moving forward 7am-6pm friday monday-...shasta family ymca • 1155 n. court st, redding ca 96001...
TRANSCRIPT
S H A S T A F A M I L Y Y M C A • 1 1 5 5 N . C O U R T S T , R E D D I N G , C A 9 6 0 0 1 • 5 3 0 - 2 4 6 - 9 6 2 2 • W W W . S F Y M C A . O R G
SIGN UP TODAY! K-8TH GRADE
LIMITED SPACESAVAILABLE!
$50 DEPOSIT
We realize the price might be cost-prohibitive due to the
small group sizes required to adhere to social distancing
recommendations. Financial Aid is available to those who
qualify.
PRE-REGISTER TODAYEmail completed packet to:[email protected] = $195 | 5day = $250
Youth wil l be organized in small groups (10 youth &1 staff) and activit ies are careful ly planned with aconsideration for social distancing.Frequent hand washing and use of hand sanitizersfor staff and youth.Limit unnecessary contact and potential exposure,by l imiting camp access to YMCA Camp Staff andcamp participants only.Parents/Guardians wil l be dropping off and pickingup at the entrance and not al lowed to access theprogram space.Ongoing cleaning wil l be scheduled during the day.
SUMMER CAMPAT THE Y
Moving forward
ADVENTURE AWAITS!
To Keep Your Children Safe
MONDAY-FRIDAY
7AM-6PM
With Support From:
The Ruffcorn & Miranda Group
QUESTIONS? CALL: 530-224-0952
SHASTA FAMILY YMCA • 1155 N. COURT ST, REDDING CA 96001 • P 530 246 9622 • F 530 246 9645 • WWW.SFYMCA.ORG
Shasta Family YMCA COVID-19 Screening Agreement:
The Shasta Family YMCA has been monitoring the Coronavirus (COVID-19) and ask that each camp participant and staff member honestly answer the questions below, as outlined by the CDC, before access will be given to the Shasta Family YMCA Emergency Day Camp.
A. Have you experienced the following symptoms within the last 4 days: • Fever• Shortness of breath• Cough
B. Have you been in close contact with a person known to have COVID-19? C. Have you traveled to an area with widespread or ongoing community spread of
COVID-19 in the last 14 days? D. Has anyone in your home or who you have been in close contact with
experienced the following symptoms within the last 4 days: • Fever• Shortness of breath• Cough
E. Has anyone in your home or who you have been in close contact with been in close contact with a person known to have COVID-19?
F. Has anyone in your home or who you have been in close contact with traveled to an area with widespread or ongoing community spread of COVID-19 in the last 14 days?
For the safety of others, if you, as a camp participant or staff member, answered yes to any of the questions above, access will not be given to the Shasta Family YMCA Summer Day Camp.
I HAVE READ THE ABOVE SCREENING AGREEMENT AND CAN TRUTHFULLY ANSWER “NO” TO ALL OF THE QUESTIONS ASKED.
Signature: ________________________________ Date: ______________________
Camper Employee Outside Vendor
SHASTA FAMILY YMCA • 1155 N. COURT ST, REDDING CA 96001 P 530 246 9622 • F 246 9645 • WWW.SFYMCA.ORG
SUMMER CAMP REGISTRATION
Participant Name (Last/First/Middle):_____________________________________________________________Child Date of Birth_________________________________
Grade Next Fall: __________________________ Age: ____________ Gender: M F Sibling in YMCA Camp Yes No
Parent/GuardianName(Last/First/Middle):_________________________________________________________________________________________________________________
Parent Date of Birth_______________________________________EmailAddress:___________________________________________________________________________________
Home Address:_________________________________________________________________ City:_______________ State:________Zip Code___________________________
Home phone:____________________________________________ Cell phone:______________________________________ Work phone____________________________________
Before registering please note, the YMCA requires a zero balance due on all childcare accounts prior to registering for summer camp. If there is a balance due on your account, the balance due plus your first session will be drafted on the date you indicated below. ________________ Initial
Please submit your registration 7 days prior to the first week of camp. Pre–scheduling is required at the time of registration for all weeks of summer camp. A 14-day written notice, on a Child Care Adjustment/Cancellation form, is required for any schedule changes. There is no refund of fees for non–attendance or cancellations. Withdrawal from all weeks of camp requires 14 days written notice on a Child Care Adjustment/Cancellation form. Without a written notice of withdrawal, you will be financially responsible for all pre-scheduled weeks. Credit Card automatic drafts are required. No payments will be accepted at camp.
