Fall 2010 Private & Parochial SACC

2010-11 After School Program

Laugh, Learn and Grow with the

YMCA School-Age Child Care Program!

The YMCA of Greater Louisville, in partnership with area Private and Parochial Schools, offers the School-Age Child Care Program — where your child will learn, grow and have a great time!

en kindergart through hool middle-sc

ymcalouisville.org Financial assistance available.

YMCA School-Age Child Care Program ● (502) 637-1575 Enrichment is our Name

Registration

We pride ourselves on providing a safe environment where your child can participate in fun activities that enrich, strengthen and expand their learning. Our activities are focused around literacy, arts and humanities, recreation, science & technology, academic support, healthy actions and fitness, character development and asset building. Our goal is to help your child build a healthy spirit, mind and body.

Registration will continue throughout the school year based on space availability. All sites have minimum and maximum enrollment numbers and registrations are processed on a first-come, first-served basis.

Completed registrations must be received at least 2 business days prior to your child’s start date in order for your child to begin the program.

Daily Schedule Regular program hours are close of school until 6 p.m. Continuous care is also available from 7 a.m. until 6 p.m. when school is not in session, at select locations. Spring Break, Winter Break and Summer programs require a separate registration. In addition to planned activities and programs, each child will receive healthy afternoon snacks.

To register submit your registration form and non-refundable registration fee one of the following ways:

• Online at ymcalouisville.org through August 9th

• Bring registration form and fee to your Site Director

• Mail the registration form and fee to:

YMCA School-Age Child Care Services 2411 Bowman Avenue Louisville, KY 40217

Trained Staff

Mail must be post-marked one week prior to start date.

Our outstanding staff members receive extensive hours of professional development training that exceeds state licensing requirements.

All staff are CPR and First Aid certified and we meet or exceed state staff-to-child ratios.

Parental Involvement All our programs have an open door policy and parents are welcome and encouraged to take part in their child’s day. Each site will host special family events. We welcome parents to join our Parent Advisory Committee, where monthly luncheon meetings give you the opportunity to provide key input, feedback and program development ideas. Throughout the year, we distribute surveys to parents and participants. Your feedback is valuable and greatly appreciated!

School Sites

Payment Options All payments are to be made by bank or credit card draft. Automatic draft payments must be set up prior to the first day of attendance. All parents must pay registration fees. Drafts will occur each Wednesday for the current week, unless otherwise scheduled through our main office.

In-Service & Snow Days Full day care available during in-service and snow days from 7 a.m. until 6 p.m. Site locations may vary due to site consolidation. In addition to completing the registration form, participants must be signed up to attend these days at the site of their choice. Details available at your site or at ymcalouisville.org. In-service and snow days are included in total number of days attended for the week.

Financial Assistance & 3rd Party Subsidies

Christian Academy of Louisville – Rock Creek 3110 Rock Creek Drive

Through the Spirit Program, we strive to turn no one away due to an inability to pay. The Spirit Program is a sliding-scale income-based financial assistance program available through the YMCA. Call (502) 637-1575 or go to ymcalouisville.org for a Spirit Application. All sites are also eligible for third-party subsidy reimbursements provided by 4-C, Foster Care, United Way, etc. Valid contracts must be on file with our main office prior to the program start date. Spirit Program assistance is only available for those that do not qualify for 4-C or other third-party subsidies.

Christian Academy of Louisville – English Station 711 S. English Station Road St. Leonard Catholic School 440 Zorn Avenue St. Margaret Mary Catholic School 7813 Shelbyville Road St. Patrick Catholic School 1000 North Beckley Station Road St. Raphael School 2131 Lancashire Avenue

Weekly Rates First Child

Each Additional Child

Program Members

YMCA Facility Member/ Partnership Employee Dependents

Program Members

YMCA Facility Member/ Partnership Employee Dependents

4- or 5-day

$58

$53

$48

$43

1-, 2- or 3-day

$47

$43

$39

$35

Registration Fees Per Child

Through August 9, 2010

$30 per child

August 10, 2010 throughout school year

$45 per child

In-service and snow days are included in total number of days attended for the week.

2010-11 School Year YMCA School-Age Child Care Program Registration Form

Please attach a recent wallet size photo and immunization certificate for each child.

Please print legibly and include your registration fee.

Register Online through August 9th at ymcalouisville.org.

Program Start Date_ _____________________________________

E-mail Address to receive confirmation_ ______________________________________________________________

1st Child’s Name First _____________________________ Middle _____________________________ Last_____________________________ Date of Birth _ _____/______ /______ Gender: African American/Black

Race:

Alaskan

Native Asian/Pacific Islander

Caucasian/White

Hispanic

Native American

M

F

Age_ ________

Other

Physical Conditions/Special Needs_________________________________________________________ Medications/Allergies___________________________________________________________________ To better serve your child, please indicate if he/she has been diagnosed with any of the following: ADD/ADHD

Convulsions

Rhett Syndrome

Bleeding/Clotting Disorders

Down Syndrome Yes

Does this child have an IEP?

