Dear Kennett YMCA Y Care Parents,
Please take a few moments to fill out the following packet for each child that you will be
enrolling or re-enrolling. Be sure that each line in your child’s packet is clearly marked. Your
child will not be fully enrolled until the packet is complete. (See note on physical below.)
Below is a checklist for your reference of what needs to be returned to the YMCA:
____ Please provide 2 small wallet-sized photos to be used for attendance and internal use only.
_____ Up-to-Date Membership with the Kennett Area YMCA, or a non-member waiver.
_____ $40 registration fee, per child, which is waived if you draft payments (credit card or bank draft)
or have CCIS.
_____ Fee Agreement forms with days selected, times child will attend, start date, all lines initialed,
and signed.
_____ Emergency Contact complete (including health insurance policy name and number) & signed.
_____ “Getting to Know You” form complete & signed.
_____ Civil Rights Compliance Program Participant Awareness form signed.
_____ YMCA Character Values Contract signed.
_____ Support Services letter signed.
_____Program Draft Authorization Form completed. (Must be filled out each year.)
** Child Health Report must be filled out by child’s doctor and include an immunization record.
Form must be returned to the YMCA no later than 30 days from time of enrollment. **
Be sure to review the parent handbook, as some policies and procedures have changed.
If you have any questions regarding enrollment, please email or call Becky Cushman, School Age Child
Care Director, for assistance. bcushman@ymcagbw.org or 610-444-9622, ext. 2335.
ADDITIONAL INFORMATION:
1. Families making less than $80,000 in annual household income are eligible for reduced fees.
Please contact Lenda Carrillo, Outreach Director, at 610-444-9622, ext. 2317 for more information.
2. Payments are due the 20th of each month for the following month’s care; with the first payment
due August 20th, for September, and the last payment due April 20th for May. There is no billing for
June if you have been in the program since August’s payment. (9 identical payments per year.)
3. Please notify your child’s school office of their YCare schedule before their first day of YCare using
the form enclosed in the registration packet. Please also notify your district transportation office of
your child’s schedule.
please return to YMCA
Year:__2015 - 2016__
The YMCA of Greater Brandywine
School Age Child Care Agreement
Kennett YMCA
Child’s Name ___________________________________________  Male
 Female
School Attending______________________________________________________
Birth Date _____/_____/_____
Grade as of 9/1/15 ____________
Home Address_______________________________________________________________________________________
Street Address
City
State / Zip
Home Phone # __________________________ Primary E-mail _______________________________________________
Parent/Guardian Name (1) _______________________________________ Cell #:_______________________________
Parent/Guardian Name (2) _______________________________________ Cell #:_______________________________
Child Lives With:
____
IS THERE A CUSTODY AGREEMENT? YES
Type of YMCA Membership (required)
waiver
NO If yes, you MUST provide a copy of the agreement to the Program Director.
 Full Family Member (FM) OR  Non-Member (NM)-must complete non-member
Do you qualify for a reduced rate?
Chester County Assistance (CCIS)
 Yes
 No
YMCA Financial Assistance
 Yes
 No
Sibling Discount
 Yes
No
YMCA Employee Discount
Yes
No
Do you have a sibling(s) registered in:
Montessori
K-Care
Preschool
SACC
Sibling’s Name(s):___________________________________________________________________________________
X________________
Parent / Guardian Signature
1
Child’s Name ___________________________________________
Please check the program your child will be attending. Fees are listed as monthly (except for noted daily rates):
School Age Child Care (SACC)
For children attending school full day
Kindergarten (K-Care)
√
√
Wrap Around
Program
(7:00am-8:45am,
K-Care, & 3:256:00pm)
Full Family
Membership
20% Discount
After School Care
√
(3:25-6:00pm)
Value
Pricing
Full Family
Membership
20% Discount
$ 665.00
$ 532.00
5 Days
$ 365.00
$ 292.00
4 Days
$ 665.00
$ 532.00
4 Days
$ 350.00
$ 280.00
3 Days
K-Care
Enrichment
Program only
$ 460.00
$ 368.00
3 Days
Before School Care
$ 295.00
$ 236.00
5 Days
$252.00
$202.00
Please update us when you
know your school am or pm
K assignment.
