KKiiddss QQuueesstt SSuummmmeerr CCaammpp EEnnrroollllmmeenntt PPaacckkeett 22001155

YWCA Northeast Kansas 225 SW 12th St

Topeka, KS 66612

Kids Quest Summer Camp provides a safe, secure, positive and nurturing environment for

children grades K-8th. In our program children can grow, discover, build confidence, enrich education and form friendships.

Our program features indoor and outdoor activities including;

Swimming STEM Projects

Planting, growing, and maintaining a garden Economics lessons including a KQ Farmer’s Market

Weekly Field Trips Breakfast, Hot Lunch, and Afternoon Snack

The YWCA youth program will be held beginning June 1 – August 7, 2014. We will not have Summer Camp on Friday, July 3rd in celebration of Independence Day.

Full pay tuition cost is $100 per week with a one-time $60 activity fee. Financial assistance

may be available if you qualify. If your child is not currently enrolled in a YWCA Kids Quest school year program, there is a $20 enrollment fee to be paid at the time of

application.

All activity fees and the first week of tuition are due along with this completed application packet prior to the first day your child attends Summer Camp. Enrollment is final once confirmed by the KQ

Supervisor.

ffoorr qquueessttiioonnss oorr mmoorree iinnffoorrmmaattiioonn pplleeaassee ccoonnttaacctt

KKiiddss QQuueesstt SSuuppeerrvviissoorr 778855--223333--11775500 xx 334477 llaauurreennjj@@yywwccaanneekkss..oorrgg

YWCA Summer Camp Policy Guidelines

Registration

• Registration: If your child(ren) is not currently enrolled for the 2014-2015 school year, a $20 enrollment fee for one child, $35 for two or more children is due with enrollment application.

• One time $60 Activity Fee Payment Discounts & Billing Procedures

• YWCA Kids Quest Summer Camp is a PRE-PAY program. • Invoices will be generated on a bi-weekly basis beginning May 15th. Payment is due the first

day of the bi-weekly cycle beginning June 1st . All late pickup fees will be added to the next bi-weekly billing cycle.

• A 10% Multi-Child Discount will be applied for 2nd and each additional children in a family, • A 10% Discount will be provided if the entire summer (all enrolled weeks) are paid in full

by May 25th, 2015. • Any current Kids Quest family that refers a new family(never enrolled in KQ or summer

camp) will be eligible for a $100 credit to their account if that family enrolls their child/children in the summer camp program. (The referring family must be noted on the new child’s application in order to be eligible.)

• A 25% discount will be provided for current YWCA employees (In place of other payment/enrollment discounts listed above).

• A $10/week discount will applied for any students with one or more parent currently employed in the downtown Topeka area.(Between Tyler St. to Jefferson St./ 3rd St. to 13th St.) (In place of other payment/enrollment discounts listed above)

• Cash and Checks will be accepted at the YWCA main location. Cash payment will only be accepted with a receipt given by a YWCA employee at the main location. No cash shall be placed in the drop boxes.

• Checks should be made out to YWCA Kids Quest with notation of the child covered by payment. • Checks can be mailed to the following address (please do not mail cash):

YWCA Northeast Kansas ATTN: Summer Youth Program Payments

225 SW 12th Street Topeka, KS 66612

• Credit Card payments can be made at the YWCA front desk or by clicking on the “Pay My Bill” link attached to your current invoice. No credit card payments should be made through the website.

• Vision payments are to be made by calling the “800” number on the back of the card. The Provider ID number is: C883496

• Suspensions will occur if payments have not been received. Payments that are not made for Summer Youth Programs and are outstanding for more than two weeks will be suspended from the program until payments have been made.

o This does not apply to payments made by assistance programs other than DCF. • Enrollment and activity fees are non-refundable. • Any tuition that has been made in advance is non-refundable unless proper notice to the

program has been given. • Prearrangements concerning payment may be discussed in advance and require approval from

finance. You may contact the YWCA Kids Quest Clerk at 785-233-1750 x 217.

