2020-2021 registration form ymca nd school-age learning center › wp-content › ... · 2020-2021...

2020-2021 Registration Form

YMCA ND School-Age Learning Center Completion of registration form does not guarantee a spot in program. Registration is based on openings. . Updated 2/13/2020

YMCA OF CASS AND CLAY COUNTIES I P 701.364.4117 I E [email protected] I www.ymcacassclay.org

1. Child Info Child’s Legal Name Birthdate (ex: 04-22-2010) Gender

Male Female

Racial / Ethnic Data (optional) Hispanic or Latino Alaska/American Native

Black/African American Multi-Racial/Other

White Asian Native Hawaiian/Pacific Island

Check if Any Following Apply

Foster Care PATH ND Child Care Assistance

2. Primary Contact Name of Contact Payer on Account?

Yes No Relationship to Child Birthdate (ex: 6-30-1981)

Current Address City State Zip

Cell Phone Number Name of Cell Provider Text Ok? Yes No

Lives With Yes No

Work Phone Number Name of Employer Email Address

3. Secondary Contact Name of Primary Contact Payer on Account?

Yes No Relationship to Child Birthdate (ex: 6-30-1981)

Current Address City State Zip

Cell Phone Number Name of Cell Provider Text Ok? Yes No

Lives With Yes No

Work Phone Number Name of Employer Email Address

4. Emergency Contacts (other than parents/guardians) check all that apply

Name of Contact Relationship Phone Number Emergency Contact

May Pick Up

Under 18 Years Old


May Pick Up Under 18 Years Old


May Pick Up Under 18 Years Old

5. Unauthorized to Pick Up FOR OFFICE USE ONLY Name:

Relationship to Child:

You must submit a court order to prevent a

parent from picking up their child.

Paperwork Received: (Date)

Start Date:

Group: Wildcats Cobber Dragons Bison

Comments:

mailto:[email protected]

http://www.ymcacassclay.org/




6. YMCA Site (please check site child will attend) Please check the name of YMCA Learning Center you are attending

Aurora

Brooks Harbor

Deer Creek

Fercho YMCA

Freedom

Harwood

Horace

Independence

Legacy

Oak Grove

Osgood

Schlossman YMCA

South Elementary

Westside

Willow Park

Calvary YMCA

South ELC

7. Schedule Your Child Will Be Attending Desired Start Date

Allow 5 business days to process.

School Child Will Attend Fall 2020 Grade Fall 2020

Explanation of Rates

Contract Care means you are signing up for the entire session. A four week notice does not relieve you of the obligation to pay for the full session. You must stay enrolled in the program for the full school year or summer.

Non-Contract Care means you may put in a four week notice at any time to end care and are subject to a non-refundable registration fee to return to the program. Only

emailed notices to [email protected] are accepted.

**Part time schedules must be 3-4 set days. Rotating schedules are not accepted.

Select Your Schedule Below Contract School Age Rates *Sign for rate below

Non-Contract School Age Rates *Sign for rate below

Before + After School Full Time Monday–Friday OR

Part Time: M T W R F

FT: $20 per day / $100 WK

PT: $22 per day

Signature Required


PT: $24 per day

Signature Required

After School Only Full Time Monday–Friday OR



PT: $19 per day

Signature Required


PT: $21 per day

Signature Required

Before School Only Full Time Monday–Friday OR



PT: $12 per day

Signature Required


PT: $14 per day

Signature Required

Summer Care Full Time Monday–Friday OR



PT: $38 per day

Signature Required


PT: $40 per day

Signature Required

We bill bi-weekly. You will receive your billing statement at the email address you provided.

To ensure constant care for your child, it is the YMCA’s policy that you pay whether your child

attends the program or not. A complete listing of the closed YMCA days are listed in the

Parent Handbook: http://ymcacassclay.org/family-corner/

Late Pickup Fee $1.00/minute after center closing

Non-School Day Fee $20.00 additional fee per day. Sign-up sheets will be available at your

site 2 weeks in advance of each non-school day.