√
(7:00-8:45AM)
5 Days
$ 450.00
$ 360.00
4 Days
$252.00
$202.00
4 Days
$ 450.00
$ 360.00
$185.00
$148.00
3 Days
K-Care
Enrichment +
$ 290.00
$ 232.00
3 Days
Before and After
School Care (7:00-
5 Days
$ 508.00
$ 406.00
4 Days
$ 428.00
$ 343.00
3 Days
$ 342.00
$ 274.00
√
8:45am & 3:256:00pm)
Before School Care
(7:00-8:45am &
K-Care)
√
SACC
Pricing
5 Days
(8:45am-12:45pm or
11:25am-3:25pm)
√
K-Care
Pricing
Value
Pricing
5 Days
$ 505.00
$ 404.00
4 Days
$ 505.00
$ 404.00
3 Days
K-Care
Enrichment +
After School Care
$340.00
$ 272.00
(K-Care & 3:256:00pm)
5 Days
$ 565.00
$ 452.00
4 Days
$ 565.00
$ 452.00
3 Days
$ 345.00
$ 276.00
Y-Day and Half Days

Drop in Half Day=$25 per day

All planned half days that fall on your child’s
scheduled days of Aftercare will be included
with monthly tuition rates.
Y – Day Option
$ 50.00
Please sign below and complete Page 3
X________________
Parent / Guardian Signature
Business Manager Signature
Membership Checked
2
Please initial the following:
I have received a copy of the YMCA Parent Handbook and written program information at time of enrollment.
I understand that failure to comply with the YMCA of Greater Brandywine Child Care policies may result in termination of
services. I understand that my child’s membership or facility use may be revoked if deemed necessary.
I give permission for the YMCA to assist in the application of sunscreen (supplied by parent) to my child.
I understand payments are due on the 20th of the month prior to the month of service (or weekly if CCIS).
I understand the late tuition fee is 10% of the monthly tuition and is assessed on the 21st day of each month. You have
until closing on the 20th to pay your account.
I must provide 30-days written notice to withdraw my child(ren) from the program and 14 days written notice for
program changes, or be charged according to the written policy. I understand all tuition withdraws AND changes must be
in writing and require a new financial agreement.
I understand the late pick-up fee is $1.00 per minute. Late pick up fees will be billed to my account if I am on auto-draft or
must be paid immediately upon notification at the Front Desk.
I understand that if I receive the Family Membership Discount and my Membership status changes, I will be charged the
participant rate from the time of the status change.
I understand that if I am terminated by CCIS I am responsible for all child care expenses incurred.
I give permission for the YMCA of Greater Brandywine to use photographs, digital images and/or quoted statement by my
child or me for the purpose of promotion and advertising of the YMCA of Greater Brandywine and its programs. I understand
that there will be no paid compensation for any such usages.
I understand that the YMCA is responsible for my child only during the hours he/she is registered for School Age Child Care.
I understand if there is a custody/court order document, I must provide a copy of said agreement upon registration. I
understand if there is an IEP document, I must provide a copy upon registration.
I understand, if my child is in YMCA care for 15hrs or more, they will be given a child service report every 6 months, assessing
student progress.
I understand that a health assessment (doctor’s physical) is required at the time of enrollment by the Department of Human
Services, under which YMCA child care programs are licensed and that the assessment must be within 12 months prior to
enrollment date, including immunization records.
I certify that the participant listed above is in normal health and capable of safe participation in YMCA recreation programs
and/or use of facility.
I understand that Homework/Quiet Time is a component of the program, and that children will be asked to work
independently or engage in a quiet activity during that time.
I understand that I am required to update the emergency contact/parental consent form information whenever changes occur
or every 6 months at a minimum.
I understand fees are subject to change.
Monthly Fee
$
Sibling Discount of 10% for each
additional child.
$
Less Financial Assistance
$
Other Adjustments
$
TOTAL MONTHLY FEE
$
$40 Registration Fee is waived for automatic monthly draft.
Summary of Services: Fun and safe before/after school care,
including homework help and indoor and outdoor play activities.
Snack is provided for after care times. Parents are responsible for
lunch on all Y-Days.