By signing here, you agree to the terms listed above:
Signature of Applicant/Parent: ___________________________________________________________________________Date:_____________________________________
Weeks & Dates Days-Check 3 or 5 days
Total Weekly Charge
Date Payment is Drafted
Initial for Parent Payment Agreement
Week 1 6/01/20 M T W TH F $ 6/01/20
Week 2 6/8/20 M T W TH F $ 6/08/20
Week 3 6/15/20 M T W TH F $ 6/15/20
Week 4 6/22/20 M T W TH F $ 6/22/20
Week 5 6/29/20 M T W TH $ 6/29/20
Week 6 7/6/20 M T W TH F $ 7/06/20
Week 7 7/13/20 M T W TH F $ 7/13/20
Week 8 7/20/20 M T W TH F $ 7/20/20
Week 9 7/27/20 M T W TH F $ 7/27/20
Payment Agreement Form
Today’s Date: _________________________________ Camp Site: _____________________________________________________________________________Grade:_____________
Child’s Last Name: Child’s First Name: Child’s Date of Birth:
Parent’s Last Name: Parent’s First Name: Parent’s Date of Birth:
Home Address: __ City: State: Zip Code:
Home Phone: ____________Email:
Employer: _____________ Work/Cell Phone: _ _ _ _ _ _ _ _
Employer Address: __________________________________City: State: Zip Code: _________________
Payment Authorization Information THIS PERSON MUST SIGN THIS FORM BELOW
I authorize payment to be drafted from my account for $
Name on Account:
Payment Type: _____________ MasterCard _____________ Visa _____________ Discover _____________ Other
Account Number: Expiration Date: _______________ Security Code:___________
Payment Agreement - PLEASE INITIAL that you have read and agree to all of the Payment terms below:
Payments will be drafted upon registration.
Payments not honored by the bank for any reason, (NSF, closed account, invalid expiration date, referral) will incur a returned payment fee. This is in addition to any fees charged by the bank. Returned payments will automatically be redrafted, and will include a returned payment fee.
Two or more returned drafts may result in termination from the program.
There will be no refund of fees for non-attendance or cancellation.
YMCA will have the right to initiate legal action for collection of fees or outstanding balances, and the undersigned will be responsible for all costs of collection, including court expenses and reasonable attorneys fees.
I HAVE CAREFULLY READ THE ABOVE PAYMENT AUTHORIZATION AND AGREEMENTS, AND I AGREE TO ABIDE BY ALL OF ITS TERMS AND CONDITIONS AS OUTLINED ABOVE.
Signature: _____________________________________________________________________________________________________________ Date: _______________________________________
Please fill this out in person, not online. Thank you.
