GREATER BURLINGTON YMCA AfterSchool Program
ENRICHING CHILDREN’S LIVES GREATER BURLINGTON YMCA AfterSchool Program
Our Philosophy The Greater Burlington YMCA is committed to providing children with a safe, enriching environment where they can spend their afterschool hours. Our highly trained School Age staff fosters positive growth by offering developmentally appropriate activities that promote social, physical, creative and cognitive growth. Children are empowered to make their own choices about how they spend their time. History We began offering our School Age programs in 1985— serving approximately 30 children at two sites. We now offer the broadest School Age programming in the state, with numerous programs in four different counties. Each day, hundreds of children further their educational, social, and healthy lifestyle pursuits with the Y; because of this, we are now recognized as the leader in School Age care in Vermont. The Curriculum Y AfterSchool provides children with a variety of fun and stimulating activities throughout the school year. Our curriculum compliments the school day with extended learning opportunities that include sports, outdoor play, the arts, skill building, clubs, STEM, literacy, and more.
2013 - 2014 PROGRAM SITES BFA Fairfax Ferrisburgh Central School Georgia Elementary and Middle School St. Albans Town Educational Center* * St. Albans City School students can take the bus to the SATEC site.
Our Staff Y staff are selected for their education, enthusiasm and experience working with school age children. All staff meet Vermont State licensing requirements with regard to education and experience. Each schoolbased Y AfterSchool location has a Site Director who is responsible for developing and implementing the program. Each Director has, at minimum, one staff assistant for every 12 children in the program. Administrative functions of Y AfterSchool are conducted by Julie Peterson, Director of School Age Programs and Tricia Pawlik, Director of Youth and Family Programs. Schedule & Calendar Y AfterSchool programs run Monday – Friday, from the dismissal of school until 6 pm. Programs at each site correspond to the school calendar for that district. The downtown location follows the Burlington School District calendar. During most school vacations, a fullday program is offered at the Y and at select program locations. Information about these and other options will be provided in the fall. Enrollment Options You may enroll your child in Y AfterSchool for 1, 2, 3, 4 or 5 days a week. Enrollment is on a first-come, firstserved basis. A minimum enrollment of 12 children per day is required for the program to operate at a site. The YMCA reserves the right to cancel sites due to insufficient enrollment as of July 2nd.
2
School Closings Weekly tuition is the same, regardless of school closings or child’s absence. When a school is closed due to snow, Y AfterSchool at the site is closed as well. There will be no credit for emergency AfterSchool closings imposed by the school district. These include any unplanned early-release days. The Y Program will make up snow days, if the school calendar dictates, at the end of the year. If school is closed for a full week, you are not responsible for tuition for that week. Updated tuition policies and procedures will be mailed out with your confirmation letter. Additional Fees An annual processing fee of $30, and the first week’s tuition, is required with each application. The annual processing fee is independent of tuition. Both the annual processing fee and first week’s tuition are non-refundable. Here for You Everyone belongs at the Y, regardless of ability to pay. The generosity of our members and donors, through the Y's Annual Campaign, means that we can offer all of our School Age programs at reduced prices through scholarships and subsidies for qualifying families. Should you wish to apply for financial assistance, you may obtain an application by calling the Y at 802-8629622, or by visiting our website at www.gbymca.org. Your completed application, as well as the Y School Age application, must be sent together.
FIRST DAY INFORMATION All Y AfterSchool programs begin the first day of school. Tuition is due in full for the first week, regardless of your child’s attendance. If enrolling after the start of the school year, your application must be received at least five working days prior to your desired start date. This start date may not be possible due to staffing, funding, or other extenuating circumstances. We will contact you to confirm your child’s actual start date. We welcome you to contact our Director of School Age Programs at 652-8152 about eligibility requirements. A determination of your child’s eligibility for tuition assistance will be made prior to the start of the program, if information is received by August 3rd. Registration Registration for current enrollees begins April 9th. New enrollees may register beginning May 7th. Child applications received by Friday, August 16th will start the first week of school. Children whose applications are received after August 16th will not begin the first week of school; their start date will be determined by availability in the program, staffing, and other considerations. This process will take a minimum of 5 business days. No exceptions will be made. To register: 1. Complete and sign the enclosed registration form. Please note that due to licensing requirements, we cannot accept registration forms via fax or email. 2. Return the Registration and EFT Authorization Forms, including your non-refundable annual processing fee of $30 and the first week’s tuition payable to: The Greater Burlington YMCA. 3. You will receive confirmation within 15 business days. Parent handbooks will be available on our website at gbymca.org by August 9th. Please call the Y if you would prefer to have a copy mailed to you. Please complete all sections and sign, or we will need to return your application for re-submission. Current Child Care accounts must be in good standing in order to enroll in the 2013-2014 school year.
