BUILDING BRIGHTFUTURES School-Age Child Care Program YMCA OF GREATER LOUISVILLE

2012-13 SCHOOL YEAR REGISTRATION

Save by registering early! REGISTER ONLINE AND RECEIVE A FREE LUNCH BAG.

ymcalouisvillechildcare.org

CONNECTING WITH OUR FAMILIES Our programs have an open door policy and you are welcome and encouraged to take part in your child’s day. Each site hosts special family events throughout the year and our Parent Advisory Committee offers parents the opportunity to give valuable feedback. Parent surveys will also be distributed throughout the year, so we can continuously improve your experience.

SCHOOL SITES•ChristianAcademyofLouisville–RockCreek

•ChristianAcademyofLouisville–EnglishStation

•HolyTrinitySchool

•St.LeonardCatholicSchool

•St.MargaretMaryCatholicSchool

•St.PatrickCatholicSchool

•St.RaphaelSchool

REGISTER TODAYRegistration for the after school programs will continue throughout the school year based on 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 two business days prior to your child’s start date.

You can register online at ymcalouisvillechildcare.org through August 9 and receive a FREE lunch bag.

You can register throughout the school year by: • Bringing registration form and fee to your Site Director

• Mailing the registration form and fee to:

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

Mail must be post-marked one week prior to start date. Please do not fax registration forms. If you have additional questions, call 502.637.1575 or visit ymcalouisvillechildcare.org.

PAYMENT OPTIONSPayments can be made by bank or credit card draft. Automatic draft payments must be set up prior to the first day of attendance for your child to attend our program. Drafts occur each Wednesday for the current week, unless otherwise scheduled through our main office.

ACCESS FOR ALLAt the Y, we believe everyone should have the opportunity to grow up healthy, happy, confident and secure. That’s why we strive to make our programs and services available to everyone, even if they are unable to pay the full fee. Families can apply for financial assistance with the cost of Y programs and membership. Assistance is on an income-based sliding scale. All sites are also eligible for 4-C and other third-party subsidy reimbursements. Valid contracts must be on file with our office prior to the program start date. Applicants who qualify for 4-C or other child care subsidies will not be eligible for additional assistance through the Y.

YMCA SCHOOL-AGE CHILD CARE PROGRAM2012-2013 School Year

LEARN, GROW, THRIVE The Y makes our community stronger. Through our affordable child care programs we create a nurturing environment to engage children and help them develop skills that will serve them throughout their lives. We focus on ensuring that your child’s time is spent creatively and constructively in the critical hours after school and during school breaks.

HELPING BUILD CONFIDENCE With the Y’s values of caring, honesty, respect and responsibility as our guide, you can feel confident your child is safe and well cared for by our qualified staff. Every staff member receives extensive hours of training and professional development and is CPR and First Aid certified. We meet or exceed state licensing requirements.

BUILDING THE WHOLE CHILD Your child will experience academic support, self-esteem building and character development through activities designed to enrich and expand their learning. We offer homework assistance through our Homework Club and maintain a strong focus on literacy. We also provide opportunities for physical activity, and provide nutritious snacks daily.

ALWAYS HERE FOR YOU Our after school program operates from the close of your child’s school day until 6 p.m. Continuous care is also available 7 a.m. to 6 p.m. during school breaks, including in-service days and snow days. Spring Break, Winter Break, and Summer Camps require separate registrations.

REGISTER ONLINE AND RECEIVE A FREE LUNCH BAG!

4- or 5-day

1-, 2- or 3-day

Program Members

$60

$49

Program Members

$50

$41

Y Facility Member/

Partnership Employee

Dependents

$55

$45

Y Facility Member/

Partnership Employee

Dependents

$45

$37

First Child Each Additional

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

snow day only rate is $22 per day, per child.

WEEKLY RATES 2012-13 YMCA School-Age Child Care Program

REGISTRATION FEES PER CHILD: $15 through July 17 $30 July 18 through August 1 • $45 starting August 2

1st CHILD

2nd CHILD

1st PARENT/GUARDIAN

2nd PARENT/GUARDIAN

INSURANCE INFORMATION

PLEASE LIST ANY ADULT OTHER THAN THE ABOVE THAT MAY BE PICKING UP THIS CHILD OR THAT MAY BE CONTACTED IN AN EMERGENCY. Anyone picking up your child must be at least 18 years of age or older. A picture ID is required at pick-up.

YMCA SCHOOL-AGE CHILD CARE PROGRAM 2012-13 SCHOOL YEAR REGISTRATION FORMPLEASE PRINT LEGIBLY and include your registration fee. Register Online through August 9 at ymcalouisvillechildcare.org.

Program start date Email address (To receive important program updates and registration information)

First name Middle initial Last name Date of birth / / Gender M F Age

Race African American/Black Alaskan Native Asian/Pacific Islander Caucasian/White Hispanic Native American 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 Bleeding/Clotting Disorders Autism Aspergers Fragile X Cerebral Palsy Bipolar Disorder Tourettes Rhett Syndrome Down Syndrome Chronic Health Problems Asthma/Severe Allergies Diabetes Heart defect/disease Other

Does this child have an IEP? Yes No

School Attending

Attendance 1-3 Days 4-5 Days Grade in School (2012-13)

Participation After-School Care In-Service Day Care Snow Day Care

First name Middle initial Last name Date of birth / / Gender M F Age

Race African American/Black Alaskan Native Asian/Pacific Islander Caucasian/White Hispanic Native American 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 Bleeding/Clotting Disorders Autism Aspergers Fragile X Cerebral Palsy Bipolar Disorder Tourettes Rhett Syndrome Down Syndrome Chronic Health Problems Asthma/Severe Allergies Diabetes Heart defect/disease Other

Does this child have an IEP? Yes No

School Attending

Attendance 1-3 Days 4-5 Days Grade in School (2012-13)

Participation After-School Care In-Service Day Care Snow Day Care

Name Relationship to child Date of birth / /

Address City State Zip

Cell phone Home phone Work phone Employer

Name Relationship to child Date of birth / /

Address City State Zip

Cell phone Home phone Work phone Employer

Health insurance company Policy number

Name of physician Physician phone

.

Name Relationship to child Phone 1 Phone 2

Name Relationship to child Phone 1 Phone 2

The YMCA has permission for my children to be photographed and/or interviewed for promotional purposes Yes No My child(ren) have permission to participate in basic health and fitness evaluations Yes No

Yes, I would like to make a charitable donation to the Y’s annual giving campaign $10 $25 $50 $100 Other/please contact me

Check here if either parent is School partnership employee YMCA employee YMCA family facility member Financial assistance recipient 4-C recipient

YES! I would like to learn more about FREE or LOW-COST health insurance for my children and teens.

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

I am currently on draft. Please use the account on file ending in ___ ___ ___ ___. Authorized account holder signature _________________________________________________________________________

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 on card Authorized cc signature

Card number Expiration date

Billing street address Billing zip code

I have the legal authority to sign up the child/children named on this form and to the best of my knowledge the information on this application form is complete and accurate. I understand that my application will not be processed unless it includes the full fee or automatic draft authorization. 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-overs, etc. 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 medical care. I also give permission for the attending physician to order injections, anesthesia or surgery for this child as named above. I understand that medical and accident insurance is the responsibility of the parent or guardian. There may also be times when the YMCA may take photographs (or other digital images) of students participating in activities. Those images may appear in the YMCA’s or publications, including electronic publications. By signing this form, I am giving permission to the YMCA to use my child(s) image for the purposes listed above. I understand that this release may be revoked by me at any time by written request.

Signature Date Signed

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