Enrollment Form
Today’s Date: ___________________________ Camp Site: _____________________________________________________________________________Grade:_____________
Participant’s Information
Child’s Last Name: __________________________________________________________________ First Name: ______________________________________________________ MI: _________________
Child’s D.O.B: _______________________________ Gender M / F Child Lives with Mother: Father: Other: __________
Home Address: ____________________________________________________________________ City: _________________________________________ State: ____________ Zip Code: ____________
Home Phone: ______________________________________________________________________ Parent’s Email: __________________________________________________________________________
Enrollment Information (Please check all that apply)
New to YMCA ProgramsCurrently enrolled in YMCA afterschool program Have two or more children in the YMCA program
Days your child will attend camp
Fees Holiday Program Fee: $
Less Sibling Discount (10%): $
Less YMCA Employee Benefit: $
Total: $
Enrollment Agreement – PLEASE INITIAL that you have read and agree to all of the Enrollment terms below: _________ I have received and understand the current rate sheet. _________ There will be no refund of fees for non-attendance or cancellation. _________ The YMCA can terminate this agreement if the parent or child becomes disruptive to the center; or if, in the opinion of the Site Director, the child does not progress well in our environment. _________ The center will close promptly at 6:00 p.m. There is a late pick-up fee of $1 for every 1 minute you are late
picking up your child. In the event we cannot reach you or an authorized person by 7:00p.m., the Shasta County Child Protection Agency will be called.
_________ While participating in YMCA Child Care, the YMCA has my permission to photograph myself and/or my children for publicity purposes.
__________ The Department of Licensing Agency shall have the authority to interview children, staff, and to inspect and audit child or facility records without prior consent. The Licensee shall make provisions for private interviews with
any children or staff members, and for the examination of all records relating to the operation of the childcare center. The Department of Licensing Agency has the authority to observe the physical condition of the children, including conditions that could indicate abuse, neglect or inappropriate behavior.
I HAVE READ THE ABOVE AGREEMENT AND AGREE TO ABIDE BY ALL OF ITS TERMS.
Signature:_____________________________________________________________________________________ Date:_______________________________
Monday Tuesday Wednesday FridayThursday
Payment Due Now: Registration Fee: $
Less Discount/Benefit: $
Total Due Now: $
Department of Social Services
520 Cohasset Road, Suite 6
Chico 95926 530-895-5033
Shasta Family YMCA 1155 North Court St., Redding, CA 96001
Shasta Family YMCA
State of California – Health and Human Services Agency California Department of Social Services
IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE
CENTERS/FAMILY CHILD CARE HOMES
LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2
To Be Completed by Parent or Authorized Representative
CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE
( )
ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE
PARENT /
AUTHORIZED
REPRESENTATIVE
NAME
LAST MIDDLE FIRST BUSINESS
TELEPHONE
( )
HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME
TELEPHONE
( )
PARENT /
AUTHORIZED
REPRESENTATIVE
NAME
LAST MIDDLE FIRST BUSINESS
TELEPHONE
( )
HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME
TELEPHONE
( )
PERSON
RESPONSIBLE
FOR CHILD
LAST MIDDLE FIRST HOME
TELEPHONE
( )
BUSINESS
TELEPHONE
( )
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY
NAME ADDRESS TELEPHONE RELATIONSHIP
PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE
( )
DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE
( )
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?
CALL EMERGENCY HOSPITAL OTHER EXPLAIN: ________________________________
State of California – Health and Human Services Agency California Department of Social Services
LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2
NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN
AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)
NAME RELATIONSHIP
TIME CHILD WILL BE PICKED UP
SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY
CHILD CARE HOMES LICENSEE
DATE OF ADMISSION LAST DATE OF ENROLLMENT
Department of Social Services
520 Cohasset Road, Suite 6, Chico, CA 95926
530-895-5033
Shasta Family YMCA
SHASTA FAMILY YMCA (A) 1155 N. COURT ST, REDDING CA 96001 ( P) 530 246 9622 (F) 246 9645 (W) WWW.SFYMCA.ORG
WELCOME TO A LLShasta Family YMCA Financial Assistance EVERYONE IS WELCOME The Shasta Family YMCA is committed to ensuring that everyone has the opportunity to learn, grow, and thrive. To that end, the Y provides financial assistance for those who may not be able to afford the full cost of membership and programs. The Y’s Financial Assistance Program is supported by contributions to our Annual Campaign.
COMMITTED TO OUR COMMUNITY By offering financial assistance to eligible individuals, YMCA programs become accessible to individuals and families of all income levels. Financial assistance only reduces the cost of membership and programs, with intent that all individuals contribute towards the fees to some extent. Y participants can feel confident knowing they are part of an organization that cares greatly for the well-being of the community.
