FOR YOUTH DEVELOPMENT®

FOR HEALTHY LIVINGFOR SOCIAL RESPONSIBILITY

2013-2014 BEFORE & AFTER SCHOOL ENRICHMENTYMCA OF GREATER INDIANAPOLISYOUTH ENRICHMENT CENTER

ENCOURAGE GROWTHNURTURE POTENTIAL

WE’RE AT A SCHOOL NEAR YOU!2013-2014 YMCA YOUTH ENRICHMENT (Y.E.) PROGRAM SITESLocations are subject to change. For up-to-date information, please call:

North Programs: (317) 577-2070 or 1-866-577-2070

South Programs: (317) 887-8788 or 1-888-500-9622

Central & East Programs: (317) 226-9122

West Programs: (317) 484-9622

Benjamin Harrison Y: (317) 226-9122 or (317) 547-9622

Hendricks Regional Health Y: (317) 273-9622

Jordan Y: (317) 577-2070 or (317) 253- 3206

Ransburg Y: (317) 226-9122 or (317) 357-8441

Y.E. NORTHCenter Affi liation:

Fishers & Jordan Ys

Hamilton SoutheasternSchoolsBrooks School ElementaryCumberland Road ElementaryDurbin ElementaryFall Creek ElementaryFall Creek Intermediate (PM)Fishers ElementaryGeist Elementary

Harrison Parkway ElementaryHoosier Road ElementaryLantern Road ElementaryNew Britton ElementaryRiverside Intermediate (PM)Sand Creek ElementarySand Creek Intermediate (PM)Thorpe Creek Elementary

Indiana School for the Deaf

MSD of Washington TownshipServed at: Jordan YMCA (PM)

Sheridan Community SchoolsSheridan Elementary

Y.E. SOUTH Center Affi liation:

Baxter Y

Beech Grove City SchoolsCentral Elementary (PM)

Also serving:Hornet Park ElementarySouth Grove Intermediate

Clark-Pleasant CommunitySchool CorporationClark ElementaryClark-Pleasant Intermediate (PM)Pleasant Crossing ElementarySawmill Woods Elementary

Also serving:Break o’ Day Elementary

Whiteland Elementary

Edinburgh School Community CorporationEast Side Elementary (PM)

Franklin Township Community School Corp.Adams ElementaryArlington ElementaryBunker Hill ElementaryKitley ElementaryMiddle School EastMiddle School WestSouth Creek ElementaryThompson Crossing Elementary

Greenwood CommunitySchool CorporationNortheast Elementary

Also serving:Isom Elementary

Southwest ElementaryAlso serving:Westwood Elementary

Johnson County:Center Grove CommunitySchool CorporationCenter Grove Middle School Central (PM)Center Grove Middle School North (PM)Maple Grove ElementaryPleasant Grove ElementarySugar Grove Elementary

MSD of Perry TownshipAbraham Lincoln ElementaryServed at Baxter YMCA (PM)

Perry 6th Grade Academy (PM)Southport 6th Grade Academy (PM)

Burkhart ElementaryDouglas MacArthur ElementaryGlenns Valley ElementaryHomecroft Elementary

Also serving:Southport ElementaryClinton Young Elementary

Jeremiah Gray ElementaryMary Bryan ElementaryRosa Parks ElementaryWinchester Elementary

Southport PresbyterianChristian School

Y.E. CENTRALCenter Affi liation:

Benjamin Harrison Y

Charter SchoolsChallenge Foundation AcademyChristel House AcademyFall Creek AcademyGeist Montessori Academy - NorthGeist Montessori Academy - SouthParamount School of Excellence

Indianapolis PublicElementary SchoolsCenter for Inquiry (327)

Also serving:Center for Inquiry (302)

Elder W. Diggs (42)Francis W. Parker (356)George H. Fisher (93)Jonathan Jennings (109)Lew Wallace (107)Louis B. Russell Jr. (48)Meredith Nicholson (96)Paul I. Miller (114)Stephen Foster (67)Theodore Potter School (74)

Y.E. EASTCenter Affi liation:

Ransburg Y

Community SchoolCorporation of SouthernHancock CountyNew Palestine Elementary (Also offering Y Preschool)

Also serving:Brandywine Elementary

Sugar Creek ElementaryAlso serving:Doe Creek Elementary

Greenfi eld-CentralCommunity SchoolCorporationEden Elementary (PM)J.B. Stephens Elementary (PM)Harris Elementary (PM)

