted Total Weekly Fee: Sibling name discount: Monday Tuesday Wednesday Thursday Friday BSP ASP Wrap BSP ASP Wrap BSP ASP Wrap BSP ASP Wrap BSP ASP Wrap Parent/Guardian Signature Date Parent/Guardian Signature Date YWCA Lancaster Signature Date Office Use Only: Site Informed by Date / / Scheduled updated by Date / / Tuition Updated by Date / / 6

7 Questionnaire for Parents How did you find out about YWCA Lancaster Program s? o Newspaper Add o Magazine o Online o Returning family o By friends or families o Other please indicate GETTING TO KNOW YOU FORM Basic Information Child s Name: Birthdate: What time do you expect to drop off/pick up? Illness or Injury Contact If your child becomes ill, who would you prefer us to call? Name: Phone Number: When do you wish to be informed on a minor injury or illness (i.e. scratch, headache, etc) o Immediately by phone o At pick up o Other: Food and Allergy Information Food Allergies: Favorite Foods: Special Information What are your child s strengths? What skills do you most want to see your child develop? What are your child s favorite activities? Please provide any other information that will be helpful for our staff to know that we did not cover on this paper: Parent/Guardian Signature: Date 8

8 Parents may write immunization dates, health professionals should verify and complete all data. Parents & Child Care Providers fill-in this part. CHILD S NAME: (LAST) DATE OF BIRTH: CHILD CARE FACILITY NAME: (FIRST) CHILD HEALTH ASSESSMENT HOME PHONE: FACILITY PHONE: COUNTY: Lancaster PARENT/GUARDIAN: : WORK PHONE: PA child care providers must document that enrolled children have received age appropriate health services and immunizations that meet the current schedule of the American Academy of Pediatrics 141 Northwest Point Blvd., Elk Grove Village, IL The schedule is available at < > or Faxback 847/ (document #9535 and #9807). Print copies provided by DPW have the schedule on the back of the form. Health history and medical information pertinent to routine child care and emergencies (describe, if any): NONE Allergies to food or medicine (describe, if any): NONE Date of most recent well-child exam: Do not omit any information. This form may be updated by health professional. (Initial and date new data.) Child care facility needs 2 copies. LENGTH/HEIGHT WEIGHT HEAD CIRCUMFERENCE BLOOD PRESSURE (BEGINNING AT AGE 3) IN/CM %ILE LB/KG %ILE IN/CM %ILE / PHYSICAL EXAMINATION =NORMAL IF ABNORMAL - COMMENTS HEAD/EARS/EYES/NOSE/THROAT TEETH CARDIORESPIRATORY ABDOMEN/GI GENITALIA/BREASTS EXTREMITIES/JOINTS/BACK/CHEST SKIN/LYMPH NODES NEUROLOGIC & DEVELOPMENTAL IMMUNIZATIONS DATE DATE DATE DATE DATE COMMENTS DTaP/DTP/Td POLIO HIB HEP B MMR VARICELLA MENINGOCOCCAL PNEUMOCOCCAL INFLUENZA HEP A ROTAVIRUS OTHER SCREENING TESTS DATE TEST DONE NOTE HERE IF RESULTS ARE PENDING OR ABNORMAL LEAD ANEMIA (HGB/HCT) URINALYSIS (UA) at age 5) HEARING (subjective until age 4) VISION (subjective until age 3) PROFESSIONAL DENTAL EXAM HEALTH PROBLEMS OR SPECIAL NEEDS, RECOMMENDED TREATMENT/MEDICATIONS/SPECIAL CARE (ATTACH ADDITIONAL SHEETS IF NECESSARY) NONE YWCA Lancaster NEXT APPOINTMENT - MONTH/YEAR: MEDICAL CARE PROVIDER: SIGNATURE OF PHYSICIAN OR CRNP: : PHONE: LICENSE NUMBER: DATE FORM SIGNED: CD 51 10/06

9 YWCA Lancaster

10 EMERGENCY CONTACT / PARENTAL CONSENT FORM 55 PA CODE CHAPTERS (a)(b), &.182, (a)(b), &.182: (a)(b) &.182 CHILD'S NAME BIRTHDATE MOTHER'S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER BUSINESS NAME BUSINESS TELEPHONE NUMBER FATHER'S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER BUSINESS NAME BUSINESS TELEPHONE NUMBER EMERGENCY CONTACT PERSON(S) NAME TELEPHONE NUMBER WHEN CHILD IS IN CARE PERSON(S) TO WHOM CHILD MAY BE RELEASED NAME TELEPHONE NUMBER WHEN CHILD IS IN CARE NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER TELEPHONE NUMBER SPECIAL DISABILITIES (IF ANY) ALLERGIES (INCLUDING MEDICATION REACTION) MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION MEDICATION, SPECIAL CONDITIONS ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD HEALTH INSURANCE COVERAGE FOR CHILD or MEDICAL ASSISTANCE BENEFITS POLICY NUMBER (REQUIRED) PARENT'S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT OBTAINING EMERGENCY MEDICAL CARE ADMIN. OF MINOR FIRST - AID PROCEUDURES WALKS AND TRIPS SWIMMING TRANSPORTATION BY THE FACILITY WADING PERIODIC REVIEW SIGNATURE OF PARENT or GUARDIAN DATE SIGNATURE OF PARENT or GUARDIAN DATE

11 Automated Payment Processing Safe Convenient Easy We are excited to offer the safety, convenience and ease of Tuition Express a payment processing system that allows secure, on-time tuition and fee payments to be made from either your bank account or credit card. ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD I (we) hereby authorize (business name) to initiate credit card charges to the below referenced credit card account (Section A) OR, initiate debit entries to my (our) Checking or Savings Account, indicated below (Section B). To properly affect the cancellation of this agreement, I (we) are required to give 10 days written notice. Credit Union Members: Please contact your Credit Union to verify account and routing numbers for automatic payments. Check with the center for accepted credit card types. COMPLETE ONE SECTION ONLY SECTION A (Credit Card) Cardholder Name Phone # Cardholder Address City State Zip Account Number Expiration Date Cardholder Signature Date SECTION B (Bank Account) Your Name Phone # Address City State Zip Bank or Credit Union Name Bank or Credit Union Address City State Zip Checking Savings Routing Transit Number (see sample below) Account Number (see sample below) For Official Use Only A service of Date Received Employee Signature Copyright Procare Software

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