Autism

Chronic Health Problems

Aspergers

Fragile X

Asthma/Severe Allergies

Cerebral Palsy

Diabetes

Bipolar Disorder

Heart defect/disease

Tourettes

Other______________________________

No

School Attending________________________________________________________________________________________________________________________ Grade in School (2010-11)______________ Attendance:

1-3 Days

Participation:

After-School Care

4-5 Days In-Service Day Care

Snow Day Care

2nd Child’s Name First _____________________________ Middle _____________________________ Last_____________________________ Date of Birth _ _____/______ /______ Gender: African American/Black

Race:

Alaskan

Native Asian/Pacific Islander

Caucasian/White

Hispanic

Native American

M

F

Age_ ________

Other

Physical Conditions/Special Needs_________________________________________________________ Medications/Allergies___________________________________________________________________ To better serve your child, please indicate if he/she has been diagnosed with any of the following: ADD/ADHD

Convulsions

Rhett Syndrome

Bleeding/Clotting Disorders

Down Syndrome Yes

Does this child have an IEP?

Autism

Chronic Health Problems

Aspergers

Fragile X

Asthma/Severe Allergies

Cerebral Palsy

Diabetes

Bipolar Disorder

Heart defect/disease

Tourettes

Other______________________________

No

School Attending________________________________________________________________________________________________________________________Grade in School (2009-10)______________ Attendance:

1-3 Days

Participation:

After-School Care

4-5 Days In-Service Day Care

Snow Day Care

1st Parent/Guardian Name______________________________________________________________ Relationship to Child_____________________________________ Date of Birth ______ /______ /_ _____ Mailing Address_ _______________________________________________________________________ City_______________________________________ State_____________ Zip_______________________ Home Phone___________________________ Cell Phone_ _________________________ Work Phone __________________________ Employer_____________________________________________________ 2nd Parent/Guardian Name_ ____________________________________________________________ Relationship to Child_____________________________________ Date of Birth ______ /______ /_ _____ Mailing Address_ _______________________________________________________________________ City_______________________________________ State_____________ Zip_______________________ Home Phone___________________________ Cell Phone_ _________________________ Work Phone __________________________ Employer_____________________________________________________ Insurance Company _________________________________________________________________________________________ Policy Number_ __________________________________________________ Name of Physician_ _________________________________________________________________________________________ Physician Phone__________________________________________________ Yes! I would like to learn more about FREE or LOW-COST health insurance for my children and teens.

Emergency Contact and Authorized Pick-Up Information Please give the names and phone numbers of people to contact in an emergency and/or names of persons authorized to pick up your child/children. Anyone picking up your child/children must be 18 years of age or older. A Photo ID is required at pick-up.

Name_______________________________________________ Relation to child_ __________________________________ Phone 1_____________________________Phone 2____________________________ Name_______________________________________________ Relation to child_ __________________________________ Phone 1_____________________________Phone 2____________________________ The YMCA has permission for my child(ren) to be photographed and/or interviewed for promotional purposes: My child(ren) have permission to participate in basic health and fitness evaluations: Yes, I would like to make a charitable donation to The Spirit Campaign: Check here if either parent is: I currently receive a:

YMCA Employee

Spirit Program discount

Yes

$10

$25

School Partnership Employee 4-C

Yes

$50

No I am registering a tuition-based Pre-K student:

No $100

Yes

No

Other/please contact me

YMCA Family Facility Member

Other 3rd party subsidy discount

You must choose one of the three options below in order to process your registration. Drafts will occur each Wednesday for the current week unless otherwise scheduled through our main office.

I am currently on automatic draft. Please use the information on file to draft my account for my registration fee(s) and to set up my weekly payments. Account ending in ____ ____ ____ ____.

EFT

Credit Card

I am authorizing a NEW bank draft from my checking account and I have attached a voided check.

I am authorizing a NEW credit card draft and I have provided all the information below:

Credit Card Type:

Visa

MasterCard

Discover

Name as it appears on card ____________________________________________________________ Card Number_ _______________________________________ Expiration Date_ _______________

Billing Street Address_____________________________________________________________________________ _ _____________________________________________Billing Zip_ _______________

I have the legal authority to sign up my child/children named on this form. I understand that this is an application and the named child’s/children’s participation is contingent upon space being available in this program. I also understand that once my application is confirmed, I must complete payment by the deadline. I understand that the YMCA prohibits staff members from being alone with children they meet in YMCA programs outside of the YMCA. This includes but is not limited to baby sitting, tutoring, sleep-over’s, etc. This health history is correct as far as I know and the child/children herein described have my permission to engage in all activities and field trips except as noted by me. A photo of each child and a copy of each child’s current immunization certificate will be on file with the YMCA prior to my child/children attending the program. Failure to comply with the above could result in the loss of child care space. In the event I cannot be reached in an emergency, I hereby give permission to the director of the program or designee to secure emergency medical services, including transportation and a physician. I also give permission to the attending physician to order injection, anesthesia or surgery for my child/children as named above. Medical and accident insurance is the responsibility of the parent or guardian. To the best of my knowledge; the information on this form is complete and accurate. I have read and agree to these terms and conditions.

Signature_______________________________________________________________________________________ Date Signed________________________