3
GREATER BURLINGTON Y CHILD CARE FINANCIAL POLICIES Who to Contact about Billing Questions: Alicia O’Gorman Krystn Perettine Business Office Supervisor Business Office Account Rep [email protected] [email protected] 802-652-8142 802-652-8162
Greater Burlington Y 266 College St Burlington VT 05401 802-862-9622
Tuition Payment Process: Payment must be made by credit card or bank draft from a checking or savings account. You may choose to have your payment processed every Friday for the following week or on the first day of the month. If your payment is declined, the Y will attempt to reprocess the payment one time before contacting you. Please note that we will not accept payment by phone or by check or cash unless pre-authorized due to special circumstances. Please submit a Child Care EFT Authorization Form with your program application to Y at 266 College Street, Burlington, VT 05401. You may also fax the EFT Form to the attention of Alicia O’Gorman at 802-660-8689. Failure to Make Payment: If your payment declines and the account is not paid in full or communication is not made with the Business Office Supervisor, the Y reserves the right to cancel your enrollment in the program. The child’s enrollment in any other Y program (e.g. vacation camp, summer programs, etc.) will not be permitted until the account is paid in full. It is the sincere wish of the Y that none of the above steps will need to be taken. We appreciate you keeping your account up to date. Please contact the Y immediately if your financial circumstances change and you are unable to make your tuition payments. Vermont State Child Care Assistance: Families receiving financial assistance from the State of Vermont are responsible for confirming that the Y receives a valid certificate and for paying the balance due until a certificate is received. Families are responsible for their co-pay to the Y (the difference between tuition and financial assistance) as well as any remaining balance if eligibility is terminated. All of the payment due dates and payment policies apply to families receiving financial assistance. Financial Assistance: In keeping with the Y’s commitment to serve families regardless of their ability to pay, full and partial scholarships may be available to those who qualify for tuition assistance. We welcome you to contact our VP of Child & Youth Services, Marsha Faryniarz at 652-8140 about eligibility requirements. Tuition for School Closings and Absences: Your tuition starts the first partial or full week of school and continues through the last scheduled week of school. Your weekly tuition amount remains constant during weeks when school is scheduled to be in session. There are no refunds or pro-rations for absences, partial weeks (e.g. the first week of school), full-day closings or emergency closings (e.g. snow days). Please refer to your program handbook for payment polices and refunds specific to your childcare program. Withdrawals & Schedule Changes: If you choose to withdraw from a program, you are required to give the Y a two week advance notice for Y School Age and three week notice for all other childcare programs. Tuition paid beyond the two-week or three week period will be refunded. Registration fees are non-refundable. Cancellation is not permitted after May 31, 2014 for programs that follow the school year calendar. Schedule changes are handled by the director of your child’s program. Change requests are based upon program space and staffing availability, please note change fees may apply. Flexible Spending Accounts: At your request, we will provide a receipt with the information needed to submit a reimbursement to a flexible spending plan for dependent care expenses. We are not able to complete forms for you or submit forms on your behalf. You can request a receipt by calling 862-9622, mailing a self-addressed stamped envelope to the Greater Burlington Y or login to your account through www.gbymca.org. Tax Information: Log in to your account through www.gbymca.org to access payment receipts any time of the year. At your request, a statement will be sent showing childcare payments made to the Y during the previous calendar year. Per IRS requirements, your requested statements will be mailed no later than January 31st . For your tax filing information, our provider number is 03-0185810.
4
For more information about the Greater Burlington Y childcare programs, please refer to our website, www.gbymca.org.
IMPORTANT INSTRUCTIONS
2013-2014 Y AFTERSCHOOL REGISTRATION
Please complete a separate registration form for each child and include the Family Census Form on p 5. Financial assistance is available; call 802-862-9622, or visit gbymca.org, for more information. Return this form, including your non-refundable annual processing fee of $30 and the first week’s tuition payment to: Greater Burlington YMCA - AfterSchool Registration, 266 College Street, Burlington, VT 05401. Applications may not be faxed or emailed.
