DISCOVER SUMMER Explorer & Adventure Licensed Summer Child Care Program 2017 Registration Packet MID VALLEY FAMILY YMCA Chandler License # 191220762

Welcome to the YMCA!

The YMCA is a charitable 501(c)(3) non-profit community organization. We’re here for

Youth Development, Healthy Living and Social Responsibility. Our Strength is in

Community.

WHO SHOULD COMPLETE THIS PACKET? Parents of children entering grades transitional Kinder-4 (ages 4.9-9) that would

like to attend the Chandler Explorer Day Camp. Parents of children entering grades 5-9 (ages 10-14) that would like to attend the

Chandler Adventure Camp.

REGISTRATION FORM

SUMMER CHILD CARE PROGRAM MID VALLEY FAMILY YMCA

STEP 1: REGISTRATION INFORMATION – COMPLETE ONE FORM, PER CHILD

Child’s Name (Last Name, First Name) T-Shirt Size: size choice

Youth Sizes ___S___M___L___XL Adult Sizes___XS___S___M___L

Primary Parent Name (Last Name, First Name) Primary Parent Email Address

Primary Parent Cell Number Secondary Parent Cell Number

STEP 2: SELECT A SUMMER CHILD CARE CAMP

CHANDLER ELEMENTARY

EXPLORER SUMMER CHILD CARE

14030 Weddington St.

Sherman Oaks, CA 91403

M-F, 7 am – 6 pm (closed Tuesday, July 4) 818 906 1923 | License #191220762

This site offers child care for grades TK-4th Grade

Campers need to be 4.9 years old

ATS FEES:

TK-4:$180/session | week 4* $144/session CASH FEES: TK-4:$144/session | week 4* $159/session REJECTED ATS PAYMENTS OR CASH PAYMENTS NOT RECEIVED THE MONDAY BEFORE YOUR

WEEK STARTS WILL RESULT IN BEING DROPED FROM THE ROSTER

CHANDLER ELEMENTARY

ADVENTURE SUMMER CHILD CARE

14030 Weddington St.

Sherman Oaks, CA 91403

M-F, 7 am – 6 pm (closed Tuesday, July 4)

818 906 1923 | License #191220762

This site offers child care for 5th – 9th Grade

Camper cannot be older than 14 years of age

ATS FEES:

5TH-9TH:$200/session | week 4* $160/session CASH FEES:

5TH-9TH:$215/session | week 4* $175/session REJECTED ATS PAYMENT OR CASH PAYMENT NOT RECEIVED THE MONDAY BEFORE YOUR

WEEK STARTS WILL RESULT IN BEING DROPED FROM THE ROSTER

STEP 3: SELECT CHILD CARE WEEKS ATTENDING

SESSION

SESSION DATES

PAYMENT

DUE DATE

ATS

Payment

EXPLORER

Cash

Payment

Explorer

ATS

Payment

ADVENTURE

Cash

Payment

Adventure

1 June 12 – June 16 June 5 $180 $195 $200 $215

2 June 19 – June 23 June 12 $180 $195 $200 $215

3 June 26 – June 30 June 19 $180 $195 $200 $215

4* July 3 – July 7 (4 days) June 26 $144 $159 $160 $175

5 July 10 – July 14 July 3 $180 $195 $200 $215

6 July 17 – July 21 July 10 $180 $195 $200 $215

7 July 24 – July 28 July 17 $180 $195 $200 $215

8 July 31 – August 4 July 24 $180 $195 $200 $215

9 August 7 – August 11 July 31 $180 $195 $200 $215

STEP 4: ADDITIONAL FEES

Registration Fee $30.00 (one-time fee/includes 1 camp shirt)

Earthquake Kit $15.00 (you may take with you when your child leaves the program)

Extra Camp Shirt $10.00 (For SAFETY reasons, camper will not be allowed to attend field trip without camp shirt on)

STEP 5: SELECT PAYMENT OPTIONS

Cash, Cashier’s Check or Money Order (payment is due in full 1 week prior, the Monday before your camp week starts)

Set me up with Automatic Payment using my Credit Card or Checking Account (Payment will be charged 1 week prior, the Monday before your camp week

starts & this option guarantees your camper a spot in camp)

CCRC Payment (camper may not start until Notice of Action has been received by our camp accountant)

I have read and understand that I am responsible for payment to the YMCA of all fees noted above and will pay such fees one week prior, the Monday before your camp week starts.

There are no credits for missed days or refunds. I also understand that spaces are limited and spaces are filled as payments are received.

Parent/Guardian Signature____________________________________________________________Date_______________________________

Parent/Guardian (please print) _______________________________________________________Date_______________________________

PAYMENT AUTHORIZATION FORM

SUMMER CHILD CARE PROGRAM YMCA OF METROPOLITAN LOS ANGELES

_____________________________________________________________________________________________________________________________________________________________ ( __________ ) __________________________________________ Legal name (include middle initial) Phone

________________________________________________________________________________________ _____________ _________________________________________________________________ _________ _________________________

Address Apt. City State Zip code

PAYMENT AUTHORIZATION

Amount to be charged for each session checked: _______________________

Weekly cost of care,

TK-4th grade: $180/session | week 4 $144/session

5th -9th grade: $200/session | week 4 $160/session

(Financial aid will vary fees depending on awarded amount)

Date of first draft or charge: ________________________________________

(This is the first draft date of the first session you checked).