• Financial assistance reduces membership and program fees on apercentage basis; it does not eliminate them. Assistance may range up to 50% for membership and swim lessons; up to 20% for child care; and up to 20% for programs that cost $30 or more.
• All applications must be completed entirely before beingprocessed. Applications with all required information will be processed within five business days of being received.
• You will be notified once the application is processed. To acceptfinancial assistance, you must join in-person at the Y.
• Participants will be asked to reapply annually.
• Any falsification of application information and documentationwill result in removal from the Financial Assistance Program.
SHASTA FAMILY YMCA • 1155 N. COURT ST, REDDING CA 96001 P 530 246 9622 • F 246 9645 • WWW.SFYMCA.ORG
LIST INCOME FOR ALL ADULTS IN HOUSEHOLD
In order to verify information, you may be asked to provide proof of income
⃝ Gross wages, salaries, tips, etc. $____________________ ⃝ Child/spousal support $____________________
⃝ Unemployment compensation $____________________ ⃝ Social security: SSI, SSDI, SDI $____________________
⃝ Calfresh $____________________ ⃝ Passport To Services $____________________
⃝ Retirement/pension $____________________ ⃝ School financial assistance $____________________
⃝ HUD assistance $____________________ ⃝ Other $____________________
⃝ Are there circumstances that substantially impact your gross income and household finances? _______________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________
⃝ Taking into consideration our regular memberships rates, how much do you feel you can afford to pay per month for memberships? $ ____________/ month
FOR OFFICE USE ONLY:
Income total $__________________________ # in household_______________ ⃝ Qualifies for: _____________ ⃝ Does not qualify Awarding: ________ % membership _________ % program _________ % camp/child care _________ % swim lessons Comments ______________________________________________________________________________________________________ Processed by_______________ Date_______________
Print Name _______________________________________________________________________________________________________________________________________________________
Mailing Address ___________________________________________________________________________ City ______________________________________ Zip____________________
Primary Phone __________________________________________________________________ Other phone _______________________________________________________________
Email: ______________________________________________________________________________________________________________________________________________________________
I am applying for:⃝ Youth membership ⃝ Student membership
⃝ Adult membership ⃝ Adult Couple membership
⃝ Senior membership ⃝ Senior Couple membership
⃝ Family membership ⃝ Afterschool care: location: __________________________________________
⃝ Swim lessons ⃝ Summer/Holiday Day Camp: _________________________________________
⃝ Camp McCumber
Please complete information below for all individuals to be included on the membership or program:
Name____________________________________________________ DOB _______________________ Relation ___Self________________ ⃝ adult ⃝ child
Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child
Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child
Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child
Name____________________________________________________ DOB _______________________ Relation ________________________ ⃝ adult ⃝ child
Shasta Family YMCA Financial Assistance Application
YMCA Child Care Policies
1.) Parents are responsible for informing the Site Director and the Y office of any changes in their child’s attendance schedule, address, phone, work, or
emergency telephone numbers, etc. 2.) There is a 3-day minimum charge per week. Monthly fees apply regardless of absences, illness, vacation, etc. 3.) There will be no refund of fees for non-attendance. 4.) Fees are paid by an automatic draft from either a Credit Card or Debit Card. A second form of payment from either a bank account or credit card is
required. Payments not honored by the bank for any reason, (including NSF, closed accounts, invalid expiration date) will incur a returned payment fee. This is in addition to any fees charged by the bank. In the event a payment is returned we will automatically redraft, using the second form of
payment and will include a returned payment fee. 5.) For those using a Third Party Payer, I authorize the YMCA to charge my credit card on file for any balances left unpaid by the Third Party Payer
selected. I understand that my primary form of payment will automatically be charged on the 25th of each month for any balances left unpaid by the Third Party Payer.