Pick-Up & Late Fee

• All children must be picked up by 5:30pm to avoid penalty fees. If your child(ren) are not picked up by the designated time you will be assessed the late charge of $1 per minute per child.

• Failure to pay this fee or recurrence of late pick-up will be treated in the same manner as negligent accounts and may warrant suspension or program termination.

• The names you provide on this application are the ONLY adults that will be allowed to pick-up your child from the Kids Quest Program unless prior arrangements are made and confirmed in writing.

• Anyone picking up your child(ren) must be at least 18 years of age with valid identification Cancellation & Status Change

• TWO WEEK WRITTEN NOTICE must be provided in order to withdraw from the program. Notices must be submitted to the Kids Quest Supervisor prior to program cancellation for approval. Payments are due during the two week written notice period.

• Any change or alteration of program attendance hours requires written notice. • Failure to provide proper notice will result in continued fees until notification is received and

authorized by the Kids Quest Supervisor. • Children are accepted in the YWCA programs without regard to race, color, religion, economic

background, or national origin. • Kids Quest is a licensed school aged care program by the Kansas Department of Health and

Environment and the Child and Adult Care Food Program. Parents/guardians are always welcome to visit sites and participate in activities.

Meals • We will provide a hot lunch, breakfast and afternoon snack every day. If your child is allergic

to specific foods or you have concerns regarding snack time please disclose any allergies in this application and notify the Supervisor.

• In order to receive breakfast, your child must be present at 8:00am. Breakfast is made and served at 8:15am for those students. If your child is dropped off after 8:00am, feel free to bring breakfast in from home. Breakfast ends promptly at 8:45am. Students will not be allowed to bring in breakfast after 8:45am.

Questions or further information please contact Kids Quest Supervisor

at 785-233-1750 x 347 laurenj@ywcaneks.org

YYWWCCAA SSuummmmeerr CCaammpp AApppplliiccaattiioonn 22001155

Application must be complete and approved before your child can attend the summer Youth Program (Kids Quest Summer Camp). Return this application to the YWCA with non-refundable enrollment fees and the first week tuition. (Current 2014-2015 KQ students not required to pay enrollment fee) The Summer Youth Program will be held at the YWCA, located at 225 SW12th St, Topeka, KS 66612 All families will be allowed two weeks of their choosing to take leave from Summer Camp. If you choose to take up to two weeks of leave, your child will not attend during those weeks and your account will not be billed. (You are not required to take any leave from the program. If you chose to take off more than two weeks, any weeks past the first two full weeks of leave will be billed as normal regardless of days attended.) Leave dates must be specified on application and Financial Agreement at time of enrollment. child’s full name grade age sex date of birth parent/guardian name home phone cell phone email residential address zip parent social security number date of birth parent driver’s license number place of employment occupation business address phone ext best method of contact parent/guardian name home phone cell phone email residential address zip parent social security number date of birth parent driver’s license number

(APPLICATION CONTINUES ON NEXT PAGE)

place of employment occupation business address phone ext best method of contact child resides with: both parents mother father other (please specify) eemmeerrggeennccyy ccoonnttaaccttss authorized to pick-up your child(ren): provide aatt lleeaasstt 22 contacts, ootthheerr tthhaann ppaarreennttss, who reside in the Topeka area. name relationship to child address: zip primary phone secondary e-mail name relationship to child address: zip primary phone secondary e-mail name relationship to child address: zip primary phone secondary e-mail CHILDREN ARE ACCEPTED IN YWCA PROGRAMS WITHOUT REGARD TO RACE, COLOR, RELIGION, ECONOMIC BACKGROUND OR NATIONAL ORIGIN. To file a complaint of discrimination, write USDA Director, Office of Adjudication, 1400 independence Avenue, S.W., Washington D.C. 20250-9410 or call (866)632-9992 (voice). Individuals who are hearing impaired or have speck disabilities may contact USDA through Federal Relay service (800)877-339 or (800)845-6136 (Spanish). USDA is an Equal opportunity employer.