Also serving:Greenfi eld Intermediate (PM)

Maxwell Intermediate (PM) Weston Elementary (PM)

Mt. Vernon CommunitySchool CorporationFortville Elementary

Also serving:Mt. Vernon Intermediate

McCordsville ElementaryMt. Comfort Elementary

Y.E. WESTCenter Affi liation:

Hendricks Regional Health Y

Hendricks County:Avon Community SchoolsAvon Intermediate School EastAvon Intermediate School West Cedar ElementaryHickory ElementaryMaple ElementaryPine Tree ElementaryRiver Birch ElementarySycamore ElementaryWhite Oak Elementary

Marion County:MSD of Wayne TownshipBridgeport ElementaryChapel Glen ElementaryChapelwood Elementary (PM)Maplewood Elementary (AM) McClelland Elementary (PM)North Wayne ElementaryRhoades Elementary

Also serving:Garden City ElementaryStout Field Elementary (PM)

Robey ElementaryWestlake Elementary

Plainfi eld Community School CorporationClarks Creek Elementary

Also serving:Brentwood ElementaryCentral ElementaryVanBuren Elementary

Call for New School

Updates!

3

YMCA YOUTH ENRICHMENT CONTACT INFORMATIONHeather Perkins Mistie Timmons Dee RiceExecutive Director Associate Executive Director Director of Administrative Services317-713-8553 317-865-6476 317-865-6480

YOUTH ENRICHMENT - NORTH9093 Technology Drive, Suite 101, Fishers, IN 46038 Ph: 317-577-2070 F: 317-577-2075

Amy Panetta Brian Shelley Erin Neff Shawna Hood Senior Program Director Program Director Program Director Offi ce Manager317-554-1661 317-865-6462 317-558-3232 317-558-3233

YOUTH ENRICHMENT - SOUTH7800 South Shelby Street, Suite 100, Indianapolis, IN 46227 Ph: 317-887-8788 F: 317-887-8790

Tiffany Dow Carinne Atkerson Ashleigh Coster Shelly Perry Amber TippettsSenior Program Director Program Director Assoc. Program Dir. Assoc. Program Dir. Offi ce Manager 317-865-6481 317-865-6474 317-865-6455 317-865-6462 317-865-6451

YOUTH ENRICHMENT - CENTRAL & EAST615 North Alabama Street, Suite 400, Indianapolis, IN 46204 Ph: 317-226-9122 F: 317-269-6068

Cara Scott Monica Richardson Becky Ricks Kara OvertonProgram Director Assoc. Program Dir. Assoc. Program Dir. Program Coordinator317-713-8529 317-713-8569 317-713-8566 317-713-8560

YOUTH ENRICHMENT - WEST7811 West Morris Street, Indianapolis, IN 46231 Ph: 317-484-9622 F: 317-484-2360

TBA Clarissa Call Nikki Reed Tory Draper Cecily EvansSenior Program Director Program Director Program Director Program Coordinator Offi ce Manager317-554-1661 317-554-1663 317-554-1657 317-554-1659 317-554-1656

WHAT’S INSIDE:GENERAL INFORMATION ..................... 4Programs for AllY for All CampaignDevelopmental AssetsEnriching Curriculum & Core Content

THE FIRST DAY ................................... 5Program HoursSign In/Out Procedures

WHEN SCHOOL IS OUT ........................ 6School’s Out Camp InformationEarly Dismissal / Half Days

Inclement Weather Policy / School DelaysSnow Day Programs

HEALTH & SAFETY .............................. 7Medication PolicySick or Ill ChildrenContagious DiseasesHead LiceOther EmergenciesStaff Relationships with Children Outside YMCA Babysitting PolicySpecial Needs

REGISTRATION & RATE INFORMATION ... 8 Late Pickup PolicyLate Payment Policy

REGISTRATION FORMS ........................ 9

WELCOME!Thank you for allowing us to serve your child in our YMCA Before and After School Youth Enrichment program. We look forward to the year ahead, and hope this information answers your questions. If you need further assistance or wish to speak to one of our YMCA staff team members, please refer to the contact information below. As always, we appreciate your feedback and look forward to getting to know you and your family.

- YMCA of Greater Indianapolis Youth Enrichment Center Staff

4

Get along better with others who are different from him or her.