6.) The YMCA has the right to initiate legal action for collection of fees or outstanding balances, and the undersigned will be responsible for all cost of collection, including court expenses and reasonable attorney’s fees.
7.) The YMCA may terminate this agreement if the parent or child becomes disruptive to the center; or if, in the opinion of the Site Director, the child
does not progress well in our environment. 8.) Year-end tax notices are available upon request. Our tax ID # is 94-1212141. 9.) The YMCA reserves the right to adjust fees at any time with a 30 day advance notice to program participants.
10.) Only authorized adults (must be18) with identification will be permitted to sign children in and out of camp. Parents must walk their children into the Y to sign them in and out. The center will close promptly at 7:00 p.m. There is a late pick-up fee of $1 for every 1 minute you are late picking up
your child. In the event we cannot reach you or an authorized person by 8:00 p.m., the Shasta County Child Protection Agency will be called. 11.) Medications can only be given with specific written instructions from a physician. Directions on the bottle must include dosages, times and dates
that medication is to be administered. Children cannot attend if they are ill. You must make alternate arrangements for child care. (See the Health Policy in your Parent Handbook).
12.) The YMCA staff will act according to his/her best judgment in any emergency requiring medical care. Parents will be notified immediately and are
responsible for the cost of all medical care. 13.) If deemed necessary for the safety of your child or others, the YMCA staff has permission to restrain and/or physically remove a child from an
unsafe situation. Parents will be notified if this circumstance occurred.
14.) Photographs or likeness or voice of your child may be used in promotional material such as brochures, newspaper, or radio releases without reimbursement for such photographs or promotions.
15.) The Department of Licensing Agency shall have the authority to interview children, or staff, and to inspect the audit child or facility records without prior Notice.
16.) I understand that failure to adhere to these conditions will jeopardize continued participation in the program.
WAIVER: I hereby agree for myself, my child(ren), my heirs, executors and administrators, to indemnify, defend and hold the Shasta Family YMCA and its officers, directors, board members, employees, volunteers, agents, independent contractors and other participants in the program, harmless from any and all liability and claims with respect to any bodily injury, personal injury or illness, including death, or property damage which may occur to my child(ren) or which may be aggravated by participating in a YMCA program. I take full responsibility for the welfare and safety of my minor children, during Shasta Family YMCA activities. I also agree to abide by the rules of the YMCA in regard to my child being in their program. The Y reserves the right to dismiss a child for continual behavioral problems. I understand the Shasta Family YMCA carries no medical insurance, and it is expected that I have health insurance to cover any injuries or losses. In case of accident or illness, the Shasta Family YMCA has my permission to secure the necessary medical attention if unable to contact me. I, individually, and on behalf of any minor children, hereby release the Shasta Family YMCA from any claim whatsoever which may arise as a result of any first aid treatment or assistance provided to my child(ren) in connection with any injury that arises from participating in a YMCA activity. I consent to be photographed and to allow the Shasta Family YMCA to use photos taken of me and/or my minor children for promotional purposes. The Shasta Family YMCA Child Care programs are a non-profit child care center. The operation of our program is overseen by the Shasta Family YMCA Board of Directors. For the names and addresses of current members, please contact the Sr. Director: Finance & Operations. I have received and understand the YMCA Parent’s Manual and the current school year rate sheet.
_______________________________________________________________________________________ Child’s Name
____________________________________________ _____________________________ Parent or Guardian Signature Date
____________________________________________ _____________________________ Staff Signature Date
YMCA Copy
YMCA Child Care Policies
1.) Parents are responsible for informing the Site Director and the Y office of any changes in their child’s attendance schedule, address, phone, work, or
emergency telephone numbers, etc. 2.) There is a 3-day minimum charge per week. Monthly fees apply regardless of absences, illness, vacation, etc. 3.) There will be no refund of fees for non-attendance. 4.) Fees are paid by an automatic draft from either a Credit Card or Debit Card. A second form of payment from either a bank account or credit card is
required. Payments not honored by the bank for any reason, (including NSF, closed accounts, invalid expiration date) will incur a returned payment fee. This is in addition to any fees charged by the bank. In the event a payment is returned we will automatically redraft, using the second form of
payment and will include a returned payment fee. 5.) For those using a Third Party Payer, I authorize the YMCA to charge my credit card on file for any balances left unpaid by the Third Party Payer
selected. I understand that my primary form of payment will automatically be charged on the 25th of each month for any balances left unpaid by the Third Party Payer.