Select ONE of the two payment options below and provide the

requested information.

YMCA OF METROPOLITAN LOS ANGELES FINANCIAL POLICIES

I further agree to the following conditions (Please read and sign below.):

• I understand that the weekly program session fee charges or debits will be charged to the above listed account, based on the program sessions that I selected on the

Program Options form. I will be charged one week prior to the start of each program session that I have selected. The frequency and occurrence of my visits or my

child’s visits to the YMCA or its programs has no bearing on my weekly program session fees, charges or debits.

• I understand that the weekly program session fee charges and debits will be charged to the above listed account, based on the program sessions that I selected on

the Program Options form, until I give written notice to change or cancel a weekly program session.

• I understand that I must give the YMCA written notice prior to the Draft Date for Cancellations or Changes for each weekly program session. Written notice may be

submitted in-person or by e-mail. I understand that at the time of my request for a cancellation, exit or change, I may be asked by a YMCA employee to complete a

YMCA Exit, Change and / or Cancellation form and I will be given a deadline by the YMCA employee to return the form. Failure to notify the YMCA of a cancellation,

exit or change prior to the Draft Date for Cancellations or Changes or failure to return the YMCA Exit, Change or Cancellation form within the requested timeframe,

will make the subsequent draft non-refundable. Any outstanding balances will be due at the time of the cancellation. I am liable for any fees that the YMCA may

incur in its effort to collect any remaining balance due.

• I understand that I must inform the YMCA 15 days in advance of any changes to my name, address, telephone number or payment information. Failure to provide the YMCA

with current information may result in non-refundable fees. I am personally responsible for any payments not processed by my financial institution and/or the YMCA.

____________________________________________________________________________________________________________________________________________ __________________________________________________

Signature Date

MEMBER INFORMATION

AUTOMATIC PAYMENT SCHEDULE: DRAFT DATE & DEADLINE FOR CANCELLATIONS OR CHANGES Debit or charge to account will happen on the following dates at 12:01 am (please check the sessions you are

attending and make note of the Draft Date & Deadline for Cancellations or Changes for each session):

WEEKLY SESSIONS DRAFT DATE & DEADLINE

FOR CANCELLATIONS OR

CHANGES WEEKLY SESSIONS

DRAFT DATE & DEADLINE FOR

CANCELLATIONS OR CHANGES

S1: June 12 – June 16 June 5 S6: July 17 – July 21 July 10

S2: June 19 – June 23 June 12 S7: July 24 – July 28 July 17

S3: June 26 – June 30 June 19 S8: July 31 – Aug 4 July 24

S4: July 3 – July 7 (4 days) June 26 S9: Aug 7 – Aug11 July 31

S5: July 10 – July 14 July 3

Automatic funds transfer (Attach a voided check.)

Type of account: Checking Savings

_________________________________________________________________________________

Name on the account registration (print)

_____________________________________________ _________________________________

Account number Routing number

I hereby authorize my financial institution to honor preauthorized debit entries

by the YMCA on my account for weekly program payments. When my financial

institution honors such debits by charging my account, this shall constitute my

receipt for payment.

_______________________________________ _______________________________________

Member initial Payee initial

Recurring credit card or debit charge

Type of account: Visa MC Amex Discover

_________________________________________________________________________________

Name as it appears on the credit card (print)

_____________________________________________ _________________________________

Credit card number Expiration date

I hereby authorize the YMCA to charge my credit card on a weekly basis for

payments as indicated above. When my financial institution honors such debits

by charging my account, this shall constitute my receipt for payment.

______________________________________ _______________________________________

Member initial Payee initial

ADMISSIONS AGREEMENT

MID VALLEY FAMILY YMCA

ACKNOWLEDGEMENT/AGREEMENT – As the parent or legal guardian of the above named child I understand agree

to and/or acknowledge the following:

A. I acknowledge that I have received a copy of the YMCA 2016-2017 Afterschool & Summer Child Care Program Handbook

and will comply with the policies set forth. I further acknowledge that I have received copies of the following documents

required by the State of California Community Care Licensing: “Parents Right (LIC 995)”, “Personal Rights (LIC

613A)”, “Parent Handbook”, “Fee Schedule Page”, “Caregiver Background Check Process (LIC 995E) and

“Acknowledgment of Receipt of Licensing Reports” if applicable. Some of these documents are located in this

registration packet, while others are located in the Parent Handbook.

B. Field trips, chartered buses are a part of the Child Care program activities. No additional permission slips will be required.

C. Authorization for the YMCA to take photographs, videos, motion pictures and /or sound recordings of the child care

participant of members of the participant’s family. I further grant the YMCA permission to use the photographs video,

motion pictures or sound recordings in its general publicity materials. See attached waiver.