Do what is right even when other kidswant to do something else.

At YMCA activities, my child has learned that it’s important to help other people.

People in Y activities expect my child to respect others’ feelings and property.

People at the YMCA encourage my child to do well in school.

Parents who were surveyed reported:“YMCA activities have helped my child ...”

98%

96%

98%

98%

97%

NURTURING DEVELOPMENTAL ASSETS

YMCA staff members design our Before and After School Programs to give children the support they need to become successful adults. In addition, the YMCA of Greater Indianapolis collaborates with The Search Institute and an independent research fi rm to receive annual feedback from parents with children in our program. Survey questions focus on The Search Institute’s 40 Developmental Asset model, a nationally regarded tool in assessing the outcome measurement of youth programs and activities.

• 98% of the parents surveyed last year in our before and after school programs rated their child’s experience as excellent or good.

YMCA MISSION: To put Christian principles into practice through programs that build healthy spirit, mind, and body for all.

A LONG-STANDING NOT-FOR-PROFIT• The YMCA of Greater Indianapolis has been serving this

community since 1854, meeting changing community needs for more than 150 years.

• In response to the needs of the community, the YMCA is the largest provider of school age programs in the Greater Indianapolis area and surrounding communities.

Y FOR ALL• At the YMCA, one of our most important goals has always

been to enrich the lives of children in our communities. Children develop self-confi dence, learn values for the future, and grow up stronger and healthier by participat-ing in YMCA programs.

• We believe every child should have the opportunity to be in a before and after school program, regardless of their ability to pay the full rate.

• Your child will have an opportunity to help with service projects to raise funds for this campaign, thus also teaching the importance of helping those in need.

• By contributing to our campaign, you are making an investment in the future. Please consider how you might help with this important project, such as with a direct contribution and through company matching programs.

UNDERSTANDING SPECIAL NEEDS• The YMCA welcomes families and children with special

circumstances. Please see page 7 for more information.

SAFETY FIRST• More than 6,800 school-aged children are entrusted to

our care every day.

• 98% of the parents surveyed last year felt their child was safe in our programs.

• We exceed state standards for staff to child ratio. Our maximum ratio is 1:15 (1:12 for 5 year olds), and we exceed this at most sites.

TRAINED, CARING STAFF• An integral component of the YMCA’s quality

programming is staffi ng. Our staff consists of mature and enthusiastic individuals who help us provide a quality, safe, and enjoyable program. Reference checks are conducted, documented and fi led on all employees working with children. A Criminal history Background Check, mandatory Drug Test, and a TB Test are also required.

• The YMCA of Greater Indianapolis requires all school age program staff to take CPR, First Aid, and Child Abuse Prevention trainings within the fi rst 30 days of employment. Our staff are able to receive over 100 hours of training during their fi rst year.

WHY THE Y IS BETTER

5

ENRICHING CURRICULUMThe YMCA’s national character building campaign pledges to incorporate the values of CARING, HONESTY, RESPECT and RESPONSIBILITY as part of all youth services programming.

Our program provides a resource-rich environment and introduces children to activities that build on what they learned during the school day. YMCA staff implement curriculum in active learning centers, which inherently embodies the common core without duplicating the classroom.

For additional enrichment resources, we utilize After School KidzLit, a literacy program, After School KidzMath and our own National Geographic web site.

OUR CURRICULUM INCLUDES EIGHT CORE CONTENT AREAS:• Arts and Humanities• Character Development• Health, Wellness, and Fitness• Homework Support• Literacy• Science and Technology• Service-learning• Social Competence and Confl ict Resolution

The specifi c activities associated with the core content areasgenerally take place in one or more of the following contexts, each of which is balanced throughout the day or week:

• Free Choice: The child chooses from several activity options, some relatively unstructured and some that are staff-directed learning centers.

• Small Group and Individual: The activities available can be done either in small groups or alone. They may be initiated by the adults with the expectation that all children will work on the activity (e.g., homework or quiet time), or they may be initiated by the children themselves.

• Project Time: Time set aside for children or youth to begin or return to a long-term project needing specifi ed space, materials, tools, or leadership.

• Large Group: Activities designed for large group participation usually under the leadership of a responsible person (e.g., read a book or participate in an active game such as soccer).

