TOGETHER
WE CARE
ASES
Parent Handbook
2012-2013
Lompoc Family YMCA
A branch of the Channel Islands YMCA
805.736.3483
Ciymca.org
IT’S NOT JUST
KID’S STUFF
The Y is a diverse organization of men, women, and children
joined together by a shared commitment to nurturing the potential
of kids; promoting healthy living and fostering a sense of social
responsibility.
TABLE OF CONTENTS
Channel Islands Mission Statement
page 3
Character Counts!
40 Developmental Assets
Welcome to ASES
Program Goal and Description
page 4
ASES Staff
Baby Sitting
Ratio
Days and Hours of Operation
Enrollmentand Registration
page 5
Parent Involvement
Attendance, Absence, and Early Release
Student Pick Up
Student Behavior and Expectations
page 6
Emergency Card
Illness
Injury
page 7
Medication
Child abuse or Neglect or Special Needs
Nutrition
Causes of Termination
Lost and Found
Photo Release
Program Concerns
page 8
Site Locations
Contact Information
Thank You
2
CHANNEL ISLANDS YMCA MISSION
STATEMENT
The Channel Islands YMCA is a charitable
organization providing programs based upon
Christian principles to men, women, and children
of all ages, races, religious beliefs, and economic
status, to develop and enrich the spirit, mind, and
body.
CHARACTER COUNTS!
The Channel Islands YMCA promotes the
Character Development Program designed by
The Josephsen Institute. By implementing
"Character Counts", we focus on Caring, Fairness,
Respect, Responsibility, Trustworthiness, and
Citizenship. The Afterschool Care Staff will use
these values in planning their curriculum. For
more information visit charactercounts.org.
Trustworthiness: Being honest, dependable &
loyal.
Respect: Living the Golden Rule, accepting
others, showing courtesy and manners.
Responsibility: Being accountable, doing one’s
best.
Fairness: Playing by the rules, treating everyone
fair & equal.
Caring: Being kind, compassionate &
understanding, showing love and charity to others.
Citizenship: Respecting authority, obeying the
rules, protecting the environment.
40 DEVELOPMENTAL ASSETS
The YMCA uses the Search Institute's 40
Developmental Asset Model to measure the
success of our youth and teen programs. Through
extensive research the Search Institute of
Minneapolis has identified 40 positive experiences
and qualities - "developmental assets" - that all
youth and teens need to become healthy,
contributing adults - assets like adult role models,
high expectations, and safety. Ideally all youth and
teens should experience at least 31 of the 40
developmental assets; however, current national
studies show that most youth experience less than
20. YMCA programs are designed to help fill the
gap and give youth and teens the assets they
need to succeed. Search-institute.org.
WELCOME TO ASES
Dear Families,
Welcome to the Lompoc Unified School
District/Family YMCA Education and Safety
Program (ASES). ASES is committed to providing
a safe place for students to experience academic
support, enrichment in arts, physical education,
and other enrichment activities. The program is
supported by a state grant and community
partners. This handbook is a comprehensive guide
to understanding the ASES program. Please read
this handbook in its entirety and become familiar
with its contents. As a participant in this program,
you will be responsible to follow program policies.
Failure to comply with the policies stated in this
handbook may result in the termination of current
or future enrollment in the ASES program. After
you read this handbook, please feel free to contact
our staff to discuss the contents or answer
questions.
We believe that the family is a vital part of
our community and that parent involvement is
essential to student success. This handbook is the
first step in your participation in the ASES program
and we encourage you to become involved in the
after school community. We hope your child’s
participation in our program will be beneficial to
his/her overall development and school
performance. Our goal is to give students and their
families the support they need to succeed in
school and in life.
Sincerely,
After School Education and Safety Program Team
3
CHANNEL ISLANDS YMCA MISSION
STATEMENT
The Channel Islands YMCA is a charitable
organization providing programs based upon
Christian principles to men, women, and children
of all ages, races, religious beliefs, and economic
status, to develop and enrich the spirit, mind, and
body.
CHARACTER COUNTS!
The Channel Islands YMCA promotes the
Character Development Program designed by
The Josephsen Institute. By implementing
"Character Counts", we focus on Caring, Fairness,
Respect, Responsibility, Trustworthiness, and
Citizenship. The Afterschool Care Staff will use
these values in planning their curriculum. For
more information visit charactercounts.org.