PLEASE COMPLETE THE PAYMENT INFORMATION BELOW:
A valid EFT Authorization Form is required for all Child Care program participant(s), including all financial assistance recipients, in order for your registration to be complete. □ Please charge my annual processing fee of $30 and first week’s tuition using the billing information on my EFT Authorization Form enclosed. □ My annual processing fee of $30 and first week’s tuition is not required because I will receive financial assistance from the State of Vermont Department of Children and Families. (A valid certificate must be enclosed for payment to be waived.) □ I am receiving financial assistance through another third party:_______________________ □ My application for financial assistance through the Y is enclosed. Please visit gbymca.org for an application. □ Please charge my annual processing fee of $30 and first week’s tuition to secure my child’s placement while the Y financial assistance is determined. □ My annual processing fee of $30 and first week’s tuition is not to be charged until my financial assistance has been determined. I understand my child’s spot will not be secured until that time.
1. Child’s grade as of Fall 2013:___________________________________________________________________ 2. Program site:____________________ 3. School(s) attended: Same as program site Other:_____________ 4. Please select the enrollment plan(s) and tuition below. Number of days is per week; tuition is per child:
5 days: $80
4 days: $70
3 days: $58
2 days: $45
1 day: $26
5. Please circle which days your child(ren) will attend: M T W Th F 6. Personal Information Child’s Name:_______________________________________ DOB:________________ Age:____________ ❑ M ❑ F Address:_______________________________________________________________ Home Phone:_____ City:______________________________________________ ST:_________________ Zip:_____________ Parent/Guardian Name:_______________________________ DOB:________________ Employer:_______________ Work Phone:__________________________ Cell Phone:________________________ Email:__________________ Parent/Guardian Name:_______________________________ DOB:________________ Employer:_______________ Work Phone:__________________________ Cell Phone:________________________ Email:__________________ The following people have permission to pick up my child: Name:____________________________________________ Relationship:_________ Day Phone:______________ Name:____________________________________________ Relationship:_________ Day Phone:______________ 7. Emergency Contacts (if parent/guardian cannot be reached) Name:____________________________________________ Relationship:_________ Day Phone:______________ Name:____________________________________________ Relationship:_________ Day Phone:______________ 8. Medical Information Allergies:__________________________________________ Dietary Requirements:_________________________ Current Medications: Physician’s Name:___________________________________ Address:_____________ Phone:_________________ Dentist’s Name:_____________________________________ Address:_____________ Phone:_________________ Insurance Company:_________________________________ Policy Number:_______________________________ 9. Parent/Guardian Authorization I, ___________________________, parent/guardian of the above participant, ___________________, authorize him/her to attend a 2013-2014 YMCA AfterSchool program and to take part in all activities. In case of emergency, the YMCA staff has my permission to give first aid or to take the participant to a physician for treatment. I hereby give my permission to the site director or to the YMCA staff to call a doctor for medical or surgical care for my child. Should an emergency arise, I understand that a conscientious effort will be made to locate me or an emergency contact before any action is taken, but I agree to accept any expense associated with such an emergency if it is not possible to locate me in advance of treatment. I give permission for people I have listed to pick up my child. I understand that these people will be asked for identification if not recognized by Y staff and that no one other than those listed may pick up my child. I also understand that both parents may add names to or delete names from the list. I understand that when a field trip is scheduled, my child will be transported on a Mountain Transit bus contracted by the YMCA. I acknowledge that I have read and understand the Financial Policies in the Y AfterSchool Brochure. I understand that if my account falls delinquent, I am responsible for all fees accrued, including the cost of collections activities, and that this delinquency could result in my child losing a spot in the program.