D. The YMCA staff and volunteers are not allowed to babysit or transport children at any time outside of the YMCA program

(The YMCA will take immediate staff and volunteer disciplinary action if a violation occurs). Staff are not permitted, under

any circumstances, to transport children in their personal vehicles.

E. That I am not allowed to leave my child at the YMCA program center unless a YMCA staff is there to receive and supervise

my child.

F. That should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child’s

safety, staff may have no recourse but to contact the police. (Please do not put staff in a position where they have to make

this judgment call.)

G. That the YMCA is mandated by state law to report any suspected child abuse or neglect to the appropriate authorities for

investigation.

H. That per Department of Social Services, Community Care Licensing, Title 22 regulations, and my child’s file is available for

review by the Department of Social Services and representatives from these agencies may interview my child without prior

parental/guardian permission. In addition Law Enforcement personnel may request the information listed in your file and

may interview your child if necessary.

I. If your child is suspended from the program due to behavioral / discipline issues, you have exactly 60 minutes to pick-up your child from the program center; the child can be picked up by either a parent or a parent’s designee (designee listed on

the enrollment form authorized for pick-up). Parents will not receive reimbursement, credit or refund for these missed days. It is important for parents to pick-up their child immediately if suspended due to discipline issues. Our goal is to provide your child with a stimulating environment that keeps them engaged in positive behavior. Unfortunately, some severe discipline issues can arise throughout the day that require immediate parent intervention and possibly a suspension from the program for any set amount of days.

J. That the YMCA may terminate my child’s enrollment for any of the following reasons:

Emergency names and phone numbers are incorrect. Parent is late picking up child after program center closes. Non-payment, late payment or ATS reject of fees. Failure to adhere to the sign in and out policy. Child leaving the program center without authorized permission. Behavior that is continually disruptive or dangerous to others and/or self. Behavior that is disruptive to property and/or refusal to replace said property. Any single incident that is deemed by the program center director to be dangerous, harmful or disruptive. Harassment, violent behavior or threat of such behaviors against a staff person or other member by parent/guardian or

persons associated to the child (family member, family friend, etc.).

K. That program participation requires that my account is in good standing with all balances up to current. This includes program fees and membership dues (if applicable). Non-payment of program fees and / or membership dues (if you are a

ADMISSIONS AGREEMENT

MID VALLEY FAMILY YMCA

facility member) will result in my child not being allowed to participate in the program and could result in legal referral with the additional costs to myself, until the balance is paid and current. I further understand that there is an administrative processing fee for any payment returned by my bank or credit account.

L. The YMCA and the staff employed by the YMCA will not become involved in custodial disputes between parent/guardian. If YMCA documents are requested, the court must request them. The staff’s responsibility is to provide a safe environment for children.

M. I understand I am required to give 15 days’ written notice when terminating my child from YMCA child care programs. If 15 days is not provided I will not receive a refund or credit and I will be billed or charged as regularly scheduled. Registration Fees are non-refundable.

N. Pick-Up of Child from Child Care Center: I understand and agree that in the event my child is not called for by closing, the Child Care Center will immediately make every attempt to contact me, or other persons authorized by me to take my child from the center. If I or my authorized individual cannot be located, or if satisfactory arrangements for calling for the child cannot be made, that the office will continue to try to locate me or another designed person; but if those efforts are unsuccessful within a reasonable period of time (one hour), the appropriate law enforcement and welfare authorities will be

contacted, and my child may be released to the custody of those welfare authorities as a possible ward of the Juvenile Court. I hereby release the YMCA, its employees and agents, from all liability for any damage sustained by my child or by me which results directly or indirectly from the procedure outline above. I further agree that if this procedure must be utilized because I fail to pick-up my child on time from the center, or because any person designated by me fails to pick up my child on time from the center, I will indemnify and hold the YMCA Child Care Center harmless for any damage sustained by my child. I hereby release the YMCA, its employees and agents from all liability and responsibility for any damaged sustained y my child after closing time. I understand and agree that if my child is not called for at the designated time, my child and I may be dropped from the program. I have read the foregoing acknowledgement and release. My signature below indicates that I understand and agree to it.

O. My child, listed below has my permission to participate in all activities which are a part of the YMCA Child Care Program. These activities include water play, use of the playground and apparatus, woodworking, cooking, animal care, messy arts and crafts, adult supervised walks in the immediate neighborhood / community of the YMCA Child Care Center, field trips and other active play experiences typical in a Child Care Program. I, the undersigned, hereby release and discharge the YMCA, officers, employees, agents and servants (herein, collectively referred to as the YMCA). For the purpose of this agreement, liability means all claims, demands, losses, courses of action, suits or judgments of any kind that I, my heir, executors, administrators or assignees may have again the YMCA because of any loss or damage to property that results from any cause other than the negligence of the YMCA. I have no objection to my child being included in photographs, slides or movies taken in the YMCA which might be used for the purposes of interpreting the Child Care Program. I understand that college students may be making observations at the YMCA as a part of class assignments and that any photography or observation will be done only under the supervision of the director. I understand that the discipline methods use with my child shall include warnings, redirection, denial of privileges and logical consequences. Continued behavioral issues may warrant a suspension from the program, as outlined in our Parent Handbook (see Positive Discipline section). I have read, understand and agree to the stipulations and policies in the child care registration packet and policy handbook and realize that abuse of the policies may lead to the termination of my child’s enrollment.