6.) The YMCA has the right to initiate legal action for collection of fees or outstanding balances, and the undersigned will be responsible for all cost of collection, including court expenses and reasonable attorney’s fees.
7.) The YMCA may terminate this agreement if the parent or child becomes disruptive to the center; or if, in the opinion of the Site Director, the child
does not progress well in our environment. 8.) Year-end tax notices are available upon request. Our tax ID # is 94-1212141. 9.) The YMCA reserves the right to adjust fees at any time with a 30 day advance notice to program participants.
10.) Only authorized adults (must be18) with identification will be permitted to sign children in and out of camp. Parents must walk their children into the Y to sign them in and out. The center will close promptly at 7:00 p.m. There is a late pick-up fee of $1 for every 1 minute you are late picking up
your child. In the event we cannot reach you or an authorized person by 8:00 p.m., the Shasta County Child Protection Agency will be called. 11.) Medications can only be given with specific written instructions from a physician. Directions on the bottle must include dosages, times and dates
that medication is to be administered. Children cannot attend if they are ill. You must make alternate arrangements for child care. (See the Health Policy in your Parent Handbook).
12.) The YMCA staff will act according to his/her best judgment in any emergency requiring medical care. Parents will be notified immediately and are
responsible for the cost of all medical care. 13.) If deemed necessary for the safety of your child or others, the YMCA staff has permission to restrain and/or physically remove a child from an
unsafe situation. Parents will be notified if this circumstance occurred.
14.) Photographs or likeness or voice of your child may be used in promotional material such as brochures, newspaper, or radio releases without reimbursement for such photographs or promotions.
15.) The Department of Licensing Agency shall have the authority to interview children, or staff, and to inspect the audit child or facility records without prior Notice.
16.) I understand that failure to adhere to these conditions will jeopardize continued participation in the program.
WAIVER: I hereby agree for myself, my child(ren), my heirs, executors and administrators, to indemnify, defend and hold the Shasta Family YMCA and its officers, directors, board members, employees, volunteers, agents, independent contractors and other participants in the program, harmless from any and all liability and claims with respect to any bodily injury, personal injury or illness, including death, or property damage which may occur to my child(ren) or which may be aggravated by participating in a YMCA program. I take full responsibility for the welfare and safety of my minor children, during Shasta Family YMCA activities. I also agree to abide by the rules of the YMCA in regard to my child being in their program. The Y reserves the right to dismiss a child for continual behavioral problems. I understand the Shasta Family YMCA carries no medical insurance, and it is expected that I have health insurance to cover any injuries or losses. In case of accident or illness, the Shasta Family YMCA has my permission to secure the necessary medical attention if unable to contact me. I, individually, and on behalf of any minor children, hereby release the Shasta Family YMCA from any claim whatsoever which may arise as a result of any first aid treatment or assistance provided to my child(ren) in connection with any injury that arises from participating in a YMCA activity. I consent to be photographed and to allow the Shasta Family YMCA to use photos taken of me and/or my minor children for promotional purposes. The Shasta Family YMCA Child Care programs are a non-profit child care center. The operation of our program is overseen by the Shasta Family YMCA Board of Directors. For the names and addresses of current members, please contact the Sr. Director: Finance & Operations. I have received and understand the YMCA Parent’s Manual and the current school year rate sheet.
_______________________________________________________________________________________ Child’s Name
____________________________________________ _____________________________ Parent or Guardian Signature Date
____________________________________________ _____________________________ Staff Signature Date
Parent Copy