Arrival Time:
Departure Time:
3 or 4 day options, please circle days:
M T W TH F
I give permission for my child to participate in swim activities related to the program. Parent Signature:
I give permission to seek medical treatment for my child in the event of an emergency. Parent Signature:
I give permission for the YMCA to transport my child for program needs and emergencies. Parent Signature:
I give permission for the YMCA to take my child on walks and trips. Parent Signature:
I give permission for the YMCA to administer minor first aid. Parent Signature:
I give permission for my child to participate in swim activities related to the program. Parent Signature:
Start of School – Parent Signature:
Date:
6 Month Review – Parent Signature:
Date:
Director Signature:
Date of Admission:
Date of Withdrawal:
3
Emergency Contact / Parental Consent Form
Please complete ALL information, write “N/A” if not applicable
please return to YMCA
2015-2016
Child’s Name: ___________________________________________________________ Birth Date: ________________
Address: __________________________________________________________________________________________
Street Address
City
State/Zip
Parent/Guardian Name (1):__________________________ Home Address: ___________________________________
Home Phone #: ____________________Cell Phone #: ___________________ Work Phone #: ______________________
Work/ Employment Name and Address:_________________ ______________________ ___________________________
Parent/Guardian Name (2):__________________________ Home Address: __________________________________
Home Phone #: _____________________Cell Phone #: __________________ Work Phone # _______________________
Work/Employment Name and Address:
_______________________________________________________________________________
Emergency Contact Persons: Please list at least 2 other people we may contact in case of an emergency and we
are unable to reach you. (fill in all information, including full street address)
Name: ______________________________Full Address: ____________________________________________________
Phone #______________________
Name: ______________________________Full Address: ____________________________________________________
Phone #______________________
Person(s) to whom child may be released (can be the same as above, or additional emergency contacts)
(fill in all information, including full street address)
Name: ______________________________Full Address____________________________________________________
Phone#_______________________
Name: ______________________________Full Address____________________________________________________
Phone #_______________________
Name of Child’s Physician/Medical Care Provider:
Name: ________________________________________________ Phone #: ____________________________________
Address:____________________________________________________________________________________________
Special Disabilities (if none write “N/A”):_____________ ________________________________________________
Allergies (including medication reaction): ________________________________________________________________
Medical or dietary information necessary in an emergency situation:_________________________________________
Medication, special conditions:_________________________________________________________________________
Additional information on special needs of child:_______________________________________________________
___________________________________________________________________________________________________
Health Insurance coverage for child (or medical assistance benefits): _________________________________________
Policy number: REQUIRED:__________________
I agree to update all governmental documentation (emergency contact / personal consent form and financial agreement)
whenever changes occur or at a minimum of every six (6) months and yearly for child health appraisals.
Parent/Guardian Signature ___________________________________________Date _____________________________
(After 6 months, please review all information, update, then sign below)
6-month Review Parent / Guardian Signature ___________________________________Date ____________________
4
The YMCA of Greater Brandywine
School Age Child Care Getting to Know You Form
Family and Social History
Child’s Name:_______________________________
Marital Status of Parents:   Married
Nickname:_________________________________
 Separated  Divorced
 Widowed
 Single
Stepmother___________________________ Stepfather_______________________________
Custody/Visiting Arrangements__________________________________________________________
*Please provide custody/court order document upon registration
Siblings (names and ages) __________________________________________________________________
Describe your child socially and emotionally:____________________________________________________
What are your child’s interests? ______________________________________________________________
Does your child have any special fears that you are aware of? ______________________________________
Does your child have an IEP or behavioral plan in place during the school year?
 Yes  No
If yes, describe the reason for the behavioral plan:_______________________________________________
_______________________________________________________________________________________
After reviewing the stakeholders from the Parent Handbook, are you interested in adding anyone else to the
list?____________________________________________________________________________________
Do you wish to schedule a conference with the staff at the school site to discuss this information any
further?_________________________________________________________________________________
*If your child has an IEP or behavioral plan we will need a copy on file. Please contact your
Program Director to set up a meeting, and review our special needs and support services policies
and procedures in this document.