My signing below, I acknowledge that I have read and agree to all the statements in this document:

Parent/Guardian

Signature:

Date

Parent Name (Please print)

Name of Child being

enrolled in YMCA program:

YMCA OF METROPOLITAN LOS ANGELES RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as “the undersigned”) hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities and/or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or par-ticipation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children.

IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, volunteers and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or demands on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA.

2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA.

3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence, active or passive, of releasees or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA.

THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

THIS AGREEMENT DOES NOT APPLY TO LICENSED CHILD CARE SERVICES.

I HAVE READ THIS RELEASE

Date: Printed Name Signature of Applicant/Guardian Name(s) of Child(ren) in Program and/or YMCA Facility Revised 5/22/08

Rev. 2014

PHOTO & VIDEO/AUDIO RECORDING RELEASE

YMCA OF METROPOLITAN LOS ANGELES

PLEASE PRINT

I ______________________________________________________ am eighteen years of age or older, and if not,

then my Mother/Father/Legal Guardian has also signed below under my signature.

With regard to my participation in activities sponsored by or related to any activity in which I participate in any way

sponsored by the National Council of Young Men’s Christian Associations of the United States of America, and to any

YMCA of the USA Association, including the Young Men’s Christian Association of Metropolitan Los Angeles (collectively,

“YMCA”), I hereby give my permission and consent, now and for all time (without any further compensation, claim or

demand by me) to the YMCA, and to advertising agencies, agents, entities and third parties collaborating with the YMCA

and their representatives, if any, (the “Organizations”) to make, reproduce, edit, broadcast or rebroadcast any video,

film, or digital footage and other sound track recordings, or photo reproductions of my image or voice in any form, and

my narrative account of my experience with YMCA activities (“Materials”) for publication, display, sale or exhibition

thereof in promotions, advertising and legitimate business uses without any further compensation to me. I may or may

not be identified by name in such reproductions. However, I shall not be stated by name to have endorsed any particular

commercial products or commercial services without my express written permission.

I further agree to the following:

• Any Materials created subject to this Release shall belong to the YMCA as its property, with full right of disposition of

them without my oral or written permission.

• The Materials will not be subject to any obligation of confidentiality and may be shared with and used by the

Organizations, as well as with any third parties as the YMCA may elect.

• The YMCA shall not be liable for any claim arising from the use or disclosure to a third party of any of the Materials.

• The YMCA shall exclusively own all known or later existing rights to the Materials worldwide and shall be entitled to the

unrestricted use of the Materials for any purpose without compensation to me or the provider of the Materials.

AGREEMENT AND CONSENT

I have read and understood the contents of this Release. I agree that my consent to this Release is irrevocable. I hereby

voluntarily release and discharge the YMCA and the Organizations and their representatives from any and all claims

arising out of or relating to or in connection with the uses and reproductions of my image and voice and my narrative

account as described herein. I understand that the term “YMCA” in this Release specifically includes the YMCA of

Metropolitan Los Angeles.

Signature: ____________________________ Date: ____/____/________ Age: ___________________

Email Address: ________________________ Phone: _________________ Cell Phone: _______________

Address: ____________________________________________________________________________________

I am the Mother/Father/Legal Guardian of ___________________________. I have read and understand PLEASE PRINT the contents of this Release and hereby voluntarily consent to this Release on behalf of my minor child.

Signature of Mother / Father / Legal Guardian: _____________________________ Date: ___________________

Email Address: ___________________________

Phone: ________________________________ Cell Phone:_______________________________ Address: ______________________________________________________________________________________

MID VALLEY FAMILY YMCA MULTIJURISDICTIONAL AUTHORIZATION & RELEASE

FOR MEDICAL AND DENTAL TREATMENT CHILD’S NAME (Last name, First name)

SEX BIRTH DATE (M/D/Y)

PARENT’S NAME

I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the YMCA

Program. I hereby grant permission for my child to leave the YMCA Program premises under the supervision of a staff member for neighborhood walks or field trips in authorized vehicles. I hereby grant permission for my child to be included in evaluation and pictures connected with YMCA Program. The undersigned, as the parent(s) or legal guardian(s) of the above-named person, (the “minor”) authorize YMCA of Metropolitan Los Angeles and its employees, directors and adult volunteers (collectively “YMCA”) to consent to any x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively “dental care”) to be rendered to

the minor by a dentist licensed under the law of the State or other jurisdiction in which dental care is sought. For the purpose of medical care or dental care obtained outside of California, this authorization is given with the intent that any consent given pursuant to this authorization shall be the consent of each of the undersigned.