Registration Fees: $25 for one child and $40 for a family




http://ymcacassclay.org/family-corner/




8. Tell Us About Your Child Is there any information which will help us to better prepare for your child? (Example: has

your child suffered a loss; have a parent deployed; have an IEP; require a therapist to visit; medical conditions, likes and dislikes, etc…)

9. Statements of Understanding and Authorization for Services

Your signature below confirms that you agree to YMCA policies and grant permissions for your child.

Policy or Permission Initial & Date

a. Authorization for Medical Treatment

I hereby authorize the YMCA Learning Center personnel to secure emergency

medical treatment for my child. In case of an emergency, I hereby give

authorization to call any qualified emergency services. I understand the YMCA

Learning Center personnel will attempt to contact me before requesting medical

treatment, if possible. YMCA staff will not administer any over the counter drugs

without a doctor’s written consent.

Date:

b. Field Trip Consent

My child listed on this form has permission to go on walks and field trips planned by

the YMCA during my child’s attendance at the YMCA Learning Centers.

Date:

c. Sunscreen Permission

I give permission for YMCA Learning Center personnel to apply SPF 50, hypo-

allergenic, fragrance free, non-greasy and non-comedogenic formula sunscreen

provided by the YMCA. Will be used outdoors at YMCA personnel discretion.

Date:

d. Insect Repellent Permission

I give permission for YMCA Learning Center personnel to apply hypo-allergenic,

fragrance free, child approved formula insect repellent provided by the YMCA. Will

be used outdoors at YMCA personnel discretion.

Date:

e. Consent to Help Teachers After-School

I grant permission for the child listed on this form to assist a teacher after school while

in the care of the YMCA. The teacher is required to escort my child to and from the YMCA program.

Authorize

Unauthorized

Initials:_______

f. Information Sharing

I understand that my child’s information will be shared with legal parent/guardians,

state licensors, state administrators, and YMCA program administrators.

Date:

g. School Disclosure

I grant permission to share information with the school and the school to share

information with the YMCA regarding my child. This information will be used to plan

care for your child. This may include homework assignments, challenging behavior, free or reduced meal classification, etc.

Date:

h. Liability Insurance

The center is covered under liability insurance in case of a major accident or

incident involving your child. Your insurance would be required to cover injuries for

your child and would include any emergency services requested. The YMCA

coverage is secondary.

Date:

Signature (Required):

Date: _________






10. Statements of Understanding and Authorization for Services (continued)

Your signature below confirms that you agree to YMCA policies and grant permissions for your child.

Policy or Permission Initial & Date

i. Outside Food Policy

No outside food of any kind is allowed into the YMCA program unless the child has

a life threatening allergy/disease. A meal modification form plus a physician

signature is required to modify any meal. The YMCA is a nut free and pork free

program.

Date:

j. Classroom Photo/Video Consent

I give the YMCA permission to include my child in photos sent to classmates via

Seesaw, Newsletters, and e-mail. My child’s picture may be posted in the

classroom and on bulletin boards for other families and children to view.

Authorize

Unauthorized

Initials:_______

k. External Photo/Video Consent

The YMCA prepares brochures, ads, flyers, and videos to inform the public of YMCA

programs. I hereby authorize the YMCA of Cass-Clay Counties, its nominees,

agents, successors, and assigns to use a photo or video of my child in YMCA

advertising, promotion, trade, publication, or any other purpose without limitation.

Authorize

Unauthorized

Initials:_______

e. Social Media Understanding

I agree as a parent of the YMCA Childcare to refrain from publicly posting on social

media sites any picture involving YMCA children, other than my own, without explicit

permission from the families of the children.

Date:

f. Parent Handbook

I have read and will adhere to the Parent Handbook and I understand all the

policies that are included. http://ymcacassclay.org/family-corner/

Date:

g. Assume Financial Responsibility

I hereby assume financial responsibility for my tuition. I understand:

I am responsible to make payments by the due date or a late fee will be

charged.

I will be charged for days that my child does not attend due to

illness, holidays, emergency closures (ex: weather), or other

absences.