Signature:________________________________________________ Date:____________________________ OFFICE USE ONLY: SA APPROVAL: ____________________
ENTERED BY: ____________________
DATE: ____________________
5
START DATE: ____________________
2013 - 2014 CENSUS AFTERSCHOOL PROGRAMS As a nonprofit, cause-driven organization, the Y receives grants and charitable contributions in support of its programs in youth development, healthy living and social responsibility. We collect demographic information so that we may comply with grant reporting requirements and secure additional funding from individuals and private foundations. Please include this form with your child’s registration. Thank you for your assistance. My household information: We are Y Health & Wellness Facility Members: Yes No I/we have children who are not enrolled in YMCA Programs: We reside in:
Town:_____________________________________ County:__________________________________
Please check one:
Yes No
My family is a two-income household
My family is a single-income household Other:
Household income (please check one): $0 - $13,999 $14,000 - $24,999 $25,000 - $39,999 $40,000 - $54,999 $55,000 - $74,999 $75,000 + In paying for my child’s care, my family is best described as (please check all that apply) Receiving State tuition assistance
Receiving YMCA scholarship
Receiving other financial support
Receiving no financial support
Please complete the following information for each child in a Y program: Child #1 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________ Child #2 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________ Child #3 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________ Child #4 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________
6
2013- 2014 BEFORESCHOOL EFT AUTHORIZATION FORM
I hereby authorize the Greater Burlington YMCA to automatically transfer my periodic childcare tuition payment from the checking, savings, or credit card account listed below for Child Name(s):_________________________________________________________________________ PLEASE CHOOSE ONE: ____ Use information and payment schedule currently in place ____ Checking Account (must attach voided check or copy of) ____ Savings Account (must attach savings deposit slip) ____ Credit Card Account (VISA, MasterCard, American Express) ______________________________________________ Credit Card Number
_____________ Expiration Date
________________ Card ID
(On
back Visa & MC, front of AMEX)
PLEASE CHOOSE ONE: ____ Weekly transfer, to occur every Friday for the following week ____ Monthly transfer, to occur the 1st business day of the month If I decide or need to make any changes to the provided information, I will notify the Greater Burlington YMCA to ensure my child care account does not fall into arrears. I understand if my payment is declined, the Y will attempt to reprocess it one time before contacting me. I have read and understand the Greater Burlington Y Financial Policies.
Name_____________________________________________________________ Billing Address______________________________________________________ City___________________________________Phone#_____________________ (For questions or clarification)
State _____________________________ Zip Code _______________________ Signature ______________________________________ Date _______________ Return the authorization form to Alicia O’Gorman Greater Burlington Y 266 College St Burlington, VT 05401 or fax to 802-660-8689 if not returned with completed application.
7
GREATER BURLINGTON YMCA 266 College Street Burlington, VT 05401 802 862 9622 (YMCA) gbymca.org
NON-PROFIT ORG. U.S. POSTAGE
PAID
BURLINGTON, VT PERMIT NO. 82
Our Philosophy The Greater Burlington YMCA is committed to providing children with a safe, enriching environment where they can spend their afterschool hours. Our highly trained School Age staff fosters positive growth by offering developmentally appropriate activities that promote social, physical, creative and cognitive growth. Children are empowered to make their own choices about how they spend their time. History We began offering our School Age programs in 1985— serving approximately 30 children at two sites. We now offer the broadest School Age programming in the state, with numerous programs in four different counties. Each day, hundreds of children further their educational, social, and healthy lifestyle pursuits with the Y; because of this, we are now recognized as the leader in School Age care in Vermont. The Curriculum Y AfterSchool provides children with a variety of fun and stimulating activities throughout the school year. Our curriculum compliments the school day with extended learning opportunities that include sports, outdoor play, the arts, skill building, clubs, STEM, literacy, and more.
2013 - 2014 PROGRAM SITES BFA Fairfax Ferrisburgh Central School Georgia Elementary and Middle School St. Albans Town Educational Center* * St. Albans City School students can take the bus to the SATEC site.
Our Staff Y staff are selected for their education, enthusiasm and experience working with school age children. All staff meet Vermont State licensing requirements with regard to education and experience. Each schoolbased Y AfterSchool location has a Site Director who is responsible for developing and implementing the program. Each Director has, at minimum, one staff assistant for every 12 children in the program. Administrative functions of Y AfterSchool are conducted by Julie Peterson, Director of School Age Programs and Tricia Pawlik, Director of Youth and Family Programs. Schedule & Calendar Y AfterSchool programs run Monday – Friday, from the dismissal of school until 6 pm. Programs at each site correspond to the school calendar for that district. The downtown location follows the Burlington School District calendar. During most school vacations, a fullday program is offered at the Y and at select program locations. Information about these and other options will be provided in the fall. Enrollment Options You may enroll your child in Y AfterSchool for 1, 2, 3, 4 or 5 days a week. Enrollment is on a first-come, firstserved basis. A minimum enrollment of 12 children per day is required for the program to operate at a site. The YMCA reserves the right to cancel sites due to insufficient enrollment as of July 2nd.