Member Agency United Way of Greater Topeka

FFiinnaanncciiaall AAggrreeeemmeenntt::

TTeerrmmss aanndd ccoonnddiittiioonnss for YWCA SSuummmmeerr YYoouutthh PPrrooggrraamm 22001144--22001155

Registration: $20 one-time, non-refundable fee per child, $35 for two or more children per family. My child is already enrolled in Kids Quest for the 2014-2015 school year. Weekly Rates: $100 per child (+one time $60 activity fee) Financial assistance is available if you qualify. 1st week tuition is due on or before 1st day of attendance

Girls On The Run Enrichment Program (completed 3rd-6th grade girls only): 2 sessions/week (90 min each) and GOTR T-shirt. $10/week YES, I would like to enroll my daughter in the Girls on the Run enrichment program this summer. Discounts: Entire summer tuition paid in full by May 25, 2015 will receive a 10% discount. 10% Multi-child discounts given to the 2nd and each additional child in a family. Late Pick Up Charge: $1 per minute per child past 5:30p.m. Agreement: I desire to enroll my child, , in the YWCA Kids Quest Summer Camp between June 1st and August 7th, 2015 at the YWCA, 225 SW 12th, Topeka, KS 66612. Please indicate leave weeks (up to two if desired) child will NOT attend: ______ June 1st-5th ______June 8th – 12th ______June 15th – 19th ______June 22nd – 26th ______June 29th – July 2nd _______July 6th-10th ______July 13th – 17th _______July 20th – 24th ______June 27th – 31st _______Aug 3rd – 7th

Anticipated AM Arrival Time: PM Pick up Time:

Notice: All children’s files and records are kept completely confidential and will not be shared with anyone except parent or guardian. Termination: A written two-week notice is required for termination and/or change in services provided. Tuition will be charged two weeks after written notice of termination is received. This notice must be given to the Kids Quest Clerk. Tuition Agreement: I agree to pay the weekly tuition for June 1st – Aug 7th unless otherwise specified above. I understand fees are based upon five days per week with no partial weekly rates. I understand that all weekly rates are $100/week unless I qualify for financial assistance. I understand that the full weekly rate must be paid unless otherwise specified. I understand the YWCA Summer Camp Youth Program is a pre-pay program. I understand if I fail to pay my tuition and my account balance, this may result in my child’s suspension from care. Negligent accounts may result in immediate suspension or program termination, to be evaluated by the YWCA finance department and Kids Quest Supervisor. DCF/KVC Families: Any charges not covered by DCF, KVC, or any other assistance agency will be the responsibility of the parent/guardian. I agree to pay any late pick up fees. I understand that there will be no credits issued for absences due to illness or other causes. I assume personal and individual responsibility for all charges. I have read, understand and agree to these terms and conditions. Signature of Responsible Party Date

STATISTICAL INFORMATION

The Greater Topeka United Way, City of Topeka, our YWCA regional office, and other organizations that provide operating funds for this program, require that certain statistics be kept. These statistics help us justify the need for this program to those who would support it. Please complete the section

below. This information is kept confidential.

please circle: AGE PROFILE: 3-5 years old 5-7 years old 8-10 years old 11-12 years old 13-15 years old 16 and over GENDER PROFILE: Female Male RACIAL PROFILE: White Black Hispanic/Mexican Asian Bi-Racial Native American Other (please indicate) _______________________________ INCOME PROFILE: At Poverty Level Below Poverty Level All Others *Poverty Level is defined as: $12,492 for a family of 2; $15,672 for a family of 3; $18,852 for a family of 4.

CCL 010 Kansas Department of Health and Environment Rev. 8/2013 Bureau of Family Health 1000 SW Jackson, Suite 200 Topeka, KS 66612-1274 Child Care Program: (785) 296 -1270 Fax: (785) 296 -0803 Foster Care Program: (785) 296 -1270 Fax: (785) 296 -7025 Website: www.kdheks.gov/kidsnet

AUTHORIZATION FOR EMERGENCY MEDICAL CARE Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-582(e)(2).

Name of facility exactly as stated on the license.

License #

I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or ____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________ ___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s custody between the dates of ___________________________ and ____________________________. MM/DD/YYYY MM/DD/YYYY

Signature of Parent or Guardian Date Signed

Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic. Date Signed

Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.