• Indoors and Outdoors: As much as possible, and depending on the weather, strive to balance indoor and outdoor activities. We offer a minimum of 45 minutes of physical activity and movement each day.

• Snack: In support of a healthy environment for your child, a nutritious snack, planned to meet a child’s nutritional requirements, is served each day. The snacks we provide have no trans fats. Water, 100% juice and milk are offered as the primary drinks. Fresh vegetables and fruits are available. If your child has any allergies or requires a special diet, please make your Site Director aware of this.

THE FIRST DAYPROGRAM HOURSMorning: 6:30 am* until school begins Afternoon: School dismissal until 6:00 pm

(*Morning opening times may vary by school district. Please call your local YMCA Youth Enrichment offi ce for information.)

SIGN IN/OUT PROCEDURESIf you are new to our program, please allow a fewextra minutes at drop off and pick up times. You will be greeted by a staff member in a YMCA staff shirt and name tag. Upon arrival, the staff will share the sign in and out process and answer any questions you might have.

For the safety of your child, the staff cannot accept orrelease any child before he/she has been signed in or outby an adult (18 years old or older).

Morning Program – For safety reasons, you must accompanyyour child into the program and sign them in on the dailyattendance sheet.

Afternoon Program/Sign-out Procedures – It’s important to send a note for your child’s teacher on the fi rst day. They will help make sure your child is sent to the program. Please instruct your child to go immediately to the program locationto sign in, even if they are involved in another activity (scouts, assisting the teacher, choir, etc.). Children will be signed in by a YMCA staff person.

If your child will be absent from the program, please call our offi ce or, if applicable, your Site Director. If your child does not report to the program and we are expecting him/her (registration received and weekly payment made), we will check with the school offi ce to determine if your child was at school that day. If so, we will contact you immediately.

If you have not made advanced payments and need to make arrangements for attendance, please contact our offi ce prior to Your child’s next day of attendance so we can expect him/her to arrive to the program.

6

EARLY RELEASE & SCHOOL’S OUT DAYSSince parent’s work schedules do not always match children’s school days off, continuous care is offered during these breaks (minimum enrollment required) at several YMCA and school locations. You may attend any YMCA location you choose and any school-age child is welcome to attend. More information is available at your site. Our full day rates are: $36 per day/$134 per week for YMCA facility members, and $41 per day/$169 per week for all others.

TYPICAL SCHOOL’S OUT CAMPS: • Fall Break• Winter Break• Martin Luther King Day• Presidents Day• Spring Break• Flex Day Schedule*Balanced Calendar Schools Intercession Programs will be offered.

YMCA HOLIDAY CLOSINGS:• Labor Day• Thanksgiving Day and the day after• Christmas Day• New Years Day• Memorial Day

EARLY DISMISSAL / HALF DAYSDuring the school year, there may be several early dismissal or half days. On these days, the after school program will be available at your child’s school from the time of dismissal until 6:00 p.m. If your child is an afternoon participant, there are no extra fees for these days. If your child attends before school only and you wish to use this service on these days, you may register for the 1-2 day weekly rate.

INCLEMENT WEATHER POLICY / SCHOOL DELAYSIf the start of school is delayed, the YMCA staff will make every effort to be at your child’s school by the designated start time. On these days, the staff will stay until school begins. If your child is a morning participant, there are no extra fees for these days. If your child attends after school only and you wish to use this service, you may register for the 1-2 day weekly rate on these days.

If school is cancelled during a morning delay, our program will move to a designated YMCA Center or we will provide care at the school location (with school’s permission) until 6:00 pm. If the program is not remaining at the school site, parents will be called to pick their child up and then be given the option to transport them to the designated YMCA location.

If school is released early due to inclement weather and it is after 1:00 pm the Y will provide staff on site until parents are able to pick up. We encourage all parents to pick as soon as possible to ensure the safety of children and staff team members. If the school calls for early release any time before 1:00 pm, there will be no Y service provided.

SNOW DAY PROGRAMSIf school is closed prior to 6:30 a.m. due to inclement weather, a program will be held at center locations and other predetermined school sites. More specifi c information for the Snow Day Program will be available through your Site Director. If your child participates, please send a sack lunch with beverage. Our full day rates are: $36 per day for YMCA Members and $41 per day for All Others.