Trustworthiness: Being honest, dependable &
loyal.
Respect: Living the Golden Rule, accepting
others, showing courtesy and manners.
Responsibility: Being accountable, doing one’s
best.
Fairness: Playing by the rules, treating everyone
fair & equal.
Caring: Being kind, compassionate &
understanding, showing love and charity to others.
Citizenship: Respecting authority, obeying the
rules, protecting the environment.
40 DEVELOPMENTAL ASSETS
The YMCA uses the Search Institute's 40
Developmental Asset Model to measure the
success of our youth and teen programs. Through
extensive research the Search Institute of
Minneapolis has identified 40 positive experiences
and qualities - "developmental assets" - that all
youth and teens need to become healthy,
contributing adults - assets like adult role models,
high expectations, and safety. Ideally all youth and
teens should experience at least 31 of the 40
developmental assets; however, current national
studies show that most youth experience less than
20. YMCA programs are designed to help fill the
gap and give youth and teens the assets they
need to succeed. Search-institute.org.
WELCOME TO ASES
Dear Families,
Welcome to the Lompoc Unified School
District/Family YMCA Education and Safety
Program (ASES). ASES is committed to providing
a safe place for students to experience academic
support, enrichment in arts, physical education,
and other enrichment activities. The program is
supported by a state grant and community
partners. This handbook is a comprehensive guide
to understanding the ASES program. Please read
this handbook in its entirety and become familiar
with its contents. As a participant in this program,
you will be responsible to follow program policies.
Failure to comply with the policies stated in this
handbook may result in the termination of current
or future enrollment in the ASES program. After
you read this handbook, please feel free to contact
our staff to discuss the contents or answer
questions.
We believe that the family is a vital part of
our community and that parent involvement is
essential to student success. This handbook is the
first step in your participation in the ASES program
and we encourage you to become involved in the
after school community. We hope your child’s
participation in our program will be beneficial to
his/her overall development and school
performance. Our goal is to give students and their
families the support they need to succeed in
school and in life.
Sincerely,
After School Education and Safety Program Team
4
PROGRAM GOAL AND DESCRIPTION
It is the after school program’s goal that students
improve academically, emotionally, and socially
through community, academic, recreation, and
enrichment activities.
The ASES Program is a state funded education
and enrichment program designed to provide
school age children with a safe environment after
the regular school day ends. Students will
participate in academic tutoring, homework
assistance, leadership training, and enrichments in
the arts, academics, and recreation. Enrollment
and tuition are free of cost. This program is
available to all students and targets those that are
at risk of academic failure and/or have financial
needs.
The program consists of two elements, a literacy
component and an educational enrichment
component. We coordinate with regular day
teachers and administration to integrate these
components with the school’s curriculum,
instruction, learning support activities and behavior
policies.
The educational and literacy component provide
tutoring, monitoring and/or homework assistance in
language arts, mathematics, history, and social
science, and/or science [California Education Code
(EC) Section 842.3© (1)].Students are organized
into grade level groups of approximately 20
children supervised by 2 staff members whenever
possible.
The educational enrichment component may
include but not limited to, recreation and prevention
activities, [EC Section 842.3©(2)]. Such activities
might involve the visual and performing art, music,
physical activity, health promotion, general
recreation, career awareness, and work
preparation activities, community service-learning,
and other youth development activities, based on
students’ needs and interests.
This program is NOT a “baby-sitting” or “child care”
service, and is viewed as an extension of the
school day. Activities are held in the classrooms,
the computer lab, library, multi-purpose room and
ASES STAFF
The ASES staff at each site consists of the
program coordinator and the proper amount of
activity leaders to ensure the maintaining of a
student to staff ratio of no more than 20 to 1ratio.
All staff meets the instructional aide qualifications
established by the district (EC Section 8483.4) All
have cleared fingerprint clearance and are certified
in CPR, AED, First-Aid, and Child Abuse
Prevention. They have had a successful
experience working with children and have been
trained by YMCA Directors and are looking forward
to getting to know your family.