The YMCA of Greater Brandywine strives to provide programs that can include children of different abilities. Our
goal is to provide high quality programs and highly qualified staff to enable you child to have a fun, successful
and enjoyable learning and social opportunity. The YMCA is an equal opportunity care provider.
ATTENTION—PLEASE READ THE FOLLOWING CAREFULLY. THIS WAIVER AFFECTS YOUR LEGAL
RIGHTS
In consideration of my/my child’s participation in the activities of the YMCA of Greater Brandywine, I agree to waive,
release, indemnify and hold harmless the YMCA and its respective officers, employees, volunteers, and members for
injuries, accidents and damages that result from my/my child’s participation in the programs including but not limited to
liability for its own negligence, and do hereby on behalf of myself, heirs, executors and administrators, waive, release and
forever discharge any and all rights and claims for damages which may have or which may hereafter accrue to me/my child
arising out of or connected with participation in the programs, use of the YMCA facilities and property, or use of equipment
within its facilities and property.
I understand that even when every reasonable precaution is taken, accidents can sometimes occur. I further understand
that the activities of the YMCA have inherent risks and I hereby assume all risks and hazards incidental to my or my family’s
participation in programs or use of the facilities, or equipment within its facilities.
I UNDERSTAND THAT SIGNING BELOW DEMONSTRATES ACCEPTANCE OF THE ABOVE TERMS IN
THEIR ENTIRETY.
Signature of Parent/Guardian: ____________________________________
Date: ____/____/_____
5
YMCA of Greater Brandywine
Support Services Policies and Procedures
To: Parent or Guardian
From: YMCA Program Directors
Re: Support Services
Thank you for considering the YMCA of Greater Brandywine to serve your child and the needs of your family.
The YMCA’s mission is to put Christian principles into practice to build a healthy spirit, mind and body for all.
Our goal is to provide safe, high quality programs in an environment where everyone can thrive, grow, and
have fun. Our staff are carefully selected and trained to deliver excellent service in all that we do.
To ensure success, we must work with you as partners to maintain open and clear communication at all times
so that we can deliver a positive experience for your child each and every time they are at the Y. We know that
no two children have the same needs and some children have more diverse needs than others. Recognizing this,
we ask for your full cooperation to give us as much information as possible on the needs of your child. Please
complete all of the necessary program forms, paying close attention to the details that will allow our staff to
serve your child to the best of their ability.
The YMCA of Greater Brandywine adheres to the state childcare ratios for specific ages of children and the
appropriate compliment of staff. Although the YMCA cannot provide a 1:1 staff to child ratio, we welcome the
opportunity to work with you on a solution for your child’s needs. If your child receives support services at
school or has a home health aide or nurse we would be happy to discuss how we might be able to incorporate
these services into our program so your child can participate with his/her peers.
The following are the guidelines for proceeding with YMCA services:





Any child who has support services during the school year must also have equal support for any YMCA
program of significant time and duration.
If the child has an IEP or behavior plan we ask that it is shared with YMCA staff at the time of the
meeting.
An individualized program plan meeting prior to enrollment is required to determine the support
necessary for program participation and to meet the child and discuss the situation.
A specific program plan will be created and agreed upon prior to participation that includes the roles and
responsibilities of the support staff, the parents, the YMCA and the child.
The support staff will be expected to adhere to YMCA policies and procedures and may be asked to wear
specific clothing or identification consistent with YMCA rules.
If your child requires the assistance of support services, has unique challenges, or if there is anything you would
like to discuss, please contact your program director to schedule a meeting.
______________________________
Parent Signature
__________________
Date
6
CIVIL RIGHTS COMPLIANCE
PROGRAM PARTICIPANT AWARENESS AND
NONDISCRIMINATION IN SERVICE POLICY
Admissions, the provision of services, and referral of clients shall be made without regard to race,
color, religious creed, disability, ancestry, national origin, age or sex. Program services shall be made
accessible to eligible persons with disabilities through the most practical and economically feasible
methods available.
In accordance with applicable Federal and State civil rights laws and regulatory requirements, as a
program participant of this facility, you have the right:

To be provided with services at this facility and to be referred to services at other facilities
without regard to your race, color, religion, handicap, ancestry, national origin, age or sex.