7

HEATH & SAFETYMEDICATION POLICYAny medication given to your child at the program site must be in its original container with your child’s name on it. A medication release Form must be completed and signed with the following information:

1. Child’s name2. Type of medication3. Physician’s name4. Amount of dosage to be given5. Time to be given6. Number of days to be administered7. Possible side effects

Please note, YMCA staff are not permitted to give the fi rst dosage of any medication. Staff may dispense only pre-scription medication. If your child refuses medication, we will contact you for further instructions.

SICK OR ILL CHILDRENIf your child is ill and will not attend the program, please contact the Before and After School Program offi ce (see page 3 for phone numbers) and your Site Director.

Any child displaying or developing symptoms such as a fever, rash, diarrhea or vomiting will be removed from the group and comforted. We will ask you to make arrange-ments to pick up your child as quickly as possible. Weather permitting, all children will have a chance to play outside. Due to our ratios, if your child is unable to be outside due to illness, we may not be able to accommodate this request.

CONTAGIOUS DISEASESIf your child has a confi rmed case of a contagious disease, he/she must be kept at home. Please contact the YMCA offi ce regarding the illness so a general notice (all names will be kept confi dential) can be posted at the program location. At the discretion of the Program Director, we may ask you to submit a doctor’s statement prior to your child returning to the site. The following conditions are categorized as “highly contagious”:

• Strep Throat • Scarlet Fever• Measles • Pinworms• Mumps • Viral Infections• Chicken Pox • impetigo• Diarrhea • Head Lice

HEAD LICEIf head lice are detected while your child is attending our program, we ask that you pick them up immediately. A child with head lice is allowed to return to the program after treatment. Evidence of treatment includes no lice or nits, clean hair and scalp, and a note from you or a physician stating the treatment used.

ACCIDENTS AND INJURIESThe health and safety of the children in our care is our top priority. Even with watchful eyes, young children are often testing their physical limits making injuries inevitable. With minor accidents, YMCA staff will verbally inform you at pick up time. In the event of a medical emergency or accident requiring a doctor’s treatment, we will contact you immediately. If we cannot make contact with a parent, emergency medical personnel will take the child to the emergency room via ambulance. At all times, there will be a YMCA staff person on site who is trained in First Aid and CPR.

OTHER EMERGENCIESIn the event of a fi re, tornado, natural disaster or other related emergency situations, our YMCA staff will follow the school system or YMCA Center established plans.

STAFF RELATIONSHIPS WITH CHILDREN OUTSIDE THE YMCA SETTINGStaff members are not allowed to be alone with children they meet in YMCA programs outside the YMCA program setting. This includes babysitting, sleepovers, and inviting staff members to children’s homes. Exceptions may be made, only if one or both of the following conditions exists:

1. Staff and child’s family have a relationship that predates the staff member’s employment or child’s enrollment in the YMCA program.

2. Staff and the child’s family are related.

If you observe any infractions of this policy, please contact our offi ce immediately.

SPECIAL NEEDSThe YMCA welcomes families and children with special circumstances. We request you schedule an individual meeting with your Program Director to develop the best plan for your child. We will then be able to determine together what accommodations your child may need to be successful in our program.

8

MORE VALUE FOR YOUR DOLLARYOUTH ENRICHMENT PROGRAM RATES

MANY SITES ACCEPT CCDF VOUCHERS.• For special circumstances, our team of account specialists can arrange other payment options. For more information, call:

• For Youth Enrichment North & East: 317.577.2070 or 1.866.577.2070• For Youth Enrichment South: 317.887.8788• For Youth Enrichment West & Central: 317.484.9622

LATE PAYMENT POLICY: • If paying weekly, payment must be made by end of day the Friday prior to the week your child attends the Y program.

If paying monthly, this payment must be made by the end of day on the 1st of each month. Late Payment Fees of $10 per child will be assessed if the progam payment deadlines are missed.

LATE PICK-UP POLICY: • In order to be respectful of our staff and their family time, parents who arrive past the 6:10 p.m. “grace period” will be

assessed a late fee of $1.00 per minute per child. • For consistency, the program will use the clock at the site for time reference. • Any late fees assessed must be included in your next payment, and repeated failures to pay this amount may result in

removal from the program. After three (3) late arrivals, we will ask that you make other arrangements. • If a child has not been picked up by 7:00 p.m. and no authorized contact person has been reached, the staff will follow

the YMCA safety policy and procedures and contact the local police.