BABYSITTING
YMCA staff shall not socialize with children
enrolled in YMCA programs outside of approved
YMCA activities, including babysitting or
transporting children. Immediate disciplinary
action will be taken by the YMCA toward YMCA
staff if a violation is discovered. PLEASE DO NOT
ASK STAFF TO BABYSIT!
RATIO
Due to regulation of the ASES. program, we are
required to maintain at least a 1:20 ratio at all
times. The Channel Islands YMCA does not
provide one-on-one aides for children with special
needs. If an aide is necessary the parent may
provide one.
HOURS AND DAYS OF OPERATION
Program operates from school dismissal until 6:00
pm., including scheduled half days. We are closed
on teacher workdays and legal holidays. Annual
calendars are available from your site coordinator.
During holidays The Lompoc Family YMCA offers
camps on the following dates for an extra fee:
Winter Camp I:
December 10th-14th
Winter Camp II: December 17th-21st
Winter Camp III: December 22nd- 28th *
Winter Camp IV: December 31st-January 4th *
Spring Camp: March 29th- April 5th
5
ENROLLMENT AND REGISTRATION
Elementary enrollment to the ASES Program is
assessed after the completion of the application
and teacher referral. Students are enrolled on the
basis of academic need. Those with the greatest
need will be enrolled first. Enrollment is limited to
space available. Placement priority will be given to
students who attend the program daily (EC Section
8483). Enrollment may be terminated at any time
due to lack of funds or non-compliance to rules and
policies. You may discontinue your child’s
enrollment at any time; however, one week’s notice
is requested.
Registration forms are required, pick them up
at your schools front office.
Updated Information: Providing updated
information to the YMCA and or School is the
responsibility of the parent and must be made
immediately at the time of change.
PARENT INVOLVEMENT
The YMCA recognizes that parents are the most
important people in a child’s life. Because parents
are #1 in importance, they are also #1 in the ability
to influence and motivate their children. We
welcome your advice, participation and support.
The YMCA allows for parent visitation at any time.
In addition, parents are also encouraged to
participate in our many volunteer opportunities.
From advisory boards to campaigners, the YMCA
recognizes the importance of volunteers. Contact
the Program Director for more information on ways
in which you can volunteer.
ATTENDANCE, ABSENCES, EARLY RELEASE
Daily attendance is mandatory for elementary
students. The ASES Program is a state funded,
tuition free program. Students are required to
attend a minimum of 3 hours each day, Monday
through Friday.
Why Attendance Policy?
The grant that funds the ASES program sets this
strict attendance policy. We receive funds based
on the number of students who attend the required
three hours each day. To maintain our funding and
the quality of the program, participants must follow
In addition, there is usually a waiting list of families
who want to participate in the program and are
willing to follow all policies. A student with irregular
attendance occupies a space that another student
could fill.
Absence or Early Release:
If your student is absent, please contact the site
coordinator or leave a message with your child’s
school. Students may be released for participation
in activities with grant collaborative partners such
as: sports, arts, music, enrichment activities, field
trips, or tutoring. Students may be released for
medical or religious purposes. Students may not be
releases or leave program without a permission
slip indicating student name, activity or specific
reason they are leaving the program earlier then
required. (Ed Code 8483, Board Policy AR 5148.2).
Extended Absences:
It is understandable that unpredicted, unavoidable,
extended absences occur. In this case,
arrangements can be made with site coordinator on
a student-by-student basis.
STUDENT PICK UP
Students may be picked up after 5:15 p.m. no less
than 3 hours of attendance, but no later than 6:00
pm at all elementary school sites. Students must
be signed out before going home by parent or
person approved by the parent.
Elementary Students can only be signed out by a
parent, legal guardian, or by a person listed on the
child’s “Authorized Release” list located on their
emergency form. Parent’s initials and time of pick
up are required on sign-out sheet. No one under 18
years of age may sign a child out, unless preapproval of site coordinator. Please be sure to
include all adults you trust to pick up your child and
that their phone numbers are accurate, up to date,
and in service when filling out the Authorized
Release list to avoid any problems. Staff will strictly
enforce these rules for the safety of your child. Any
pick-up person may be asked to show identification
to a staff member. Students who leave by
themselves or go home without permission will
6
receive an unexcused absence, a note home and
may result in termination from the ASES Program.
