GREATER BURLINGTON YMCA After School Program
ENSURING BRIGHT FUTURES GREATER BURLINGTON YMCA After School Program CHITTENDEN & WASHINGTON COUNTIES
FOR YOUTH DEVELOPMENT At the Y, we believe in nurturing the potential of every child and teen. We also believe that the values and skills our kids learn—early on—are vital building blocks for quality of life. Because of the Y community, kids in neighborhoods across Chittenden and Washington counties are taking more interest in learning and making smarter, healthier life choices. When kids participate in a Greater Burlington Y School Age program, they enhance their school work through science, math and literacy activities; learn about the importance of physical activity and healthy food choices; learn to support their neighbors through community service projects; and, most importantly, learn how to be themselves. That makes for confident kids today and contributing and engaged adults tomorrow.
Y AfterSchool Philosophy The Greater Burlington YMCA is committed to providing children with a safe, enriching environment where they can spend their out-of-school 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.
Our Staff Y AfterSchool 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 school-based 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.
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.
Administrative functions of Y AfterSchool are conducted by Julie Peterson, Director of School Age Programs and Tricia Pawlik, Director of Youth and Family Programs.
The Program Y AfterSchool provides children with a variety of fun and stimulating activities throughout the school year. Sports, recreational games, outdoor play, arts and crafts, baking, drama and quiet activities are just a sample of what your child will experience at Y AfterSchool. Special events and field trips, including guest artists, instructors and community volunteers who visit the program from time to time to share their special skills and talents, are regular features.
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 locaton follows the Burlington School District calendar. During most school vacations, a fullday program is offered at the Y and select program locations. Information about these and other options will be provided in the fall. Enrollment Options You may enroll your child in Y After School for 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 1st.
2011 - 2012 PROGRAM SITES The Burlington Y Allen Brook School Brewster Pierce Camel’s Hump Middle School Charlotte Central School Essex Elementary School Founders Memorial School Hinesburg Community School
Jericho Elementary School Richmond Elementary School Shelburne Community School Smilie School Thatcher Brook Primary Underhill Central School Underhill ID School Williston Central School
3
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 after-school 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 A registration fee of $30, and the first week’s tuition, is required with each application. The registration fee is independent of tuition. Both the registration 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 After School 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 862-8993 ext. 152 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 5th. Registration Registration for current enrollees begins April 4th. New enrollees may register beginning May 3rd. The enrollment deadline for those wishing to start the first week of school is Friday, August 19th. Children whose applications are received after August 19th will not begin the first week of school; and 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 registration 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 1st. 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 2011-2012 school year.
4
2011-2012 Y AFTER SCHOOL REGISTRATION IMPORTANT INSTRUCTIONS
Please complete a separate registration form for each child and include the Family Census Form on p 6. Financial assistance is available; call 802-862-9622, or visit gbymca.org, for more information. Return this form, including your non-refundable registration fee of $30 and the first week’s tuition payment to: Greater Burlington YMCA - After School Registration, 266 College Street, Burlington, VT 05401. Applications may not be faxed or emailed.
PLEASE COMPLETE THE PAYMENT INFORMATION BELOW: My EFT Authorization Form is enclosed, or currently on file at the Y. A valid EFT Authorization Form must be on file in order for your registration to be complete. We will return any incomplete applications. Please charge my registration fee of $30 and first week’s tuition using the billing information on my EFT Authorization Form. My $30 registration fee and and my first week’s tuition is not required because I will receive financial assistance from the State of Vermont Department of Children and Families (valid certificate must be enclosed for payment to be waived).