State of Kansas County of ________________________

Signed or attested before me on ____________________ by______________________________________________. MM/DD/YYYY Name of Person (Seal, if any.) _______________________________________________ Signature of notarial officer

______________________________________________ Title (and Rank) My appointment expires: __________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency: Is child covered by health insurance? Yes No If yes, complete the following: Health Insurance Policy Name _________________________________________ Policy Number ______________________ Medical Assistance Program ____________________________________________ Card Number________________________ Military Medical Care I.D. Number ___________________________________________________________________________ If known, date of last Tetanus inoculation: __________________________________

THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST ALSO BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.

CCL. 358 Kansas Department of Health and Environment Rev. 1/2014 Bureau of Family Health Child Care Licensing Program

1000 SW Jackson, Suite 200 Topeka, KS 66612-1274

Phone: (785) 296-1270 Fax (785) 296-0803 Website: www.kdheks.gov/kidsnet

HEALTH HISTORY FOR CHILDREN AND YOUTH ATTENDING SCHOOL AGE PROGRAMS As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the department or approved by the secretary. Each health history is to be maintained in the child’s or youth’s file on the premises. As required by K.A.R. 28-4-590(d)(2), each operator shall require that each child or youth attending the program has current immunizations as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons. Complete one form for each child or youth attending the School Age Program. First and Last Name of the Child or Youth

Gender (M or F)

Date of Birth (MM/DD/YYYY)

First day at this program: (MM/DD/YYYY)

First and Last Name of the Child’s or Youth’s Mother or Guardian

Mother/Guardian’s Home Street Address

City Zip Code Home Phone #( )

Mother/Guardian’s Work Place Name & Street Address

City Zip Code Work Phone #( )

First and Last Name of the Child’s or Youth’s Father or Guardian

Father/Guardian’s Home Street Address City Zip Code Home Phone #

( ) Father/Guardian’s Work Place Name & Street Address

City Zip Code Work Phone #

( ) Names and ages of other children in the Child or Youth’s Family (Attach additional page if needed.)

Person(s) authorized to pick up the Child or Youth in case of emergency. Include first and last name and Street Address. Attach additional page if needed. 1.

City Zip Code Phone Number (during program hours):

2.

3.

First and Last Name of Physician & Street Address City Zip Code Phone Number

( ) Name of Hospital Preference in case of emergency.

Yes No N/A Complete the following information about medications for this child or youth.

Will this child or youth need to take any nonprescription or prescription medication during their time at the program?

If yes above, is there signed permission on file?

Circle any of the following conditions or difficulties that affect this child or youth.

Allergies Frequent sore throats/ colds Ear Infections or Aches Heart or Lung Conditions

Skin Problems Asthma Headaches Diabetes

Vision Speech/Communication Hearing Emotion/Behavior

Other: Please describe.

If you circled any of the above conditions, please provide additional information that will help the staff members meet the child’s or youth’s needs while attending the program. (Attach additional page, if needed.)

Provide additional information about your child or youth that might affect him/her while at the School Age Program including any special needs, restrictions to activities, major changes at home or special instructions. (Attach additional page, if needed.

Complete the following information about this child’s or youth’s immunization status. Yes No

Did this child or youth attend a public or accredited non-public school in Kansas, Missouri or Oklahoma the previous year?

If yes, are this child’s or youth’s immunizations current?

If yes to both of these questions, you do NOT need to complete the immunization history below. If no to either of the above questions, you must complete the immunization history below for this child or youth or attach a copy of the child’s or youth’s immunization history.

Please give dates in the space below for ALL immunization series completed by this child or youth. Record MM/DD/YYYY.

1 2 3 4 5

DPT, DT*, TD (*DT only if child is allergic to DTP) / / / / / / / / / /

POLIO / / / / / / / /

MMR / / / /

Single

Dose

Only

RUBEOLA (MEASLES) / / / /

MUMPS / / / /

RUBELLA (GERMAN MEASLES) / / / /

HIB (Hemophilus Influ. B) *RECOMMENDED / / / / / / / /

HBV (Hepatitis B Vaccine) *RECOMMENDED / / / / / /

VAR (Varicella-Chicken Pox) *RECOMMENDED / /

Print the First and Last Name of the Person Completing this Health History form

Relationship to the Child/Youth

Date Completed

If the Health History form was completed by a person other than a Parent/Guardian, who provided you with this information?