REGISTER NOW – Several of our programs fi ll quickly!1. Please visit our website at www.OurCauseIsYou.org for a registration form for your school district.

2. Mail your form and program registration fee (no fee for YMCA Members) to your YMCA of Greater Indianapolis Center:

• For North & East: Youth Enrichment North Offi ce - 9093 Technology Drive, Suite 101 • Fishers, IN 46038

• For South: Youth Enrichment South Offi ce - 7800 S. Shelby Street, Suite 100 • Indianapolis, IN 46227

• For West & Central: Youth Enrichment West Offi ce - 7811 W. Morris Street • Indianapolis, IN 46231

3. You may also drop your form and registration fee off at any of our local YMCA Centers.

PROGRAM OFFERINGS:• Before Care (AM ) Only * After Care (PM) Only * Both Before & After Care • Attending 1-2 Days/week (paying weekly or monthly) * Attending 3-5 Days/Weekly (paying weekly or monthly)• Special School’s Out Days & Snow Days

PLEASE CALL FOR YOUR RATE:• Due to the contributions from our generous donors, the YMCA Youth Enrichment Center is able to offer a sliding fee scale.• Please contact your YMCA Youth Enrichment Center account specialist for your personal rate. • Account specialists are available 8:30 a.m. to 5:30 p.m. • Individual School information may also be found on our web site at www.indymca.org/classes-programs

PLEASE NOTE: • Fees for Snow Days and School’s Out Days are in addition to regular before & after care fees.• Early Release and School Delays are included in regular before & after care fees. • Program offerings may vary by school and could be subject to change. Please contact your YMCA Youth Enrichment

Offi ce for up-to-date information.

9

2013-2014 BEFORE & AFTER REGISTRATION FORM YMCA YOUTH ENRICHMENT

For Offi ce Use Only:

Payment Information Faxed Entered in Computer BAS Site Copied Called BAS Director On Rosters Emailed CCDF G Form MFA ________________

PROGRAM START DATE: ____________________________________Please print legibly and include all information. Use additional forms for more children as needed.

CHILD 1: Check here if your child attended last year

(Y Offi ce use only: Unity ID: __________________________________________)

First _________________________ Middle ________ Last _________________________

Birthdate______ /______ /______ Gender M F Age_______

Race __________________ School Attending ________________________________

Grade in Fall_______

Attendance: 1-2 Days/week 3-5 Days/week

Program: Before-School After-School Before & After-School School’s Out Camp

PARENT/GUARDIAN INFORMATION

1.Guardian Name: ________________________________________________________

Relationship:_________________________D.O.B (required) :____/____/_____

Mailing Address: ________________________________________________________

City: __________________________________________ St:________ Zip:_____________

Primary Phone: ________________________________________ C W H

Alternate Phone: _____________________________________ C W H

Place of Employment: _________________________________________________

E-Mail Address: ________________________________________________________

2.Guardian Name: ________________________________________________________

Relationship:_________________________D.O.B (required) :____/____/_____

Mailing Address: ________________________________________________________

City: __________________________________________ St:________ Zip:_____________

Primary Phone: ________________________________________ C W H

Alternate Phone: _____________________________________ C W H

Place of Employment: _________________________________________________

E-Mail Address: _________________________________________________________

CHILD PICK-UP INFORMATIONParent/guardian(s) listed at left are authorized to pick up child(ren), unless otherwise noted. You may also authorize the people named below to pick up your child(ren). For your child’s safety, he/she will be released ONLY to those listed on this page. All authorized persons must be 18 years of age or older and have a photo ID. Changes to this list must be made in writing and may only be done by the parent or legal guardian whose signature appears on this registration form.

1. Name: ___________________________________________________________________

Address: ________________________________________________________________

Primary Phone: ________________________________________ C W H

Alternate Phone: _____________________________________ C W H

Relationship:________________________________________________________

2. Name: ___________________________________________________________________

Address: ________________________________________________________________

Primary Phone: ________________________________________ C W H

Alternate Phone: _____________________________________ C W H

Relationship:________________________________________________________

3. Name: ___________________________________________________________________

Address: ________________________________________________________________

Primary Phone: ________________________________________ C W H

Alternate Phone: _____________________________________ C W H

Relationship:________________________________________________________

CHILD 2: Check here if your child attended last year

(Y Offi ce use only: Unity ID: __________________________________________)