STUDENT BEHAVIOR AND EXPECTATION
It is the goal of our YMCA to provide a healthy,
safe and secure environment for all participants.
Children attending ASES are expected to exhibit
Character Counts values, follow basic behavior
guidelines and to interact appropriately in a group
setting.
Discipline is viewed by our staff as a teaching
opportunity. Our goal is to teach children the kind
of self–control that results in appropriate, and
cooperative behavior.
Redirection is the first logical step to behavior
management. Should a problem persist, natural
consequences and removal from the activity will be
used as a form of discipline. In the event that
chronic behavior problems develop, incidents will
be documented and communicated to the parent.
The following behaviors are unacceptable and may
result in the immediate suspension of a child for
the remainder of the current day and/or further time
period:
•
•
•
•
•
•
•
Endangering or threatening to endanger the
health and safety of others, self, children, staff
or volunteers.
Stealing or damaging YMCA, host site, or
personal property.
Leaving the program or boundaries as set by
staff without permission.
Continuous disruption of the program.
Refusal to follow the behavior guidelines of the
program.
Using profanity, vulgarity or obscenities.
Acting in a lewd manner.
While the before mentioned is the general outline
of behavior procedures, the YMCA reserves the
right to ask parents to find alternative
arrangements for their child without prior
notification, as deemed necessary for the safety of
staff and/or program participants, not limited to the
before mentioned behaviors.
Immediate expulsion may occur if a child is in
possession of and/or using tobacco, alcohol, illegal
drugs, firearms, knives, explosives or any other
weapon.
Be Safe
Be Respectful
Be respectful of others and obey all school
personnel
Use appropriate and polite language at all times
Be respectful of school and personal property
Students who violate ASES Program Behavioral
Expectations will receive the following
consequences:
1st Incident: Behavior Report sent home, copy of
report filed in student’s records, school teacher
notified, and parents notified.
2nd Incident: Behavior report sent home, copy of
report filed in student’s records, school teacher
notified, parents notified, and 1 week suspension
from ASES Program.
3rd Incident: Behavior report sent home, copy of
report filed in student’s records, school teacher
notified, parents notified, and child expelled from the
ASES Program.
EMERGENCY CARE CARD
•
The ASES program Emergency Card is the most
important piece of information you provide to the
staff. Your child safety and well-being depend on
it. It must be accurate and up-to-date at all times.
If your child becomes suddenly ill or has an
accident at school, the staff will use the
information on the Emergency card to call you or
your designated contact person. Remember:
•
Names on the Emergency card must be persons
you trust to pick up your child in an emergency.
•
Designated persons must be adults over 18 years
of age.
•
Phone numbers must be accurate, up-to-date and
in service.
•
Please submit all pager numbers and cell phone
numbers as well.
•
If changes in your Emergency information occur
during the year, please take the time to update
your card and inform the staff. Names may be
7
added or removed at any time.
and hearing of staff, until the parent arrives. If the
parent cannot be reached, the staff will phone the
emergency contact person(s) listed on the child’s
enrollment form. The YMCA is not licensed to
provide care for sick children. Parents or
emergency contacts are required to pick up the ill
child within one hour of being contacted.
The Site Coordinator or designated staff have
the authority to ask a parent to remove their
child from the program, if that child appears ill
or their health is judged to be detrimental to the
other children and staff.
Children exhibiting the following symptoms may not
attend the program:
•
•
•
•
•
•
•
•
•
•
Severe pain
Temperature over 100
Diarrhea
Blood in urine
Swollen joints
Jaundiced skin, yellow eyes or red eyes with
discharge
Visibly enlarged lymph nodes
2 or more episodes of vomiting in a 24 hours
Infected/untreated skin patches or rash
lasting more than one day
Evidence of head lice or nits
INJURIES
All injuries will be treated as needed, including
washing, applying Band-Aids or ice packs. Parents/
Guardians will be notified upon pick up, and given
an “ouch report” explaining the details and aid
given. Please note, in accordance with sanitation
and state regulations, YMCA staff cannot
administer any cream ointment or anti-bacterial
solutions. Parents/ Guardians will be contacted
immediately in the case of more serious injuries, in
which medical attention is needed.