My application for financial assistance is enclosed (please visit gbymca.org for a copy of the application) I am receiving financial assistance through another third party:
1. Child(ren)’s grade(s) as of Fall 2011: 3. Program site:
2. Desired start date: 4. School(s) attended: Same as program site Other:
5. Please select the enrollment plan(s) and tuition below. Number of days is per week; tuition is per child:
5 days: $82
4 days: $70
3 days: $58
2 days: $48
6. Please circle which days your child(ren) will attend: M T W Th F 7. Personal Information Child’s Name:
DOB:
Age:
Address:
Home Phone:
City:
ST:
Zip:
DOB:
Employer:
Parent/Guardian Name: Work Phone:
Cell Phone:
Parent/Guardian Name: Work Phone:
❑M❑F
Email: DOB:
Employer:
Cell Phone:
Email:
The following people have permission to pick up my child: Name:
Relationship:
Day Phone:
Name:
Relationship:
Day Phone:
8. Emergency Contacts (if parent/guardian cannot be reached) Name:
Relationship:
Day Phone:
Name:
Relationship:
Day Phone:
9. Medical Information Allergies:
Dietary Requirements:
Current Medications: Physician’s Name:
Address:
Phone:
Dentist’s Name:
Address:
Phone:
Insurance Company:
Policy Number:
10. Parent/Guardian Authorization I, ___________________________, parent/guardian of the above participant, ___________________, authorize him/her to attend a 2011-2012 YMCA After School 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 After School 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:
5
2011 - 2012 CENSUS AFTER SCHOOL 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 Members:
Yes No
I/we have children who are not enrolled in YMCA Programs:
Yes No
We reside in:
County:
Town:
Please check one:
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
In which summmer program is your child enrolled? (please list program name and location): 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
In which summer program is your child enrolled? (please list program name and location): 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
In which summmer program is your child enrolled? (please list program name and location): 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
In which summmer program is your child enrolled? (please list program name and location): This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian
6
Native American Caucasian Other (please specify):
2011 - 2012 AFTER SCHOOL FINANCIAL POLICIES Whom to Contact about Billing Questions: Alicia O'Gorman Business Office Supervisor [email protected] 802-862-8993 x142 Payment Process: Payment must be made by credit card or bank draft from a checking or savings account. If your payment is declined, the Y will attempt to reprocess the payment one time before contacting you. A valid EFT Authorization Form is required in order for your registration to be complete. The form is included in the 2011-2012 After School Brochure. Please note that we will not accept payment by phone or by check or cash unless pre-authorized due to special circumstances. 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 after-school 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. Withdrawals & Schedule Changes: All changes to enrollment and cancellations require a two-week notice. Changes and cancellations must be made by telephone or email to Julie Peterson at the YMCA at 862-8993 x 152 or [email protected]. School Age Site Directors cannot process changes to enrollment or cancellations at their site location. It is the responsibility of the parent/guardian to make this change through the main office in Burlington. No withdrawals are permitted after June 1st. 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. Failure to Make Payment: If your payment declines, the Y will attempt to reprocess the payment one time before contacting you. If your payment declines a second time you will receive one reminder from the Y. If after receiving this notice, 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. Tax Information: At your request, a statement will be sent showing child care payments made to the Y during the previous calendar year. For your tax filing information, our provider number is 03-0185810. Receipts / Flexible Spending Accounts: At your request, we will provide a receipt. For Flexible Spending Accounts, this receipt will include the information needed to submit your reimbursement 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 802-862-9622, or mailing a self-addressed stamped envelope to the Greater Burlington Y, Business Office, 266 College St, Burlington, VT 05401. 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 Director of School Age Programs at 802-862-8993 x152 to discuss eligibility requirements. For more information about the Greater Burlington Y child care programs, please refer to our website at gbymca.org.
7
2011- 2012 AFTER SCHOOL EFT AUTHORIZATION FORM I hereby authorize the Greater Burlington Y to automatically transfer my periodic child care tuition payment from the checking, savings, or credit card account listed below for: Child(ren)’s Name(s): PLEASE CHOOSE ONE: Checking Account (must attach voided check or copy of) Savings Account (must attach savings deposit slip) Credit Card Account (VISA, MasterCard, American Express) Use payment information currently on file with the Y Credit Card Number
Expiration Date
Card ID (on back: Visa & MC; on front: 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 Y 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 Y Financial Policies. Name_____________________________________________________________ Billing Address______________________________________________________ City___________________________________Phone#_____________________ (In case of questions/clarification) State _____________________________ Zip Code _______________________ Signature ______________________________________ Date _______________ Please return the authorization form to: Alicia O’Gorman Business Office Supervisor Greater Burlington YMCA 266 College St. Burlington, VT 05401 You may also fax this form only to 802-660-8689.