To file a complaint of discrimination if you feel you have been discriminated against on the
basis of your race, color, religious creed, handicap, ancestry, national origin, age or sex.
Complaints of discrimination may be filed with any of the following:
YMCA of Greater Brandywine
One East Chestnut Street
West Chester, PA 19380
Kennett Area YMCA
101 Race Street
Kennett Square, PA 19348
PA Human Relations Commission
Philadelphia Regional Office
110 N 8th Street, Suite 501
Philadelphia, PA 19107
U.S. Dept. of Health & Human Services
Office of Civil Rights
Suite 372, Public Ledger Building
150 S. Independence Mall West
Philadelphia, PA 19106-9111
Commonwealth of PA
DPW Bureau of Equal Opportunity
Southeast Regional Office
801 Market Street, Suite 5034
Philadelphia, PA 19107
Dept. of Human Services and Education
Bureau of Equal Opportunity
Room 223, Health and Welfare
P.O. Box 2675
Harrisburg, PA 17105
PARENT SIGNATURE AND DATE______________________________
DIRECTOR SIGNATURE ____________________________________
7
Youth Programs
Character Values Contract
Caring  Honesty  Respect  Responsibility
As participants in the YMCA of Greater Brandywine Youth Programs, you have the opportunity to interact with a variety of
people. This is a unique chance to exercise a new level of autonomy without parental authority. It also means increased
personal responsibility representing your family, the YMCA, and most importantly – yourself. This behavior contract is
designed to allow you the greatest opportunity while outlining your most important responsibilities to ensure a fun time at
the YMCA!
Children, Teens and Parents/Guardians: Please read over the rules below very carefully with your parents/guardians.
When you are sure you understand the expectations and consequences associated with them, please sign your name and
date at the bottom of the second page. Have a parent/guardian sign it as well and return it before the first day of the
program.
CHARACTER VALUES EXPECTATIONS
In keeping with the YMCA mission and character values of Caring, Honesty, Respect and Responsibility, appropriate behavior
is expected of all participants in YMCA programs. Respectful interactions with program participants and YMCA staff are at
the core of the YMCA mission and essential to having a successful program experience. Non-YMCA patrons are also to be
treated in a manner that is consistent.
1. Every person has the right to be safe and healthy within his or her YMCA program environment, including:
a. Security and privacy of personal items
b. Freedom of verbal, physical and mental abuse
2. Every person has the right to an opinion, and to be heard in a constructive and positive manner.
3. Every person has the right to be respected and treated fairly in a civilized manner.
4. Every person has the right to grow in spirit, mind and body and is equally valued and important to the YMCA. It is
implied that these rights apply to all individuals, staff and parents alike. If a person infringes on another’s rights,
the YMCA staff will practice zero tolerance and take appropriate action to remedy the situation.
ACCOUNTABILITY AND CONSEQUENCES
It is the responsibility of the YMCA to ensure each person’s right to achieve our goals within the YMCA program
environment.
1. Behavior that conflicts with essential YMCA values will be addressed in a nature appropriate to the disruptive
behavior and is at the discretion of the YMCA staff and directors.
a. Types of Disruptive Behavior: Disrespect of other children, and staff, continuous disruptive/uncooperative
behavior, hitting, biting, fighting, obscenity, theft, destruction of YMCA, school, or other people’s belongings.
b. Bullying: The YMCA practices zero tolerance for bullying behaviors. Bullying is when someone repeatedly
and on purpose says or does mean or hurtful things to another person who has a hard time defending
himself or herself. Bullying as defined in the YMCA of Greater Brandywine policy also includes cyberbullying.
2. The use or possession of alcohol, tobacco, weapons, or any controlled substances by any program participant will
result in dismissal from the program.
3. Use of cell phones, cameras, or other electronic devices during program hours is prohibited. Such equipment, if
present, will be asked to be put away or confiscated and returned at the end of the day.
4. Criminal behavior of any sort will not be tolerated. This includes the unauthorized use or theft of the property of any
YMCA of Greater Brandywine program participant or staff member. Also, intentional damage or theft to program
equipment or any site visited may lead to dismissal from the program for the remainder of the summer.