The undersigned understand and agree that YMCA shall not be legally or financially liable for any bill or medical expense incurred, or for any cause of action or claim arising from any medical care or dental care provided, or the lack of medical care or dental care. The undersigned hereby agree to indemnity, defend and hold YMCA harmless from any claim made

by or on behalf of minor’s heirs or parents or guardian arising out of any medical care or dental care provided. NOTE: The YMCA requests that if the minor is in the custody of both of their parents or more than one legal guardian, both or all sign this authorization. The YMCA understands that the minor is in the custody only of the person(s) who have signed this authorization.

If for religious reasons you cannot sign this, you must provide a Written statement from parent(s) or authorized representative exempting child from medical assessment, immunizations, and treatment because of adherence to a religious faith that practices healing by prayer or other spiritual means; or physician's statement that immunization is not indicated and the YMCA branch must be contacted for a legal waiver, which must be signed for attendance.

Emergency Medical Informaition (This information is required)

PHYSICIAN OR DENTIST TO BE CALLED IN EMERGENCY

MEDICAL INSURANCE COMPANY:

POLICY NUMBER: EXPIRATION:

Parent/Guardian

Signature:

Date

Parent/Guardian

Signature:

Date

SUNSCREEN UTILIZATION PERMISSION FORM The YMCA requires written approval or instructions from parents prior to administering non-prescription medication to

children in summer child care. Sunscreen is considered a non-prescription medication. As the parent or guardian of

the above child, I give permission for the staff at the YMCA programs, to provide a sunscreen product of SPF 30 or

higher, especially during the months of April-September. I understand the YMCA staff will not be applying the sunscreen

on my child.

Check one:

In the event that I forget to send sunscreen with my child on a particular day, I approve of the YMCA to provide

my child with sunscreen of SPF 30 or higher.

Please do not provide my child with sunscreen, I will provide my child with specific type of sunscreen

The YMCA has a limited supply of sunscreen available at the child care site to provide to children on days when they may forget their personal sunscreen

bottles. Parents/Guardians are required to send Sunscreen each day with their child.

Parent/Guardian

Signature:

Date

RECEIPT OF 2017 SUMMER CHILD CARE PROGRAM

PARENT HANDBOOK & ACCETANCE OF

POLICIES AND PROCEDURES

MID VALLEY FAMILY YMCA

It is our hope that this parent manual will be a helpful resource for you during your enrollment in the

YMCA Summer Child Care program. Any further questions you may have can be directed to the Site

Director or to Judith Hartmire, Director of Child Care at the Mid Valley Family YMCA, (818) 989 3800.

This page contains a summary of the various sections of the parent manual with which you have been

provided. The information contained above and herein is complete and correct, and that the above

referenced child is able to engage in all activities except where limitations have been noted.

Please read and initial the following policies and authorizations:

_______ I understand that it is my responsibility to read, understand, and to abide by all policies and

procedures included in the Parent Manual and I acknowledge having received a copy of this document

_______ The Mid Valley Family YMCA agrees to provide summer child care,

Monday-Friday from 7:00 AM until 6:00 PM for a full day program.at the Chandler site. Full day care

includes a morning and afternoon snack for participants. Parent agrees to pack a healthy lunch and

water bottle.

_______ I have read and understand the holiday closures and understand I am only to bring my child to the

site for program plan days for which I have enrolled.

________ I understand that all payments are due one week in advance, on the Monday before each camp

week. Your payment can be made in cash, credit, or money order. Or you can be setup on automatic

bank draft through your credit card, checking or savings account. Spaces are limited and are filled as

payments are received.

SESSION

SESSION DATES

PAYMENT

DUE DATE

ATS

Payment

EXPLORER

Cash

Payment

Explorer

ATS

Payment

ADVENTURE

Cash

Payment

Adventure

1 June 12 – June 16 June 5 $180 $195 $200 $215

2 June 19 – June 23 June 12 $180 $195 $200 $215

3 June 26 – June 30 June 19 $180 $195 $200 $215

4* July 3 – July 7 (4 days) June 26 $144 $159 $160 $175

5 July 10 – July 14 July 3 $180 $195 $200 $215

6 July 17 – July 21 July 10 $180 $195 $200 $215

7 July 24 – July 28 July 17 $180 $195 $200 $215

8 July 31 – August 4 July 24 $180 $195 $200 $215

9 August 7 – August 11 July 31 $180 $195 $200 $215

RECEIPT OF 2017 SUMMER CHILD CARE PROGRAM

PARENT HANDBOOK & ACCETANCE OF

POLICIES AND PROCEDURES

MID VALLEY FAMILY YMCA

________ I understand that the YMCA's supervision for my child begins when my child arrives at the YMCA

School Age site and is signed in with FULL SIGNATURE by a parent, guardian, or authorized adult (for full

day programs) . During school days, the staff will sign the child in. Failure to provide full signatures may

result in termination from the program.

________ I understand that the YMCA's responsibility for my child ceases when a parent, guardian or

authorized adult has signed OUT my child.

________ I understand that I am NOT to leave my child at the YMCA unless released to a YMCA staff person

who is there to receive and supervise my child.