2
School Closings Weekly tuition is the same, regardless of school closings or child’s absence. When a school is closed due to snow, Y AfterSchool at the site is closed as well. There will be no credit for emergency AfterSchool closings imposed by the school district. These include any unplanned early-release days. The Y Program will make up snow days, if the school calendar dictates, at the end of the year. If school is closed for a full week, you are not responsible for tuition for that week. Updated tuition policies and procedures will be mailed out with your confirmation letter. Additional Fees An annual processing fee of $30, and the first week’s tuition, is required with each application. The annual processing fee is independent of tuition. Both the annual processing fee and first week’s tuition are non-refundable. Here for You Everyone belongs at the Y, regardless of ability to pay. The generosity of our members and donors, through the Y's Annual Campaign, means that we can offer all of our School Age programs at reduced prices through scholarships and subsidies for qualifying families. Should you wish to apply for financial assistance, you may obtain an application by calling the Y at 802-8629622, or by visiting our website at www.gbymca.org. Your completed application, as well as the Y School Age application, must be sent together.
FIRST DAY INFORMATION All Y AfterSchool programs begin the first day of school. Tuition is due in full for the first week, regardless of your child’s attendance. If enrolling after the start of the school year, your application must be received at least five working days prior to your desired start date. This start date may not be possible due to staffing, funding, or other extenuating circumstances. We will contact you to confirm your child’s actual start date. We welcome you to contact our Director of School Age Programs at 652-8152 about eligibility requirements. A determination of your child’s eligibility for tuition assistance will be made prior to the start of the program, if information is received by August 3rd. Registration Registration for current enrollees begins April 9th. New enrollees may register beginning May 7th. Child applications received by Friday, August 16th will start the first week of school. Children whose applications are received after August 16th will not begin the first week of school; their start date will be determined by availability in the program, staffing, and other considerations. This process will take a minimum of 5 business days. No exceptions will be made. To register: 1. Complete and sign the enclosed registration form. Please note that due to licensing requirements, we cannot accept registration forms via fax or email. 2. Return the Registration and EFT Authorization Forms, including your non-refundable annual processing fee of $30 and the first week’s tuition payable to: The Greater Burlington YMCA. 3. You will receive confirmation within 15 business days. Parent handbooks will be available on our website at gbymca.org by August 9th. Please call the Y if you would prefer to have a copy mailed to you. Please complete all sections and sign, or we will need to return your application for re-submission. Current Child Care accounts must be in good standing in order to enroll in the 2013-2014 school year.
3
GREATER BURLINGTON Y CHILD CARE FINANCIAL POLICIES Who to Contact about Billing Questions: Alicia O’Gorman Krystn Perettine Business Office Supervisor Business Office Account Rep [email protected] [email protected] 802-652-8142 802-652-8162
Greater Burlington Y 266 College St Burlington VT 05401 802-862-9622
Tuition Payment Process: Payment must be made by credit card or bank draft from a checking or savings account. You may choose to have your payment processed every Friday for the following week or on the first day of the month. If your payment is declined, the Y will attempt to reprocess the payment one time before contacting you. Please note that we will not accept payment by phone or by check or cash unless pre-authorized due to special circumstances. Please submit a Child Care EFT Authorization Form with your program application to Y at 266 College Street, Burlington, VT 05401. You may also fax the EFT Form to the attention of Alicia O’Gorman at 802-660-8689. Failure to Make Payment: If your payment declines and the account is not paid in full or communication is not made with the Business Office Supervisor, the Y reserves the right to cancel your enrollment in the program. The child’s enrollment in any other Y program (e.g. vacation camp, summer programs, etc.) will not be permitted until the account is paid in full. It is the sincere wish of the Y that none of the above steps will need to be taken. We appreciate you keeping your account up to date. Please contact the Y immediately if your financial circumstances change and you are unable to make your tuition payments. Vermont State Child Care Assistance: Families receiving financial assistance from the State of Vermont are responsible for confirming that the Y receives a valid certificate and for paying the balance due until a certificate is received. Families are responsible for their co-pay to the Y (the difference between tuition and financial assistance) as well as any remaining balance if eligibility is terminated. All of the payment due dates and payment policies apply to families receiving financial assistance. Financial Assistance: In keeping with the Y’s commitment to serve families regardless of their ability to pay, full and partial scholarships may be available to those who qualify for tuition