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GREATER BURLINGTON YMCA 266 College Street Burlington, VT 05401 802 862 9622 (YMCA) gbymca.org
FIRST CLASS U.S. POSTAGE
PAID
BURLINGTON, VT PERMIT NO. 82
FOR YOUTH DEVELOPMENT At the Y, we believe in nurturing the potential of every child and teen. We also believe that the values and skills our kids learn—early on—are vital building blocks for quality of life. Because of the Y community, kids in neighborhoods across Chittenden and Washington counties are taking more interest in learning and making smarter, healthier life choices. When kids participate in a Greater Burlington Y School Age program, they enhance their school work through science, math and literacy activities; learn about the importance of physical activity and healthy food choices; learn to support their neighbors through community service projects; and, most importantly, learn how to be themselves. That makes for confident kids today and contributing and engaged adults tomorrow.
Y AfterSchool Philosophy The Greater Burlington YMCA is committed to providing children with a safe, enriching environment where they can spend their out-of-school 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.
Our Staff Y AfterSchool 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 school-based 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.
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.
Administrative functions of Y AfterSchool are conducted by Julie Peterson, Director of School Age Programs and Tricia Pawlik, Director of Youth and Family Programs.
The Program Y AfterSchool provides children with a variety of fun and stimulating activities throughout the school year. Sports, recreational games, outdoor play, arts and crafts, baking, drama and quiet activities are just a sample of what your child will experience at Y AfterSchool. Special events and field trips, including guest artists, instructors and community volunteers who visit the program from time to time to share their special skills and talents, are regular features.
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 locaton follows the Burlington School District calendar. During most school vacations, a fullday program is offered at the Y and select program locations. Information about these and other options will be provided in the fall. Enrollment Options You may enroll your child in Y After School for 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 1st.
2011 - 2012 PROGRAM SITES The Burlington Y Allen Brook School Brewster Pierce Camel’s Hump Middle School Charlotte Central School Essex Elementary School Founders Memorial School Hinesburg Community School
Jericho Elementary School Richmond Elementary School Shelburne Community School Smilie School Thatcher Brook Primary Underhill Central School Underhill ID School Williston Central School
3
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 after-school 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 A registration fee of $30, and the first week’s tuition, is required with each application. The registration fee is independent of tuition. Both the registration 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 After School 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 862-8993 ext. 152 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 5th. Registration Registration for current enrollees begins April 4th. New enrollees may register beginning May 3rd. The enrollment deadline for those wishing to start the first week of school is Friday, August 19th. Children whose applications are received after August 19th will not begin the first week of school; and 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 registration 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 1st. 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 2011-2012 school year.
4
2011-2012 Y AFTER SCHOOL REGISTRATION IMPORTANT INSTRUCTIONS
Please complete a separate registration form for each child and include the Family Census Form on p 6. Financial assistance is available; call 802-862-9622, or visit gbymca.org, for more information. Return this form, including your non-refundable registration fee of $30 and the first week’s tuition payment to: Greater Burlington YMCA - After School Registration, 266 College Street, Burlington, VT 05401. Applications may not be faxed or emailed.
PLEASE COMPLETE THE PAYMENT INFORMATION BELOW: My EFT Authorization Form is enclosed, or currently on file at the Y. A valid EFT Authorization Form must be on file in order for your registration to be complete. We will return any incomplete applications. Please charge my registration fee of $30 and first week’s tuition using the billing information on my EFT Authorization Form. My $30 registration fee and and my first week’s tuition is not required because I will receive financial assistance from the State of Vermont Department of Children and Families (valid certificate must be enclosed for payment to be waived).