________ I understand that I have the right to visit the YMCA program at any time to observe the program

and my child’s participation in the program.

________ The YMCA and the parent/guardian agree to mutually inform the other party of any incidents,

including: behavior infractions, illnesses, injuries, exposure to communicable diseases, etc. as needed.

________ I give permission for the YMCA to administer basic first aid, and in the event of an emergency, to

secure a physician for emergency medical treatment for my child. I understand that a conscious effort will

be made to contact the parent/guardian before seeking treatment. I understand and accept that this

expense is my responsibility as the YMCA does not carry participant accident insurance. I understand

that it is my responsibility to carry primary accident insurance.

________ I give permission to the YMCA to contact the persons listed as emergency contacts on the

identification and emergency information form and emergency card form in the event they are unable to

reach the parent/guardian.

________ I understand that my child must be signed in/out and escorted out of the school age child care

program daily, by a parent, guardian or an adult authorized by the parent, who is of the age of 18 or

older.

________ I understand that the YMCA will only release my child to the parent(s), guardians and adults

authorized by the parent on the identification and emergency information form and emergency card. I

understand that I must provide, in writing, additional authorization for other adults to pick-up my child

from the site.

________ I understand that before any medication is dispensed to my child, I must complete a Permission

to Medicate form as written authorization, and it must include: date, child’s name, name of medication,

physician’s name, prescription number (if any), dosage, date and time to be administered and

parent/guardian signature. All medication must be in its original container. The YMCA staff will keep a

written verification log of date, time, and staff member who administered the medication and will note

any adverse reactions to the medication.

RECEIPT OF 2017 SUMMER CHILD CARE PROGRAM

PARENT HANDBOOK & ACCETANCE OF

POLICIES AND PROCEDURES

MID VALLEY FAMILY YMCA

________ I acknowledge that it is my responsibility to keep the YMCA advised of any significant changes to

my child’s enrollment form to include, but not limited to: addresses and phone numbers of all individuals,

change in work location, family doctor, allergies and other health information. I agree to provide this

information to the YMCA at the time of the changes.

_________ I understand that failure to pay my assigned summer child care payments promptly may result in

removal from the program. If my child is suspended from the program for non-payment of fees, I

understand that I am responsible for obtaining alternate care for my child.

_________ I understand that I must give at least 15 calendar days written notice to the Mid Valley Family

YMCA and the site director if there are any changes in my program schedule or child care plan options. If

I do not give 15 calendar days written notice, I will be responsible for the payment in full.

________ I understand that I must give at least 15 calendar days written notice to the Mid Valley Family

YMCA and the site director if I wish to drop my child from the summer child care program. I must

complete and sign a YMCA Cancellation Notice form to stop ATS transfer of weekly billing. Failure to do

so will result in payment of full weekly fee.

________ I understand that my child may be photographed, videotaped and/or recorded by YMCA staff or

YMCA representatives during program activities and used in YMCA general publicity promotional

materials and that I have signed the Photo & Video/Audio Recording Release Form.

________ I understand that there is zero tolerance for serious behavior infractions including but not

limited to: bullying, physical attacks, failure to abide by safety and supervision rules and understand that

my child may be suspended and/or terminated if these infractions are found to be true.

________ I understand that the YMCA staff and volunteers are not allowed to baby-sit, socialize or

transport children at any time outside of the YMCA program. (YMCA will take immediate staff and

volunteer disciplinary action if a violation occurs)

________ I understand that the YMCA is mandated by state law to report any suspected or alleged child

abuse or child neglect to the appropriate authorities for investigation.

_________ I understand that neither the YMCA nor its representatives can be held responsible in the events

of an accident, injury, or accidental death. I understand that all precautions will be taken to ensure the

safety and health of my child.

_________ I understand that the YMCA and staff employed by the YMCA will not become involved in any

custodial disputes between parent/guardian. With regard to custodial orders, I understand that the Y

must uphold a court order if in receipt thereof. If copies of documents in a child’s file are requested, the

court must formally request them of the YMCA. The staff’s responsibility is to provide a safe environment

for children.

RECEIPT OF 2017 SUMMER CHILD CARE PROGRAM

PARENT HANDBOOK & ACCETANCE OF

POLICIES AND PROCEDURES

MID VALLEY FAMILY YMCA

________ I understand that the YMCA may terminate my child’s enrollment for any of the following reasons:

Parents/Guardians are continually late in picking up child after program day ends.

Non-payment, late payment or NSF payment of fees.

Failure to adhere to the State regulatory licensed child care sign-in/sign out policies.

Contact and emergency contact information is incorrect and/or not updated.

Child’s behavior that is continually disruptive or dangerous to self and/or others.

Child’s behavior that is destructive to property and/or parent’s refusal to replace said property.

Any single incident that is deemed by the YMCA to be harmful, dangerous or disruptive.

Harassment, violent behavior or threat of such behaviors against a staff person or other member

by parent/guardian or persons associated to the child (family member, friend, relative, etc.).