CHILD ABUSE, NEGLECT, AND SPECIAL
NEEDS
The State of California considers all ASES Program Staff
“Mandated Reporters.” This requires the staff to report
any and all cases of suspected child abuse. All staff are
trained in child abuse awareness. Program staffs have
been screened through the department of Justice and
Child Abuse Index.
Channel Islands YMCA will accept children with
special needs into our programs and makes a
reasonable effort to accommodate the child without
fundamentally altering the child care program. The
Channel Islands YMCA provides group child care
and
is not able to provide personal assistants for
children with special needs. If a child needs an
aide please contact the program director for
directions in placing an assistant in our program to
aide your child.
NUTRITION
As part of the National Lunch Program, all ASES
participants will receive a free afternoon snack. This
snack includes two of the four basic food groups.
Cooking projects may accompany the daily snack, as well
as provide opportunities for nutritional education. If you
provide your child with a snack from home, we ask that
it be a nutritious snack such as apples, peanut butter,
juice, oranges, cheese and crackers, ½ sandwiches.
Unhealthy snacks are not allowed.
If your child has any dietary restriction or allergies,
please contact the program coordinator so an alternative
snack may be provided. Be sure to include it on the
student’s emergency card. Please do not send fast
food, soda or candy!
MEDICATION
You must provide staff with a completed signed
medication form when your child is taking any
medication. This form is available in the school office.
8
PHOTO RELEASE
The Channel Islands YMCA may take photos,
videos or sound recordings of your children in our
childcare programs. We often use them for crafts or
projects. The YMCA is not required to contact you
regarding using photos.
Emergency/Natural Disaster Plan
In the event a natural disaster occurs, our goal is to
keep children safe and calm. The staff will
determine the safest plan of action. The Site
Coordinator will always keep the children’s
emergency information with them at all times.
Our designated area of safety in the event we need
to evacuate the facility is the grass field located on
each school’s campus. You may want to consider
making arrangements for a friend or relative who
works or lives close to the YMCA to pick up your
child in case of a disaster.
Their names must be included on the emergency
contact list on your Emergency/Health Information
Form. Remember, they must have a Photo ID and
they must be at least 18 years old. It is also a good
idea to have an out of state contact to call in case
of a natural disaster.
CAUSE FOR TERMINATION
The following is a review of reasons for which a student’s
enrollment may be terminated.:
1. Lack of program funds.
2. Determinations the student’s needs are not being
met by program after appropriate accommodations
are made.
3. More than 3 unexcused absences.
4. More than 3 late pick-ups.
5. Three “incidents” on the Behavior Incident
Expectations Report.
6. Student behavior that threatens the health and
safety of students or staff.
7. Non-compliance to rules & policies parents or
students
8. Abusive language or treatment of staff by parents or
students.
Often out of state phone lines are still active in the
event of a local disaster. Remember, making plans
prior to emergencies can expedite the safe release of
your child.
Site closure due to a natural disaster is at the
discretion of the Program Directors, or the Executive
Director. If questionable situations arise, please call
the Lompoc Family YMCA at 805.736.3483.
SITE LOCATIONS
The Lompoc Family YMCA and Boy’s and Girl’s Club
operate ASES programs at the following local schools:
La Honda Elementary
1213 North ‘A’ Street, LO 93436
805.742.2300
Lompoc Family YMCA
PROGRAM CONCERNS OR QUESTIONS
The YMCA encourages constant communication
between parents, staff, and children to assure
everyone’s needs are being met. If you should ever
have a problem, concern or question, we encourage
you to ask you’re ASES staff. Should they not be able
to meet your needs, please contact the Program
Director at the main YMCA facility. It is through your
input that we are better able to meet the needs of the
community and enhance the quality of our programs.
THANK YOU!
We are happy that you have selected the ASES
Program for your child. We offer days filled with
happiness, wonderful activities and educational fun.
We thank you for sharing your child with us.