(also please review and sign next page)
8
YMCA Behavior Management Guidelines
The YMCA of the Greater Brandywine uses two behavior management guidelines in all YMCA youth programs for
behavior which falls out of our Character Values expectations:
1.
POSITIVE BEHAVIOR MODIFICATION (day to day behavior correction)
Positive Discipline is a model that focuses on the positive points of behavior, based on the idea that there are no bad
children, just good and bad behaviors. YMCA staff teach and reinforce the good behaviors while weaning the bad
behaviors. Positive behavior modification includes a number of different techniques that, used in combination, lead to a
more effective way to manage a child behavior through:
a.
b.
c.
d.
e.
f.
2.
Mutual respect. Adults model firmness by respecting themselves and the needs of the situation, and kindness by
respecting the needs of the child.
Identifying the belief behind the behavior. Effective discipline recognizes the reasons kids do what they do and works
to change those beliefs, rather than merely attempting to change behavior.
Effective communication and problem solving skills.
Discipline that teaches and is not punitive.
Focusing on solutions instead of punishment.
Encouragement (instead of praise). Encouragement recognizes effort and improvement, not just success, and builds
long-term self-esteem and empowerment.
PROGRESSIVE BEHAVIOR MANAGEMENT (when Positive Behavior Modification is not effective)
The safety and well-being of each child in our care is our number one priority. When behavior expectations are not met,
YMCA staff will implement our Progressive Behavior Management policy to help correct the undesired behavior. Listed
below are the steps utilized by our staff:
a.
Verbal warning given: explain why behavior is inappropriate.
b.
Time out or partial loss of activity time - time to refocus and redirect. Parent will be notified of incident.
c.
If repeated behavior occurs, verbal communication between parent and program staff with written notice of
incident(s).
d.
If repeat behavior occurs, a parent conference with activity staff and program director, followed by a written
summary of meeting. Child, parent and staff sign a written contract agreeing to acceptable behavior and alternative
solutions, and consequences if behavior does not improve. Executive Director is also notified of incident and
meeting.
e.
If inappropriate behavior continues, child may be suspended from program for one day, up to one week. A parent
conference will be required prior to return to the program.
f.
Prolonged disruptive and inappropriate behavior will result in dismissal from the program.
EXTREME BEHAVIOR
In extreme cases, a child’s behavior may warrant immediate suspension or expulsion from the program. Such cases include
the use of profane or abusive language or any aggressive behavior which threatens or causes physical harm to other
participants or staff.
I have read and understand the behavior expectations, accountability, consequences, and management
guidelines, reviewed them with my child (age 3 and up) and am committed to upholding the YMCA Character
Values.
________________________________
Child/Teen’s Name (printed)
_________________________ ______
Child/Teen’s Signature (where age appropriate)
____________
Date
________________________________
Parent/Guardian’s Name (printed)
_________________________ ______
Parent/Guardian’s Signature
____________
Date
9
Dear Kennett Area YMCA Y-Care Parents,
This letter is to assure you of our concern for the safety and welfare of children attending our Before
and After School programs. Our Emergency Operations Plan provides for response to all types of
emergencies. Depending on the circumstances of the emergency, we will use one of the following
protective actions.
Evacuation/Emergency Procedures:
 In the event of an emergency and we are required to evacuate our Y Care areas, (but stay in
the school) we will use the interior bathrooms or windowless rooms as shelter.
 If we have to leave the school the children will be evacuated to the Kennett Area YMCA, 101
Race Street, Kennett Square, PA 19348. Children will follow school protocol on gathering area
while waiting for bussing to the YMCA.
 Other evacuation sites are:
o Genesis HealthCare, 101 East State Street, Kennett Square, PA 19348
 In the event of an emergency, parents will be contacted via telephone.
 Parents will be notified via telephone that the emergency has ended and where to pick up their
children. If phone lines are not working, parents may report to the Kennett YMCA, which will
be our emergency headquarters.
We ask that you not call during the emergency. This will keep the main telephone lines free to make
emergency calls and relay information. We will call you to let you know that we’ve taken one of the
protective actions. We will also call you when we’ve resolved the situation and it’s safe for you to pick
up your child.