__________ I understand that the following items are not allowed at the School Age Child Care program: cell

phones, Ipods, Ipads/tablets, Kindles, DVD players, Nintendo DS/DSI, MP3 Players, trading cards, skates,

bikes, skateboards, weapons, and other toys that do not fit into the school and/or day camp setting.

The YMCA staff is not responsible for lost, broken, or stolen items brought to the site.

Acknowledgement: I acknowledge that I have read and do understand the established policies, protocols,

procedures, and behavioral expectations as stated in the Parent Manual and have initialed each item

listed above.

Furthermore, I agree to abide by these policies, protocols, procedures, and behavioral expectations and

understand that failure to do so may result in dismissal of my child from the program.

BY SIGNING BELOW, I ACKNOWLEDGE THE FOLLOWING:

Parent/Guardian Signature: ___________________________________________ Date: _______________________

Child’s Name: ___________________________________________________

THIRD PARTY BILLING MID VALLEY FAMILY YMCA

The Mid Valley Family YMCA is happy to accept 3rd party payments on your behalf from a recognized

state or county agency. Please understand that this contract is between you and the funding provider. It

is your responsibility to keep your YMCA child care account current.

Receiving funding from another agency requires a contract between the parent and the provider and a

contract between the YMCA and provider. The YMCA cannot accept a child into the program until all

required documentation and contracts are completed and approved.

At the end of the month, 3rd party attendance forms must be turned into the Y billing office and then

received by the participating agency no later than the 5th day of the following month. Please ensure that

you sign in/out with a full signature daily on the agency’s sheet. For 3rd party providers, you must

explain your child’s absences from the program on that attendance sheet.

If this form is late to our office for any reason, causing payment to be delayed, you will be responsible to

pay the current monthly child care fee in full. Also, any difference between the YMCA’s fee schedule and

the approved amount by the 3rd party payer will be the responsibility of the parent to pay monthly.

Failure to meet the provider’s deadlines will result in your account being delinquent and that will

jeopardize your child care service. Please communicate with your Site Director about any problems or

concerns about your account.

Please understand that the YMCA can assist with coordination of your efforts to complete the required

documentation, but cannot act on your behalf with the 3rd party funding provider and can only collect

fees with your cooperation. All fees not paid by 3rd party provider become the responsibility of the

participant.

The YMCA must receive 15 days written notice for all program changes or drops.

If you have any questions regarding these policies, please speak with the Accounting Department at the

Mid Valley Family YMCA at 818-989-3800.

I have read and understand these financial policies for child care third party contracts.

________________________________________ ________________________________________ ____________________

Parent’s Name Parent’s Signature Date

_____________________________ ________________________________________

Child’s Name Name of Site

MID VALLEY FAMILY YMCA GETTING TO KNOW YOUR CHILD QUESTIONNAIRE

At the Y, we strive to develop the whole child. This includes understanding the children who participate in our

programs and understanding their family. As a part of our registration and enrollment process for all children, we

require all families to complete this questionnaire about their child. The information you provide will help us to best

provide care for your child’s individual needs. This questionnaire is required, as this information is extremely valuable

to your Camp Director and camp staff. The information below will provide us with information about your child’s daily

routine, social development, health and family.

CHILD’S NAME SEX: M F BIRTH DATE

(M/D/Y)

Who does your child live with? Please list all adults, siblings and other adults and children living in the home with the child (example, mother, father,

brother, grandparent, etc.)

Name: Relationship to child:

5 Words that describe your child and his / her personality are:

1.

2.

3.

4.

5.

What motivates your child?

What kind of things upset your child?

What are three goals you have for your child for this calendar year?

1.

2.

3.

We do not celebrate the following holidays?

What is the primary language spoken at home? Are there any other language spoken? Does your child know more than one

language?

What responsibilities does your child have at home? Such as chores, etc.

When does your child typically do homework?

Please list any fears your child may have (dogs, vacuum cleaners, etc.)

What comforts your child when he / she is upset?

What are your child’s interests and hobbies?

What outside activities do they participate in?

Does your child have any allergies? Please

list and include food allergies:

Does your child have any health problems? Has their health improved, decline or remained steady over the past 3 months?

Do you think your child feels good about himself/herself? Please comment:

What is your child favorite: Color:

Cartoon:

Treat / Snack:

Toy Brand:

School Subject:

Game:

How does your child get along with other children?

Does your child have any special needs?

Please describe any recent family events or major changes in your child’s daily routine that we should be aware of (death, divorce, marriage, new siblings, new blended family,

moving, parent change in work schedule,

etc.) if any.

What rules do you have at home?

Does your child make friends easily?

How does your child react to frustration? How does your child relax or soothe him or

herself?

How do you deal with discipline issues at home?

Does your child have a nickname that you

and other family and friends call him or her?

The YMCA is a group child care program with 1 adult staff for every 14 children. How well will your child function in an environment with a 1 to 14 teacher to child ratio?

If your child does not live with both parents, how often do they see their other parent?

What activities do you share as a family?

How do you feel that the YMCA can best support your child?

Is there anything else you would like to share

about your child?