If my child attends additional days, I will be charged for them (ex:

unscheduled days)

Contract Care: A 4 week notice does not relieve me of my obligation to

pay for the entire session’s tuition if in a contract.

Non-Contract Care: I must give a 4 week written notice to terminate

care. Only emailed notices to [email protected] are accepted. I

am responsible for payment of the full 4 weeks.

Any returned check will automatically receive an NSF FEE of $15 per check

If receiving child care assistance, I am responsible for my co-payment

amount and any remaining balance.

I will pay the first 2 weeks tuition before I start. Registration fees are not

refundable. If I leave the program and restart at a later date, a new

registration fee will be charged to my account in order to have my child

return to the YMCA.

Date:

For Office Use Only

*VERBAL confirmation of CONTRACT with Payer

Coordinator Signature:

Date:

Signature (Required):

Date: _________



http://ymcacassclay.org/family-corner/


PARENT'S STATEMENT ON HEALTH OF CHILD

ND DEPARTMENT OF HUMAN SERVICES/CFS SFN 847 (Rev. 11-2008)

INSTRUCTIONS: This form must be completed annually for any child enrolled in a licensed early childhood facility.

Full Legal Name of Child: Birth Date: Enrollment Date: Please check one: FT PT

Drop-in B/A School

Full Legal Name(s) of Parent or Guardian: Relationship:

Address: City: State: ZIP Code:

Home Telephone Number: Work Telephone Number: Family Dentist:

Family Physician: Clinic: Telephone Number:

Hospital: Telephone Number:

Last Visit to Doctor: Child's Height: Child's Weight:

Does The Child Have Any food, medication or environmental allergies: Yes No

If Yes, List Allergies: Describe Allergy Reaction: Usual treatment:

Please Check If Any Of The Following Conditions Exist:

Asthma Diabetes Vision Impairment Heart Condition Seizure Disorder

Hearing Impairment Behavioral Issues Frequent Earaches Other Conditions (please specify):

_ _

Please Explain All Checked Items:

Is the Child Under Current Medical Treatment? Yes If yes, please list:

No

Are There Any Medications That The Child Takes Daily? Yes If yes, please list:

No

Describe Any Limitation Your Child May Have For Participation in An Early Childhood Program:

Is There A Health Care Plan For Your Child? Yes If yes, please list: (ie, seizure plan, epi pen, etc)

No

INSURANCE:

Liability insurance is not a requirement for a license to provide family or group child care. Please review with your child care

provider the liability coverage that is presently in place.

CERTIFICATION:

I certify that the above information is true to the best of my knowledge. Parent or Guardian's Signature:

Signature Date

YMCA Water Activity Permission Form

Name of Child: Date of Birth: Age:

I give consent for

(Name of parent/guardian) (Name of Child)

to participate in water activities while at (Name of provider / facility)

I understand that my child’s care provider will:

A. Maintain a safe staff to child ratio while participating in water activities

B. Closely monitor my child and will never leave them unattended while they are participating in water activities listed below.

My Child MAY participate in: Please check all that apply (depending on program some may not apply)

Water Table Play

Wading Pool (on playground grassy area on hot day)

Slip & Slide Sprinkler

Community Splash Pads

Lake (example: Camp Cormorant)

Community Pool / Water Slide (example: Davies, Island Park, Fargo South etc.)

Location / address:

My Child’s Swimming Abilities: Please check all that apply

A non –swimmer

Has successfully completed formal swimming lessons

Describe what level / skills your child has in swimming:

Has special needs with water activities

Please describe: _

NON-SWIMMER: (Must be filled out if a non-swimmer)

For those who are non-swimmers we REQUIRE that you provide a properly fitted, Coast Guard

approved life jacket for your child to wear while at a community pool.

I will provide my child with a properly fitted Coast Guard approved life jacket for them to

wear while at a community pool.

I know my child is a non-swimmer, I chose to NOT have my child swim at the community

pool. My child only swims at the YMCA pool in which life jackets are provided so no life

jacket is needed.