Please make sure you have an emergency plan on file with your child’s school office. If an emergency
occurs during the school day your plan on file will be followed.
Remember that if the school closes during the school day (before 3:25 pm) then we will not start
Aftercare at 3:25 pm and all students will follow their emergency plan on file with their school.
Sincerely,
Becky Cushman
School Age Child Care Director
Kennett Area YMCA
10
Take to school office
SCHOOL NOTIFICATION FORM
Parents, please return this form to YOUR CHILD’S SCHOOL OFFICE as soon as possible. This will
serve as notification of your child’s participation in Y-Care, and their Y-Care schedule.
CHILD’S NAME ________________________________________
SCHOOL ______________________________ GRADE _________
ENROLLMENT DATE IN YCARE __________________________
My child, ___________________________ will be attending the Kennett Area Y’s Y-Care program.
My child’s schedule with the Y program will be:
Before School Care - 7:00-8:45am
After School Care - 3:25-6:00pm
Kindergarten Care –
between 8:45am-12:45pm if your child attends PM kindergarten,
or 11:25am-3:25pm if your child attends AM kindergarten.
Please circle the days and all programs attending
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Before Care
Before Care
Before Care
Before Care
Before Care
K-Care
K-Care
K-Care
K-Care
K-Care
After Care
After Care
After Care
After Care
After Care
11
KCare Enrichment Program Information:
Kennett District: Kindergarteners in the Kennett District may sign up for Before or After school care as
needed, (not KCare), since Kennett offers full day Kindergarten. We offer Before and After School Care
for Kennett Kindergarteners at their home/permanent Elementary schools, and they will be bussed to
and/or from the Mary D. Lang Kindergarten Center on district busses with the other kindergarteners.
Unionville-Chadds Ford District: We are planning to offer on-site AM & PM Kindergarten Care at each of
the Unionville-Chadds Ford schools. Please notify your child’s school immediately that you are planning to
use the YMCA KCare Enrichment program. If you only need coverage for the school day hours, chose “KCare Enrichment only.” The KCare Wrap Around program includes BOTH Before AND Aftercare. You do
not need your school kindergarten assignment to register for the YMCA KCare program, you can let us
know over the summer. We will need to know their bus number if KCare staff will be walking your child to
the bus at dismissal, this information comes out in August.
KENNETT YMCA YCARE SAMPLE SCHEDULES:
BEFORE CARE * subject to change
7:00am
7:00-8:00
8:00-8:30
8:30-8:40
8:45
Open, sign-in
Games, craft, free choice.
Group game or playground
Clean up, group meeting/team time
Dismissal
KCARE ENRICHMENT
8:45-9:00am Arrival
9:00-9:15
9:15-10:15
10:15-10:45
10:45-11:00
11:00-11:20
11:20
11:20-12:00
12:00-12:45pm
12:45
12:45-3:25
3:25
* subject to change
Attendance, Morning Circle: calendar, weather, spanish, job charts, songs
Centers: math, writing/early reading, fine motor skills, crafts.
Playground
Story Time: parallels the theme we are currently working on
Free Choice: kitchen or doll house, building materials, Legos, arts and crafts, games.
PM Class Arrives
Quiet activities and books
Lunch
AM class goes to Kindergarten
PM class follows same schedule as AM class
Dismissal
AFTER CARE DAILY SCHEDULE *subject to change
3:25-3:45pm Dismissal, Attendance
3:45-4:15
Homework and Snack
4:15-5:00
Playground or Gym
5:00-6:00
Group games, crafts, free choice, group meeting time
6:00
Clean-up, Close
--
PROGRAM DRAFT
AUTHORIZATION FORM
YMCA OF THE GREATER
BRANDYWINE
[ ] BW [ ] JV [ ] KT [ ] OC [ ] WC [ ] YPC
Participant's Name(s)
Address on Account [ ] Check if address has changed
Street
City, State, Zip
Home Phone
_
_
Email
_
Cell Phone
_
Initial Appropriate Draft Authorization(s)
Fill in all that a p p l y to this form:
Monthly Payment: Drafts on the 20th of the month [Change4Life/OC Exercise-1" of
the month] prior to each month the program is provided, for continuous programs.