My application for financial assistance is enclosed (please visit gbymca.org for a copy of the application) I am receiving financial assistance through another third party:
1. Child(ren)’s grade(s) as of Fall 2011: 3. Program site:
2. Desired start date: 4. School(s) attended: Same as program site Other:
5. Please select the enrollment plan(s) and tuition below. Number of days is per week; tuition is per child:
5 days: $82
4 days: $70
3 days: $58
2 days: $48
6. Please circle which days your child(ren) will attend: M T W Th F 7. Personal Information Child’s Name:
DOB:
Age:
Address:
Home Phone:
City:
ST:
Zip:
DOB:
Employer:
Parent/Guardian Name: Work Phone:
Cell Phone:
Parent/Guardian Name: Work Phone:
❑M❑F
Email: DOB:
Employer:
Cell Phone:
Email:
The following people have permission to pick up my child: Name:
Relationship:
Day Phone:
Name:
Relationship:
Day Phone:
8. Emergency Contacts (if parent/guardian cannot be reached) Name:
Relationship:
Day Phone:
Name:
Relationship:
Day Phone:
9. Medical Information Allergies:
Dietary Requirements:
Current Medications: Physician’s Name:
Address:
Phone:
Dentist’s Name:
Address:
Phone:
Insurance Company:
Policy Number:
10. Parent/Guardian Authorization I, ___________________________, parent/guardian of the above participant, ___________________, authorize him/her to attend a 2011-2012 YMCA After School 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 After School 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:
5
2011 - 2012 CENSUS AFTER SCHOOL 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 Members:
Yes No
I/we have children who are not enrolled in YMCA Programs:
Yes No
We reside in:
County:
Town:
Please check one:
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
In which summmer program is your child enrolled? (please list program name and location): 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
In which summer program is your child enrolled? (please list program name and location): 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
In which summmer program is your child enrolled? (please list program name and location): 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
In which summmer program is your child enrolled? (please list program name and location): This child’s Ethnic/Racial Background is best described as: African or African-American Hispanic Asian
6
Native American Caucasian Other (please specify):
2011 - 2012 AFTER SCHOOL FINANCIAL POLICIES Whom to Contact about Billing Questions: Alicia O'Gorman Business Office Supervisor [email protected] 802-862-8993 x142 Payment Process: Payment must be made by credit card or bank draft from a checking or savings account. If your payment is declined, the Y will attempt to reprocess the payment one time before contacting you. A valid EFT Authorization Form is required in order for your registration to be complete. The form is included in the 2011-2012 After School Brochure. Please note that we will not accept payment by phone or by check or cash unless pre-authorized due to special circumstances. 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 after-school 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. Withdrawals & Schedule Changes: All changes to enrollment and cancellations require a two-week notice. Changes and cancellations must be made by telephone or email to Julie Peterson at the YMCA at 862-8993 x 152 or [email protected]. School Age Site Directors cannot process changes to enrollment or cancellations at their site location. It is the responsibility of the parent/guardian to make this change through the main office in Burlington. No withdrawals are permitted after June 1st. 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. Failure to Make Payment: If your payment declines, the Y will attempt to reprocess the payment one time before contacting you. If your payment declines a second time you will receive one reminder from the Y. If after receiving this notice, 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. Tax Information: At your request, a statement will be sent showing child care payments made to the Y during the previous calendar year. For your tax filing information, our provider number is 03-0185810. Receipts / Flexible Spending Accounts: At your request, we will provide a receipt. For Flexible Spending Accounts, this receipt will include the information needed to submit your reimbursement 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 802-862-9622, or mailing a self-addressed stamped envelope to the Greater Burlington Y, Business Office, 266 College St, Burlington, VT 05401. 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 Director of School Age Programs at 802-862-8993 x152 to discuss eligibility requirements. For more information about the Greater Burlington Y child care programs, please refer to our website at gbymca.org.
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2011- 2012 AFTER SCHOOL EFT AUTHORIZATION FORM I hereby authorize the Greater Burlington Y to automatically transfer my periodic child care tuition payment from the checking, savings, or credit card account listed below for: Child(ren)’s Name(s): PLEASE CHOOSE ONE: Checking Account (must attach voided check or copy of) Savings Account (must attach savings deposit slip) Credit Card Account (VISA, MasterCard, American Express) Use payment information currently on file with the Y Credit Card Number
Expiration Date
Card ID (on back: Visa & MC; on front: 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 Y 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 Y Financial Policies. Name_____________________________________________________________ Billing Address______________________________________________________ City___________________________________Phone#_____________________ (In case of questions/clarification) State _____________________________ Zip Code _______________________ Signature ______________________________________ Date _______________ Please return the authorization form to: Alicia O’Gorman Business Office Supervisor Greater Burlington YMCA 266 College St. Burlington, VT 05401 You may also fax this form only to 802-660-8689.
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GREATER BURLINGTON YMCA 266 College Street Burlington, VT 05401 802 862 9622 (YMCA) gbymca.org
FIRST CLASS U.S. POSTAGE
PAID
BURLINGTON, VT PERMIT NO. 82