Expiration date of permission form: Today’s Date:

Parent(s) or Guardian(s) name:

Signature of parent / Guardian:

**Please see director if financial assistance is necessary in purchasing life jacket.

YMCA OF CASS AND CLAY COUNTIES

Fercho Branch Schlossman Branch 400 1st Ave S, Fargo, ND 58103 4243 19th Ave S, Fargo ND 58103 (P) 701.293.9622 | (F) 701.232.9545 (P) 701.281.0126 | (F) 701.277.4832 WWW.YMCACASSCLAY.ORG


PARENTS OF INFANTS

My Choice of CACFP

Infant Participation is:

Your child care center must offer at least one brand of formula if your child is on formula. You have the option of declining that brand and supplying your own formula. Children must be served breast

milk or iron-fortified infant formula until they are one year of age. All other food items must be provided by your center when age-appropriate, consistent with CACFP guidelines.

I choose to supply expressed breast milk to my child care provider to serve at meal time. I choose to accept the iron-fortified infant formula (brand: ) that my child care center has offered. My child care center has offered the following brand, . I have chosen to decline this brand and provide the formula for my infant.

IF NO > Go to STEP 3 IF YES > Write case number here and proceed to STEP 4 (do not complete STEP 3)

C. Child Income Sometimes children in the household earn or receive income. Please include

the TOTAL income received by all Household Members listed in STEP 1 here. $

D. All Other Household Members (Including yourself)

Howoften?

Child Inco me Weekly Bi-Weekly Monthly Bi-Monthly

List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes) for

each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Welfare/Child How often? Pensions/Retirement/ Social Security/SSI/ Howoften?

Name of Household Members not listed in Step 1

(Last Name, First Name) i

Howoften? Support/Alimony VA Benefits

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

Last Four Digits of Social Security Number (SSN) of

PrimaryWageEarner or other Adult Household Member

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that CACFP officials

may verify (check) the information. I am aware that if I purposely give false information, the participant/center may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

Print Name of Adult Signing the Form Signature of Adult Today’s Date

Address City State Zip Phone/Email

Optional Parent / guardian should fill out household income to determine the amount of CACFP funds the center will be eligible to receive. This form will be placed in our confidential files.

Optional Do any household members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

Foster Child Migrant

Head Start

CHILD’s Last Name, First Name Date of Birth Time of Care Regular Days of Care Meals Served During Care

Arrival Time Leave Time M T W T F S S B AM L PM D EV

CACFP Enrollment Form / Free and Reduced-Price Income Application Center Name

(Child Care) Complete one application per household. Please use a pen (not a pencil).

STEP 1 REQUIRED The parent / guardian must complete Parts 1 and 4. List ALL Children who attend day care

Check a

ll t

hata

pply

STEP 2

Write only one case number in this space. CASE NUMBER:

STEP 3

Are you unsure what

income to include here? Flip the page and review the charts titled “Sources

of Income” for more information.

The “Sources of Income

for Children” chart will

help you with the Child

Income section.

The “Sources of Income

for Adults” chart will

help you with All Adult

Household Members

section.

Earn ngs fr om W ork Weekly Bi-Weekly Monthly 2xMonth

Weekly Bi-Weekly Monthly 2xMonth


X X

STEP 4

Check if no SSN Total Household Members (Children and Adults) X X X

REQUIRED Sign and date the application. The form must be signed by the parent or guardian.

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and

does not affect your children’s eligibility for receiving meals during care.

Ethnicity (check one): Hispanic or Latino Not Hispanic or Latino

Race (check one or more): American Indian or Alaskan Native Asian Black or AfricanAmerican Native Hawaiian or Other Pacific Islander White

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12

How often?