9
EMERGENCY/HEALTH INFORMATION HISTORY FORM
General Information (Please print)
Child’s Name: ______________________________________________Age __________
M______F_____ Grade in Sept ’12_____________
Address: ___________________________________________________City
____________________________________Zip _______________________
Home Phone: _________________________________ School: ______________________________
Birthday: _____/______/_____
Father’s Name ___________________________________________________________ Father’s
Birthday: ________/_________/__________
Father’s Work Phone_____________________________________ Father’s Cell Phone
_________________________________ _________
Father’s E-Mail Address_________________________________ Mother’s E-Mail
Address____________________________________
Mother’s Name_________________________________________________________ Mother’s Birthday:
_________/_________/___________
Female head of household
Mother’s Work Phone_____________________________________ Mother’s Cell Phone
_________________________________________
Child lives with __________________________________________________
_____________________________________
Relationship
Please attach copies of any legal documentation regarding non-custodial parents
Health Information
Has your child had any serious or severe illnesses or accidents in the last 3 years?
Yes
No
If yes, explain
____________________________________________________________________________________
____________________________
Does the child take any medication during the day?
Yes
No
If yes, Medication Release Form is required. Please list medications:
___________________________________________
Allergies? Yes
No If yes, list:
____________________________________________________________________________________
_
Please check all immunizations which are current:
POLIO
DTP
MMR
HIB
HEB A
HEB B
CHICKEN POX
Special needs or fears?
Yes
No If yes,
explain:___________________________________________________________
Physician: ___________________________________________ Phone: _____________________________
Dentist : ___________________________________________ Phone: _____________________________
Insurance Co: ___________________________________________________________ Group #:
__________________________________________
Emergency Contacts/ Authorized Pick-Up (In addition to Parents)
Name: _____________________________ Phone: ____________________ Relationship: _______________
Name: _____________________________ Phone: ____________________ Relationship: _______________
Name: _____________________________ Phone: ____________________ Relationship: _______________
10
Walking Fieldtrip permission, Consent to Treatment and Release, Child’s
Health Statement, Photographic Release, and Insurance Disclaimer
Child’s Name (Please Print) ______________________________________________
PERMISSION FOR FIELDTRIPS, WALKING FIELDTRIPS, WALKING EXCURSIONS, AND USE
OF PUBLIC PARK FACILITIES
I hereby give consent to the Channel Islands YMCA and its designated leaders to take the above
named child on walking trips in the neighborhood, public park facilities, special excursions to
places of interest in YMCA vans, buses, commercial vehicles, public transportation, or rented
vans or buses, with the understanding that such trips are under supervision of authorized
personnel of the YMCA and that all possible precautions are taken to insure the health and safety
of my child.
Initial ___________
CONSENT FOR EMERGENCY MEDICAL TREATMENT
As the parent [ ], domestic partner [ ], or authorized representative [ ], I hereby give consent to
Channel Islands YMCA to obtain all emergency medical or dental care prescribed by a duly
licensed physician (M.D) Osteopath (D.O.) or Dentist (D.D.S.) for the child named above. This
care may be given under whatever conditions are
necessary to preserve the life, limb or well being of a child named above.
Initial ___________
CHILD’S HEALTH STATEMENT
I, the undersigned parent/legal guardian, understand that at a YMCA Camp Program and
Childcare Program, physical activity is a regular part of the program. To the best of my
knowledge, my child is in excellent physical health and needs no restrictions (except what is listed
on the Emergency/Health Information Form) from strenuous physical activity. If I have any
questions regarding my child’s health, I understand that it is my obligation to seek professional
medical advice and to inform the Channel Islands YMCA of any restrictions on my child’s
activities.
Initial ___________
PHOTOGRAPHIC RELEASE
In exchange for good and valuable consideration, the adequacy of which is hereby
acknowledged, I hereby give Channel Islands YMCA, its volunteers, employees and any other
person and entity acting with its permission the right to take, copyright, use, and publish any
photographs or video of the above named child for the purpose of any YMCA advertising,
promotion, or other purpose consistent with the YMCA mission.
I agree that any such photograph or video is the property of the Channel Islands YMCA, and I
hereby waive all rights thereto. I further waive any right to inspect or approve any printed or
electronic material that may be used in conjunction with the photographs or video, or to approve
the use to which the photographs or video may be applied.
Initial ___________
INSURANCE DISCLAIMER
Channel Islands YMCA does not carry health or accident insurance on its members or
participants. All expenses incurred in the treatment of illness, injuries or accidents will be the11
responsibility of the participant’s parents or guardians.