First _________________________ Middle ________ Last _________________________

Birthdate______ /______ /______ Gender M F Age_______

Race __________________ School Attending ________________________________

Grade in Fall_______

Attendance: 1-2 Days/week 3-5 Days/week

Program: Before-School After-School Before & After-School School’s Out Camp

10

PARENT/GUARDIAN AUTHORIZATION & SIGNATURE

HEALTH INFORMATION - CHILD 1Check all that apply, giving approximate dates, where applicable.CHILD 1 NAME:______________________________________________________________Family Physician: ___________________________________________________________

Phone:_____________________________ Date of last physical exam:_________

Insurance Carrier: _______________________ Policy # ______________________

ADD/ADHD Autism Asthma Convulsions Heart Defect/Disease Bleeding/Clotting Disorders Diabetes Frequent Ear Infection Hypertension

DISEASES** German Measles Mumps Chicken Pox

ALLERGIES** Food Medicine Poison Ivy, Etc. Insect Stings

______________________________________________________ ______________________________________________________ _____________________________ Signature of Parent or Legal Guardian Print Name Date

PROMOTION AGREEMENT (INITIAL ONLY TO OPT OUT): The YMCA staff may take photographs during programs and post pictures on the web or use them in brochures or other Y materials. Please initial below if the Y does NOT have your permission to use photographs of your child(ren) in this manner. ________(initial) Child(ren)’s Name(s): ___________________________

TRANSPORTATION AGREEMENT: Your child may be using bus transportation provided by the Y through the local schools. This might be for an afternoon swim, fi eld trips, or for trans-portation to and from the site. By my signature below, I give permission for my child to travel by bus with the YMCA staff. I understand that only licensed and qualifi ed personnel will operate any vehicle to and from the site, and that there will be at least one staff member present at all times. I agree to release the Young Men’s Christian Association of Greater Indianapolis, its offi cers and directors, and the YMCA staff from any and all claims of damages, demands or liabilities which may arise as a result of my child’s participation on these bus trips.

EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel selected by the YMCA staff to order X-rays, routine tests and treatment for me or my child, and, in the event I am not able to communicate or cannot be reached in an emergency, I hereby give permission to the physician selected by the YMCA Director to hospitalize, secure proper treatment for, and order injection(s) and/or anesthesia and/or surgery for me or my child. I will be fully responsible for any costs of such treatment, even if not covered by insurance.

PARENT AUTHORIZATION: I hereby do declare my child to be physically sound, having medical approval to participate in the activities of the YMCA. This information is correct so far as I know, and the person herein described has permission to engage in all prescribed program activities except as noted. I certify that my child is amenable to behavior management and free from habits or attitudes which would make him/her unable to appropriately participate. I have studied the brochure and fees and understand the contents thereof.

In consideration of my child’s participation in the activities of the Young Men’s Christian Association of Greater Indianapo-lis (YMCA), I do hereby agree to hold free from any and all liability the YMCA and its respective offi cers, employees and members and do hereby for myself, my heirs, executors and administrators, waive, release and forever discharge any and all rights and claims for damages which I may have or which may hereinafter accrue to me arising out of or connected with my child’s participation in any of the activities of the YMCA. I certify that I am the parent or legal guardian of this child and I have the legal authority to make the representations and grant the authorizations contained herein.

I understand the YMCA of Greater Indianapolis does not allow YMCA employees to provide care to enrolled children outside of the approved YMCA activities. This would include babysit-ting, outings or trips. I understand that all YMCA staff have been informed of this policy and have signed a statement in agreement with the policy.

Tetanus Innoc.* Date: ________________ *If no date is given, the Y will have a tetanus shot administered in case of emergency.

Child is up-to-date with all immunizations needed for school.

**Details of above: _______________________________________________________Current medications (send prescription in original bottle): __________________________________________________________________________Operations or serious injuries; Disability due to chronic or recurring illness; Any specifi c activities to be encouraged or limited by physician’s advice or Special needs (physical, mentalor psychological) for staff awareness: _________________________________

HEALTH INFORMATION - CHILD 2Check all that apply, giving approximate dates, where applicable.CHILD 2 NAME:______________________________________________________________Family Physician: ___________________________________________________________

Phone:_____________________________ Date of last physical exam:_________

Insurance Carrier: _______________________ Policy # ______________________

ADD/ADHD Autism Asthma Convulsions Heart Defect/Disease Bleeding/Clotting Disorders Diabetes Frequent Ear Infection Hypertension

DISEASES** German Measles Mumps Chicken Pox

ALLERGIES** Food Medicine Poison Ivy, Etc. Insect Stings

Tetanus Innoc.* Date: ________________ *If no date is given, the Y will have a tetanus shot administered in case of emergency.