Parent/Guardian

Signature:

Date

Parent Name (Please print)

Name of Child being

enrolled in YMCA program:

Phone: ________________________________ Cell Phone: _______________________________

MID VALLEY FAMILY YMCA POSITIVE DISCIPLINE POLICIES

It is our intent that each child enjoys the activities planned by understanding that she/he is responsible for her/his actions. With

prior knowledge of our basic rules of safety and good conduct, each child is made aware of how to exercise self-discipline. We are

here to assist her/him and to know that we expect her/him to succeed. YMCA house rules and anti-bullying strategies will be

reviewed weekly at the Day camp site. We also use positive reinforcement by consistently acknowledging good behavior.

The expectations listed below are the general expectations we have for all of our program participants:

Respect for yourself, for others, and for property. Safety first. Speak for yourself/listen attentively. Be responsible for your words and actions.

Philosophy

The YMCA strives to maintain a positive approach to managing children’s behavior at all times. “Discipline” is the process of teaching

self-control and the ability to live within limitations and agreed upon guidelines.

The staff and children at each Day camp site establish expected behavior guidelines. Positive behavior is self-rewarding and allows

for program activities to run smoothly. When children choose to behave outside of the guidelines, some consequence is required to

avoid future problems. The overall safety of all children in the program is our highest priority.

Breaking Program Rules

If a child is not following the rules, he/she will be reminded of the rules. If the child continues to break the rules, he/she will be asked to leave that area and find another area to play in. If the child still fails to follow the rules, the Counselor / Day Camp staff will assign an area for the child. If the behavior has not improved by this time, the child will be removed from the group and placed directly beside a

Counselor or staff member. Threatening the Safety of the Staff and/or Children in the Program

If a child threatens the safety or health of anyone in our program by hitting, kicking, biting, pushing, spitting or any other dangerous act they will receive a verbal warning.

If the behavior continues after the verbal warning has been given, the parent will be called to pick the child up within a half an hour. Credit will not be reimbursed for this day.

After returning to program, if the child continues this behavior, the parents will be called to pick the child up within a half an hour and the child will be suspended for one (1) program day. Credit or refund will not be reimbursed for these days. A parent conference with the Director will be mandatory at this time.

The next time the child is required to be picked up for inappropriate behavior, they will again need to be picked up within a half an hour and this time the child will be suspended for three (3) program days. Credit or refund will not be reimbursed for these days.

Upon returning to program after a three day suspension and the child’s behavior continues, the parent will be called to pick their child up within a half an hour and the child will receive his/her final suspension of one program week (5 camp days). Credit or refund will not be reimbursed for these days.

After the final suspension, if the inappropriate behavior has not stopped, the parent will be called to pick the child up within half an hour and the child will be expelled from the program thereafter. There will not be any reimbursements of any kind.

Drugs, alcohol, lighters, weapons, electronics, cell phones, animals (dead and alive), and other such items, are not allowed at the day camp center/program.

There are some cases where a child will be sent home and/or suspended on the first violation. This is left to the Director’s discretion.

The Director also reserves the judgment to suspend a child for additional days based on the severity of the incident and the

behavior.

Suspension from Program

If your child is suspended from the program due to behavioral / discipline issues, you have exactly 60 minutes to pick-up your child

from the program center; the child can be picked up by either a parent or a parent’s designee (designee listed on the enrollment

form authorized for pick-up). Parents will not receive reimbursement, credit or refund for these missed days, including the missed

days of the original suspension. It is important for parents to pick-up their child immediately if suspended due to discipline issues.

Our goal is to provide your child with a stimulating environment that we keep them engaged in positive behavior. Unfortunately,

some severe discipline issues can arise throughout the day that require immediate parent intervention and possibly a suspension

from the program for any set amount of days.

Parent/Guardian

Signature:

Date

Parent Name (Please print)

Name of Child being

enrolled in YMCA program:

For Earthquake Kits

EMERGENCY INFORMATION SHEET

My name is: ____________________________________ Phone (_____) ___________________

Address_______________________________________________________________________

City___________________________________________ Zip____________________________

IN CASE OF EMERGENCY CONTACT:

Name_________________________________________ Phone (_____) ___________________

Name_________________________________________ Phone (_____) ___________________

______________________________________________________________________________ (Fold Here)

Special Medical: ________________________________________________________________

Known Drug Allergies: ___________________________________________________________

Family Doctor: _________________________________________________________________

Phone: (_____) ___________________

Out of State Contact:

_________________________________ (______)________________ ___________________ Name Phone # Relationship

EAST VALLEY FAMILY YMCA PHOTO FOR YOUR CHILD’S FILE

At the Y, we want to keep your child safe and we also want to be prepared for all emergencies.

Along with your registration packet, please submit an up-to-date photo of your child for their file. Children’s photos and files will be locked away in a file cabinet at the child care site in an emergency binder that is taken with us at all field trips or that staff can grab-and-go in case of an emergency or

evacuation.

Chandler YMCA Childcare Center 14030 Weddington St., Sherman Oaks, CA 91403

Phone #818-906-1923

Entrance to

Child Care Site

on Hazeltine

Ave