Examples include: childcare, gymnastics team, martial arts. (Montessori & Swim Team payment
schedules differ. See handbooks for payment schedules.)
Session Payment: For 8 to 16-week programs that require registration for each
session, 50% of the fee is paid at registration and 50% is drafted on the date(s) indicated
on your receipt. Examples i n c l u d e swim lessons, youth sports, Girls on the Run, etc. Debit/
credit card drafts only
Monthly Draft Amount $·
Session Draft Amount $ ·
Weekly Payment (CAMP & Child Care)*: Debit/credit card drafts only
Drafts on the Monday prior to the program week for each week registered.
Weekly draf t amount is based on authorized registration and current rates.*
*Camp registration changes as well as any unpaid summer camp deposits for withdrawals will be automatically charged to this account.
I understand that it is my responsibility to notify the YMCA of any bank account or credit card changes, in writing, 7 business days prior to the
next scheduled draft date. The YMCA will automatically adjust my payment amount when program fees change due to Income Based
Membership, staff or sibling discounts, and when participant transfers to another academy or level. No refund or credit will be made. If the
YMCA is unable to debit my account because of account changes or insufficient funds, I understand that I am responsible for said payment plus
a $20 YMCA return draft fee. The YMCA reserves the right to suspend service if an account cannot be debited. I hereby authorize my bank or
credit card to honor monthly automatic drafts by the YMCA on my account for program payments. When the bank honors the draft by
charging my account, notation on my statement shall constitute my receipt for payment. THIS A U T H O R I T Y IS TO REMAIN IN EFFECT UNTIL
REVOKED BY ME IN WRITING.
Print Account Holder Name
Staff Use:
Account Holder Signature
Initial Payment $
Staff Name
Date
Receipt #
Date
(must be filled-in)
_
YMCA OF THE
GREATER BRANDYWINE
Bank Account- Monthly
Payments Only
Credit or Debit Card
VISA
Expiration Date
I
MasterCard
Expiration Date
I
Discover
Expiration Date
I
Card#:
American Express
Card#:
Expiration Date
I
Bank Name:
Bank Routing/Transit Number (9 digits)
_________
Bank Account Number:
_
CHILD HEALTH REPORT
Parent/Provider fill in this part.
(55 PA CODE §§3270.131, 3280.131 AND 3290.131)
CHILD’S NAME: (LAST)
(FIRST)
PARENT/GUARDIAN:
DATE OF BIRTH:
HOME PHONE:
ADDRESS:
COUNTY:
WORK PHONE:
CHILD CARE FACILITY NAME:
FACILITY PHONE:
† I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.
PARENT’S SIGNATURE:
DO NOT OMIT ANY INFORMATION
This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.
HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY):
† NONE
DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A
CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY.
† NONE
CHILD’S ALLERGIES (DESCRIBE, IF ANY):
† NONE
LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO
DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF,
EQUIPMENT AND PROVISION FOR EMERGENCIES.
† NONE
Parents may write immunization dates; health professional should verify and complete all data.
IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR
COMMUNICABLE DISEASES?
† YES † NO
IF NO, PLEASE EXPLAIN YOUR ANSWER:
HAS THE CHILD RECEIVED ALL AGE APPROPRIATE
SCREENINGS LISTED IN THE ROUTINE PREVENTIVE
HEALTH CARE SERVICES CURRENTLY RECOMMENDED
BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE
SCHEDULE AT WWW.AAP.ORG)
†
YES
†
NO
NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF
THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND
INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD
CARE FACILITY.
VISION (subjective until age 3)
HEARING (subjective until age 4)
LEAD
RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD
IMMUNIZATIONS
DATE
DATE
DATE
DATE
DATE
COMMENTS
HEP-B
ROTAVIRUS
DTAP/DTP/TD
HIB
PNEUMOCOCCAL
POLIO
INFLUENZA
MMR
VARICELLA
HEP-A
MENINGOCOCCAL
OTHER
MEDICAL CARE PROVIDER:
SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN’S ASSISTANT
ADDRESS:
TITLE:
PHONE:
LICENSE NUMBER:
DATE FORM SIGNED:
CD 51 09/08