What is that person’s relationship to the child/youth?

I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct.

Signature of person completing this form Date Signed

Dear Parent or Guardian:

Our center has been approved for participation in the Child and Adult Care Food Program (CACFP). The CACFP reimburses the center for the partial cost of meals. Participation in the CACFP enables us to keep our fees lower as well as serve nutritious meals to children in our program.

The parent/guardian must complete Parts 1 and 4 and one of the following options: Part 2, Part 3A or Part 3B, to determine the amount of CACFP funds the center will be eligible to receive. This form will be placed in our files and treated as confidential information. Note: no white out or erasure should be used. If there is an error cross through, correct, and initial. Part 1 FOR CHILD ENROLLMENT: CHILD’S NAME: List the first and last name of all children enrolled at this center.

DATE OF BIRTH: List each child’s date of birth.

TIMES OF CARE, DAYS OF CARE and MEALS SERVED: List the regular times of care for each child by listing their arrival time and leave time, check each day the child will be in care and check each meal type received while in care.

ETHNICITY/RACE: Using the codes provided, enter the codes for ethnicity and race.

FOSTER CHILD: If the child is a foster child (the legal responsibility of a foster care agency or the court), please check the box. Part 2 FOR A HOUSEHOLD RECEIVING BENEFITS FROM THE FOOD ASSISTANCE PROGRAM (FAP), TEMPORARY ASSISTANCE FOR FAMILIES (TAF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR): Complete Parts 1, 2 and 4 on the reverse side.

Provide the name and case number for the program from which benefits are received.

Part 3A FOR A HOUSEHOLD EXCEEDING THE INCOME GUIDELINES LISTED ON THE CHART BELOW: Complete Parts 1, 3A and 4 on the reverse side.

TO CALCULATE ANNUAL INCOME

Weekly Income X 52 Every 2 Weeks Income X 26 Twice a Month Income X 24 Monthly Income X 12

Part 3B FOR ALL OTHER HOUSEHOLDS: Complete Parts 1, 3B and 4 on the reverse side using the additional information below.

HOUSEHOLD NAMES: Write the names of everyone in your household not listed in Part 1. Include yourself and all other children, your spouse, grandparents, other relatives and unrelated people in your household. Use a separate sheet of paper if you do not have enough space.

GROSS INCOME BEFORE DEDUCTIONS: Write the amount of income each person gets on the same line as their name. Use the appropriate column(s): Earnings from Work, Welfare/Child Support/Alimony, Pensions/Retirement/Social Security or Other Income (see list below). Next to the amount of income write how often the income was received. Income is all money before taxes or anything else is taken out. If a person does not have income, check the box for zero income.

OTHER INCOME: strike benefits, unemployment compensation, worker’s compensation, disability benefits, interest/dividends, cash withdrawn from savings, income from estates/trust/investments, royalties/annuities/rental income, and regular contributions from persons not living in the household. FOSTER CHILDREN: List any personal income received by the foster child under Part 3B. Personal income is (a) money given for the child’s personal use, such as clothing, school fees and allowances and (b) all other money the child gets, such as money from his/her family. MILITARY HOUSING BENEFITS: Report off-base housing allowance as income. If the housing is part of the Military Housing Privatization Initiative, do not include as income. SELF-EMPLOYMENT: Report income derived from the business venture less operating costs for net income. The loss from the business cannot be deducted from a positive income earned in other employment. The least possible income is zero.

SOCIAL SECURITY NUMBER: Write the last four (4) digits of the social security number of the adult household member who signs the form. If the adult household member does not have a social security number, check the box. Use of this information is for CACFP use only and is required.

Part 4 SIGNATURE AND CONTACT INFORMATION: Sign and date the application. The form must be signed by the parent or guardian. Complete the contact information – name, address, telephone number, and employer information.