assistance. We welcome you to contact our VP of Child & Youth Services, Marsha Faryniarz at 652-8140 about eligibility requirements. Tuition for School Closings and Absences: Your tuition starts the first partial or full week of school and continues through the last scheduled week of school. Your weekly tuition amount remains constant during weeks when school is scheduled to be in session. There are no refunds or pro-rations for absences, partial weeks (e.g. the first week of school), full-day closings or emergency closings (e.g. snow days). Please refer to your program handbook for payment polices and refunds specific to your childcare program. Withdrawals & Schedule Changes: If you choose to withdraw from a program, you are required to give the Y a two week advance notice for Y School Age and three week notice for all other childcare programs. Tuition paid beyond the two-week or three week period will be refunded. Registration fees are non-refundable. Cancellation is not permitted after May 31, 2014 for programs that follow the school year calendar. Schedule changes are handled by the director of your child’s program. Change requests are based upon program space and staffing availability, please note change fees may apply. Flexible Spending Accounts: At your request, we will provide a receipt with the information needed to submit a reimbursement to a flexible spending plan for dependent care expenses. We are not able to complete forms for you or submit forms on your behalf. You can request a receipt by calling 862-9622, mailing a self-addressed stamped envelope to the Greater Burlington Y or login to your account through www.gbymca.org. Tax Information: Log in to your account through www.gbymca.org to access payment receipts any time of the year. At your request, a statement will be sent showing childcare payments made to the Y during the previous calendar year. Per IRS requirements, your requested statements will be mailed no later than January 31st . For your tax filing information, our provider number is 03-0185810.
4
For more information about the Greater Burlington Y childcare programs, please refer to our website, www.gbymca.org.
IMPORTANT INSTRUCTIONS
2013-2014 Y AFTERSCHOOL REGISTRATION
Please complete a separate registration form for each child and include the Family Census Form on p 5. Financial assistance is available; call 802-862-9622, or visit gbymca.org, for more information. Return this form, including your non-refundable annual processing fee of $30 and the first week’s tuition payment to: Greater Burlington YMCA - AfterSchool Registration, 266 College Street, Burlington, VT 05401. Applications may not be faxed or emailed.
PLEASE COMPLETE THE PAYMENT INFORMATION BELOW:
A valid EFT Authorization Form is required for all Child Care program participant(s), including all financial assistance recipients, in order for your registration to be complete. □ Please charge my annual processing fee of $30 and first week’s tuition using the billing information on my EFT Authorization Form enclosed. □ My annual processing fee of $30 and first week’s tuition is not required because I will receive financial assistance from the State of Vermont Department of Children and Families. (A valid certificate must be enclosed for payment to be waived.) □ I am receiving financial assistance through another third party:_______________________ □ My application for financial assistance through the Y is enclosed. Please visit gbymca.org for an application. □ Please charge my annual processing fee of $30 and first week’s tuition to secure my child’s placement while the Y financial assistance is determined. □ My annual processing fee of $30 and first week’s tuition is not to be charged until my financial assistance has been determined. I understand my child’s spot will not be secured until that time.
1. Child’s grade as of Fall 2013:___________________________________________________________________ 2. Program site:____________________ 3. School(s) attended: Same as program site Other:_____________ 4. Please select the enrollment plan(s) and tuition below. Number of days is per week; tuition is per child:
5 days: $80
4 days: $70
3 days: $58
2 days: $45
1 day: $26
5. Please circle which days your child(ren) will attend: M T W Th F 6. Personal Information Child’s Name:_______________________________________ DOB:________________ Age:____________ ❑ M ❑ F Address:_______________________________________________________________ Home Phone:_____ City:______________________________________________ ST:_________________ Zip:_____________ Parent/Guardian Name:_______________________________ DOB:________________ Employer:_______________ Work Phone:__________________________ Cell Phone:________________________ Email:__________________ Parent/Guardian Name:_______________________________ DOB:________________ Employer:_______________ Work Phone:__________________________ Cell Phone:________________________ Email:__________________ The following people have permission to pick up my child: Name:____________________________________________ Relationship:_________ Day Phone:______________ Name:____________________________________________ Relationship:_________ Day Phone:______________ 7. Emergency Contacts (if parent/guardian cannot be reached) Name:____________________________________________ Relationship:_________ Day Phone:______________ Name:____________________________________________ Relationship:_________ Day Phone:______________ 8. Medical Information Allergies:__________________________________________ Dietary Requirements:_________________________ Current Medications: Physician’s Name:___________________________________ Address:_____________ Phone:_________________ Dentist’s Name:_____________________________________ Address:_____________ Phone:_________________ Insurance Company:_________________________________ Policy Number:_______________________________ 9. Parent/Guardian Authorization I, ___________________________, parent/guardian of the above participant, ___________________, authorize him/her to attend a 2013-2014 YMCA AfterSchool program and to take part in all activities. In case of emergency, the YMCA staff has my permission to give first aid or to take the participant to a physician for treatment. I hereby give my permission to the site director or to the YMCA staff to call a doctor for medical or surgical care for my child. Should an emergency arise, I understand that a conscientious effort will be made to locate me or an emergency contact before any action is taken, but I agree to accept any expense associated with such an emergency if it is not possible to locate me in advance of treatment. I give permission for people I have listed to pick up my child. I understand that these people will be asked for identification if not recognized by Y staff and that no one other than those listed may pick up my child. I also understand that both parents may add names to or delete names from the list. I understand that when a field trip is scheduled, my child will be transported on a Mountain Transit bus contracted by the YMCA. I acknowledge that I have read and understand the Financial Policies in the Y AfterSchool Brochure. I understand that if my account falls delinquent, I am responsible for all fees accrued, including the cost of collections activities, and that this delinquency could result in my child losing a spot in the program.
Signature:________________________________________________ Date:____________________________ OFFICE USE ONLY: SA APPROVAL: ____________________
ENTERED BY: ____________________
DATE: ____________________
5
START DATE: ____________________
2013 - 2014 CENSUS AFTERSCHOOL PROGRAMS As a nonprofit, cause-driven organization, the Y receives grants and charitable contributions in support of its programs in youth development, healthy living and social responsibility. We collect demographic information so that we may comply with grant reporting requirements and secure additional funding from individuals and private foundations. Please include this form with your child’s registration. Thank you for your assistance. My household information: We are Y Health & Wellness Facility Members: Yes No I/we have children who are not enrolled in YMCA Programs: We reside in:
Town:_____________________________________ County:__________________________________
Please check one:
Yes No
My family is a two-income household
My family is a single-income household Other:
Household income (please check one): $0 - $13,999 $14,000 - $24,999 $25,000 - $39,999 $40,000 - $54,999 $55,000 - $74,999 $75,000 + In paying for my child’s care, my family is best described as (please check all that apply) Receiving State tuition assistance
Receiving YMCA scholarship
Receiving other financial support
Receiving no financial support
Please complete the following information for each child in a Y program: Child #1 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________ Child #2 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________ Child #3 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________ Child #4 Age:_________ Gender: Female Male This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian Native American Caucasian Other (please specify):_______________________________________________
6
2013- 2014 BEFORESCHOOL EFT AUTHORIZATION FORM
I hereby authorize the Greater Burlington YMCA to automatically transfer my periodic childcare tuition payment from the checking, savings, or credit card account listed below for Child Name(s):_________________________________________________________________________ PLEASE CHOOSE ONE: ____ Use information and payment schedule currently in place ____ Checking Account (must attach voided check or copy of) ____ Savings Account (must attach savings deposit slip) ____ Credit Card Account (VISA, MasterCard, American Express) ______________________________________________ Credit Card Number
_____________ Expiration Date
________________ Card ID
(On
back Visa & MC, front of AMEX)
PLEASE CHOOSE ONE: ____ Weekly transfer, to occur every Friday for the following week ____ Monthly transfer, to occur the 1st business day of the month If I decide or need to make any changes to the provided information, I will notify the Greater Burlington YMCA to ensure my child care account does not fall into arrears. I understand if my payment is declined, the Y will attempt to reprocess it one time before contacting me. I have read and understand the Greater Burlington Y Financial Policies.
Name_____________________________________________________________ Billing Address______________________________________________________ City___________________________________Phone#_____________________ (For questions or clarification)
State _____________________________ Zip Code _______________________ Signature ______________________________________ Date _______________ Return the authorization form to Alicia O’Gorman Greater Burlington Y 266 College St Burlington, VT 05401 or fax to 802-660-8689 if not returned with completed application.
7
GREATER BURLINGTON YMCA 266 College Street Burlington, VT 05401 802 862 9622 (YMCA) gbymca.org
NON-PROFIT ORG. U.S. POSTAGE
PAID
BURLINGTON, VT PERMIT NO. 82