Child is up-to-date with all immunizations needed for school.

**Details of above: _______________________________________________________Current medications (send prescription in original bottle): __________________________________________________________________________Operations or serious injuries; Disability due to chronic or recurring illness; Any specifi c activities to be encouraged or limited by physician’s advice or Special needs (physical, mentalor psychological) for staff awareness: _________________________________

11

Return your registration form (and Program Registration Fee – $30 per child or $50 per household, unless a YMCA member):

• For North & East: Youth Enrichment North Offi ce - 317.577.2070 • 9093 Technology Dr., Ste. 101 • Fishers, IN 46038

• For South: Youth Enrichment South Offi ce - 317.887.8788 • 7800 S. Shelby St., Ste. 100 • Indianapolis, IN 46227

• For West & Central: Youth Enrichment West Offi ce - 317.484.9622 • 7811 W. Morris St. • Indianapolis, IN 46231

The Parent or Legal Guardian listed below is responsible for the payment of fees. The YMCA offi ce must approve any changes to this plan. Please Note: A Before School Program is not offered at all schools. Please contact a YMCA offi ce listed above for up-to-date information.

The YMCA is unique because your membership rates and programs fees are based on total household income. The YMCA is able to offer this sliding fee scale thanks to the generous donors whose contributions enable us to live our mission of being open

and accessible to all. Please call a YMCA offi ce listed above if you would like more information.

Household Income (Optional): < $15,000 $15,001-$25,000 $25,001-$35,000 $35,001-$45,000 $45,001-$55,000 $55,001+

Please Check (If Applicable): We have a YMCA of Greater Indianapolis family or youth membership. Child is a dependent of a YMCA of Greater Indianapolis Staff Member. Child is a dependent of a School Employee. List School where employed: ______________________________________________

PROGRAM OFFERINGS:• Before Care (AM ) Only * After Care (PM) Only * Both Before & After Care • Attending 1-2 Days/week (paying weekly or monthly) * Attending 3-5 Days/Weekly (paying weekly or monthly)• Special School’s Out Days & Snow Days

PLEASE CALL FOR YOUR RATE:• Due to the contributions from our generous donors, the YMCA Youth Enrichment Center is able to offer a sliding fee scale.• Please contact your YMCA Youth Enrichment Center account specialist for your personal rate. • Account specialists are available 8:30 a.m. to 5:30 p.m. • Individual School information may also be found on our web site at www.indymca.org/classes-programs

PLEASE NOTE: • Early Release and School Delays are included in regular before & after care fees. • Fees for Snow Days and School’s Out Days are in addition to regular before & after care fees.• Program offerings may vary by school and could be subject to change. Please contact your YMCA Youth Enrichment

Offi ce for up-to-date information. • Late Pick-Up Fees will be assessed after the 6:10 p.m. “grace period” at $1.00 per minute per child. (Refer to Policy.)• Late Payment Fees of $10 per child will be assessed if the progam payment deadlines are missed. (Refer to Policy.)

PAYMENT METHODS - Please Check: Mail in or drop off payment with payment coupons (available for all payment options at your local YMCA Center) Monthly Bank Draft * Monthly Credit Card Draft * Weekly Credit Card Draft * Online Payments CCDF (approved voucher required) prior to program participation.) **

* No payments are permitted at the school site. * Additional forms must be completed for these plans. * Weekly payments are due the Friday prior to your child attending the program.**CCDF participants may have to pay copay or over market rate.

I certify that I am the parent or legal guardian of this child and I have the legal authority to make the representations and grant the authorizations contained herein.

PAYMENT INFORMATION

_____________________________________________________ _____________________________________________________ _____________________________________________________ Signature of Parent or Legal Guardian Print Name Date

NONPROFIT ORGU.S. POSTAGE

PAIDINDIANAPOLIS, INPERMIT NO. 3204

THE YMCA OF GREATER INDIANAPOLIS615 N. Alabama Street, Ste. 200Indianapolis, IN 46204