Total Income Household size

Categorial Eligibility

Eligibility

Determining Official’s Signature Date Confirming Official’s Signature Date Follow-up Official’s Signature Date

Source of Income for Children

Sources of Child Income Examples

Earnings from work • A child has a regular full or part-time job where they earn

a salary orwages

Social Security

- Disability Payments

- Survivors Benefits

• A child is blind or disabled and receives Social Security benefits

• A parent is disabled, retired, or deceased, and their child receives

Social Security benefits

Income from person outside of household

• A friend or extended family member reguarly gives

a child spending money

Income from any other source • A child receives regular income from a private pension fund,

annuity, or trust

Source of Income for Adults

Earnings from Work Public Assistance/Alimony/ Child Support

Pensions/Retirement/ All other sources of income

• Salary, wages, cashbonuses • Net income from self-employment

(farm or business)

If you are in the U.S. Military:

• Basic pay and cash bonuses (do NOT

include combat pay, FSSA, or privatized

housing allowances)

• Allowances for off-base housing, food,

and clothing

• Unemployment benefits

• Workers compensation

• Supplemental Security Income(SSI)

• Cash assistance from State or local

government

• Alimony payments

• Child support payments

• Veterans benefits

• Strike benefits

• Social Security (including railroad

retirement and black lungbenefits)

• Private Pensions or disability benefits

• Income from trusts or estates

• Annuities

• Investment income

• Earned interest

• Rental income

• Regular cash payments from

outside household

Children’s Ethnic and Racial Identities(Optional) OPTIONAL

*Only use this address if you are filing a complaint of discrimination.

This institution is an equal opportunity provider.

(202) 690-7442; or [email protected].

FAX: EMAIL:

U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue,SW

Washington, D.C.20250-9410

MAIL*:

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and

employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,

disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who

require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the

Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the

Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.

gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the

form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

The Richard B. Russell National School Lunch Act requires the information on this

application. You do not have to give the information, but if you do not, the funds your child

care center/provider receives may be impacted. You must include the last four digits of

the social security number of the adult household member who signs the application. The

last four digits of the social security number is not required when you apply on behalf of

a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary

Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian

Reservations (FDPIR) case number or other FDPIR identifier for your child or when you

indicate that the adult household member signing the application does not have a social

security number. We will use your information to determine the meal reimbursement for

your child care center/provider. We MAY share your eligibility information with education,

health, and nutrition programs to help them evaluate, fund, or determine benefits for their

programs, auditors for program reviews, and law enforcement officials to help them look

into violations of program rules.

For official use only DO NOT FILL OUT


Denied Reduced Free


http://www.ascr.usda/

Tuition Express Payment Form

Choose 1 of the 3 Convenient Payment Options Below

We are excited to offer Tuition Express® - a payment processing system that allows secure, on-time

tuition and fee payments to be made from either your bank account or debit/credit card.

Name

Child (Only one name required)

Site Attending

My Email (Required)

Driver’s License Number and State Phone Number

Billing Address

City

State

Zip Code

I (we) hereby authorize the YMCA of Cass and Clay Counties to initiate debit entries to my (our)

Checking or Savings Account or debit card below. A bank draft cannot be stopped without proper notice

from the parent. To properly effect the cancellation of this agreement, I (we) are required to give 10

days’ written notice.

Option 1: I want to be automatically bank drafted for the billed amount on the due date.

Please fill out banking information below and attach a voided check on bottom of form. Option 2: I want to make tuition payments online, on my own schedule, using my bank

account. I understand that after three late payments, my account will be drafted and

I will be required to change to automatic bank drafts. Please fill out banking

information below and attach a voided check. Please note if you use a debit/credit card

instead of your bank account, fees will apply as in option 3 below.

Bank or Credit Union

Bank or C.U. Address City State Zip Code

Routing Transit Number

Account Number

Checking

Savings

Authorized Signature

Date

I would like my first two weeks of payment to be drafted from the above account for $_________

Option 3: I want to make tuition payments online, on my own schedule, using a

debit/credit card. I understand that I will be charged an account maintenance fee of

$2.50/child per bill period. I understand that after 3 late payments, my account will be

drafted and I will be required to provide information to change to automatic bank

drafts. Please note using the bank account above (option 2) is free.

Account Number

Expiration Date

Cardholder Signature

Date

I would like to be CALLED at the number listed on this form to have my card charged for my first two

week of payment for $______________.

YMCA of Cass and Clay Counties

P 701.364.4117 | E [email protected] | F 701.551.5291 www.ymcacassclay.org



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