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.

Household Size: 1 2 3 4 5 6 7 Each Additional

Family Member

Annual Income: $21,590 $29,101 $36,612 $44,123 $51,634 $59,145 $66,656 + $7,511

ENROLLMENT & INCOME ELIGIBILITY FORM FOR CHILD CARE CENTERS JULY 1, 2014 THROUGH JUNE 30, 2015

Part 1. CHILD ENROLLMENT: Complete the information below for all children in care. If the child is a foster child (legal responsibility of a foster care agency or the court), please check the box.

Last Name, First Name

Date of Birth

Times of Care Regular Days of Care Meals Served During Care

Ethnicity/ Race* Foster

Child Arrival Time

Leave Time

M T W T F S S B AM

L P M

D E V

Ethnicity Race

*Ethnicity (select one): H=Hispanic or Latino or N=Not Hispanic or Latino *Race (select one or more): W=White, B=Black or African American, I=American Indian or Alaskan Native, A=Asian, or P=Native Hawaiian or other Pacific Islander

Part 2. HOUSEHOLDS RECEIVING BENEFITS FROM THE FOOD ASSISTANCE PROGRAM (FAP), TEMPORARY ASSISTANCE FOR FAMILIES (TAF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR): Complete Parts 1, 2 and 4.

Program Name: ___________________________________________________________ Case No. _____________________________

Part 3A. HOUSEHOLDS EXCEEDING THE INCOME GUIDELINES: Complete Parts 1, 3A and 4.

If your family income exceeds the income guidelines (listed on reverse side), check this box

Part 3B. ALL OTHER HOUSEHOLDS – If you do not have a FAP, TAF or FDPIR case number: Complete Parts 1, 3B and 4. GROSS INCOME BEFORE ANY DEDUCTIONS (Net for Self Employed)

W=Weekly E2=Every 2 weeks 2M=Twice monthly M=Monthly Y=Yearly

List the Names of All Household Members not listed in Part 1

Earnings from Work Welfare, Child Support, Alimony

Pensions, Retirement, Social Security All Other Income

Check

If ZERO income

How much? How often? How much? How often? How much? How often? How much? How often?

(Example) Jane Smith $200 W $150 2M $100 M

1

2

3

4

5

6

Social Security Number of Household Member who signs form:

Last four digits of Social Security Number: XXX- XX -____________ If you do not have a Social Security Number, check this box

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Food Assistance Program (FAP), Temporary Assistants for Families (TAF) or Food Distribution Program on Indian Reservation (FDPIR) case number for your child or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the CACFP.

Part 4. SIGNATURE AND CONTACT INFORMATION:

I certify that all information on this form is true and that all income is reported. I understand that the facility will receive Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose their meal benefits, and I may be prosecuted. _____________________________________ Signature of Parent or Guardian Date

________________________________________________ Print Name

________________________________________________ Address

________________________________________________ City State Zip Code

________________________________________________ Daytime Telephone

________________________________________________ Employer(s)

FOR CENTER USE ONLY _____ FAP/TAF/FDPIR HOUSEHOLD

_____ Homeless Documentation from school, emergency shelter, or agency _____ ANNUAL INCOME: _________________ HOUSEHOLD SIZE: _________ __________________________________________________________________ Sponsor’s Determining Signature Date __________________________________________________________________ Sponsor’s Confirming Signature Date

HOUSEHOLD CATEGORY: Free Reduced Price

Paid

Foster Child – Free Category List name of foster child(ren):

I _____________________________________ hereby grant YWCA Topeka full rights

to copyright, exhibit, and publish in any medium including, but not limited to, editorial,

illustration, promotion, advertising, internet, or trade all photographs taken by the

YWCA or its agents of my child __________________________________ while

he/she is participating in YWCA programming.

Parent/Guardian Signature: __________________________________________

Date: ________________________

Official online websites for YWCA Topeka:

www.ywcatopeka.org

www.facebook.com/ywcatopeka

twitter - @ywcatopeka

(print parent/guardian name)

(print child’s name)