Initial ___________
PARTICIPANT SWIM ABILITY ASSESSMENT FOR MINOR :
The YMCA program may include aquatic activities at a pool, beach or other location with water. Your initial
below authorizes your child to participate in swimming activities.
Please check the box below with the description that most closely fits the participant.
Type I: Does not know how to swim or is uncomfortable or nervous around water. Cannot put their
face in the water, hold their breath, right themselves or float.
Type 2: Can hold their breath, fully submerge their head under water, right themselves, float
unsupported for five (5) seconds, flutter kick and can turn over from front and back. Is
uncomfortable in water over their head and is unable to propel themselves beyond ten (10) yards.
Type 3: Comfortable in deep water, can demonstrate basic swimming stroke techniques with
controlled breathing, can propel themselves twenty five (25) meters and tread water for two minutes.
Type 4: Comfortable in deep water, can demonstrate advanced swimming stroke techniques with
controlled breathing, can continuously propel themselves for a minimum of 100 meters, tread water for
four (4) minutes and swim fifteen (15) meters under water.
Initial: __________
PERMISSION FOR AUTHORIZING USE OF SUNSCREEN:
I understand that providers now must have written permission from parents authorizing use of sunscreen and identifying
the Sunscreen Brand and Sun Protection Factor (SPF) to be used on children. The Channel Islands YMCA is trying to avoid
the possibility of an allergic reaction.
I hereby give consent to the Channel Islands YMCA and its designated leaders to apply sunscreen, which I have provided
for my child during the YMCA program. The staff may use the brand provided by the Channel Islands YMCA in the event
my child does not have their own sunscreen.
Sunscreen provided by parent: (brand)___________________________ SPF: ___________________
I understand that a large portion of our day will be spent outdoors.
Initial:__________
I understand that I am required to provide my sunscreen for my child and I authorize the YMCA Staff to directly
apply the sunscreen to my child.
Initial: __________
CODE OF CONDUCT FOR ALL PARTICIPANTS:
By Submitting this application, you, for yourself or on behalf of your minor child, agree to abide by the policies and
conditions of the Channel Islands YMCA Association "Code of Conduct.” The “Code of Conduct” can be found at the front
service center of your local YMCA.
Initial: __________
MANDATED REPORTING:
I understand that the YMCA staff is mandated by state law to report any suspected cases of child abuse or neglect to the
appropriate authorities for investigation.
Initial: __________
I HAVE READ AND AGREE TO THE ABOVE INFORMATION:
_________________________________________
Parent or Legal Guardian’s Signature
_________________________________________
Printed Name
_________________
Date
April 2012
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CHANNEL ISLANDS YMCA
MEMBER/CHILDREN
RELEASE and WAIVER of LIABILITY and INDEMNITY AGREEMENT
IN CONSIDERATION of being permitted to utilize the premises, facilities, services and programs of the Channel Islands
YMCA, YMCA, (or for my children to so participate) for any purpose, including, but not limited to observation or use of
facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or
herself and such participating children and any personal representatives, heirs, and next of kin, hereby acknowledges,
agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully
consider such premises and facilities or the affiliated program. It is further warranted that such entry onto the YMCA’s
facilities for observation or use of any facilities or equipment or participation in such affiliated program constitutes an
acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been
inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably
suited for the purpose of such observation, use or participation by the undersigned and such children.
IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT
LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION 1N ANY OFF-SITE PROGRAM
AFFILIATED WITH YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:
THE UNDERSIGNED ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES
AND CONVENANTS NOT TO SUE the YMCA and all branches thereof; its directors, officers, employees, and agents
(hereinafter referred to as "releasees") from all liability to the undersigned or such children and all his personal
representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account
of injury to the person or property or resulting in death of the undersigned or such children whether caused by the
negligence of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or
any facilities or equipment therein or participating in any program affiliated with the YMCA.
THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them
from any, loss, liability, damage or cost they may, incur due to the presence of the undersigned or such children in,
upon or about YMCA’s premises or in any way observing or using any facilities or equipment of the YMCA or
participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or otherwise.
THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY
DAMAGE to the undersigned or such children due to negligence of releasees or otherwise while in, about or upon the
premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any
program affiliated with YMCA.
THE UNDERSIGNED further expressly agrees that the foregoing RELEASE WAIVER AND INDEMNITY AGREEMENT is
intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof
is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
THE UNDERSIGNED' HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY
AGREEMENT, and further agrees that no oral representations, statements or inducment apart from the foregoing
written agreement have been made.
I HAVE READ AND UNDERSTAND THIS DOCUMENT AND RELEASE
Date: ______________________________
Print Name: _____________________________________________
Signature of Applicant/Parent: ______________________________
Signature of other Adult:___________________________________
Name of Child in Program: _________________________________
Name of Child in Program:_________________________________
Name of Child in Program: _________________________________
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Exhibit E 5148.2
A.S.E.S
Lompoc Unified School District
After School Education and Safety (ASES) Program
EARLY RELEASE POLICY – MIDDLE & ELEMENTARY SCHOOL
Legislation – Ed. Code 8483 (a) (1):
Every after school component of a program established pursuant to this article shall commence immediately upon the
conclusion of the regular school day, and operate a minimum of 15 hours per week for elementary and 9 hours per week
for middle school, and at least until 6p.m. on every regular school day. Every after school component of the program
shall establish a policy regarding reasonable early daily release of pupils from the program. For those programs or
school sites operating in a community where the early release policy does not meet the unique needs of the community or
school, or both, documented evidence may be submitted to the department for an exception and a request for approval of
an alternative plan
Early Release and Late Arrival Policy
The ASES grant requires after school programs begin at dismissal time for the regular instructional day and remain open
until 6:00 p.m. each day school is in session. Elementary school students are required to attend every day for a
minimum of 15 hours a week and junior high (middle school) students must attend a minimum of 9 hours a week.
Students may; however, leave the program early or enter the program late as listed below.
Students who are absent from ASES and do not appear on the school’s absence list must bring a note to the ASES
Site Coordinator the next day to explain the reason for the absence.
Any student failing below the minimum number of hours and attending 5 days per week may be dropped from ASES. If a
student is dropped, a parent must re-apply and the student may be placed on the waiting list.
A student who leaves early or arrives late may be signed in or signed out by a parent, a designee listed by the
parent/guardian on the emergency card or an ASES Program staff member and the time of departure or arrival must be
recorded.
A student may
conditions:






A student may



be released early from ASES prior to the end of the program time at 6 p.m. based on the following
Family emergencies (such as death in the family or other catastrophic incidents)
Medical appointments
Weather conditions particularly is a child walks home during Daylight Savings Months
Child accidents that occur during the ASES Program
Religious-related activities
Sports, Community Events & other activities
arrive late to program for following reasons:
Academic tutorial
Leadership classes
Sports
Each parent shall sign an early release form if their child is leaving prior to 5:15pm for middle school and 5:15pm
for elementary school students. The students may be signed out after that time period as needed without signing an
early release form. Students are STILL required to meet their hourly requirements (attending 5 days per week) for their
enrollment into the ASES program.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------I agree to follow the revised Early Release and Late Arrival Policy as outlined above. I understand that I am responsible
for my child’s attendance requirements and that my child may be dropped from ASES, if he/she does not meet the hourly
requirements for the ASES grant.
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Parent/Guardian Signature: __________________________________________ Date: __________________________
Exhibit E 5148.2
A.S.E.S
Distrito Escolar Unificado de Lompoc
Programa Educativo y Seguridad Después de Clases (ASES)
NORMAS DE SALIDA TEMPRANO –ESCUELA INTERMEDIA Y PRIMARIA
Legislación – Código Educativo 8483 (a) (1):
Cada componente de un programa después de clases establecido conforme a este articulo deberá comenzar inmediatamente
después de la conclusión del día escolar regular, y deberá llevarse a cabo por un mínimo de 15 horas por semana para los
estudiantes de escuela primaria y 9 horas por semana para los estudiantes de escuela intermedia y por lo menos hasta las
6p.m. durante cada día escolar regular. Cada componente de un programa después de clases debe establecer una norma en
referencia a una salida temprano razonable para los estudiantes del programa. Para aquellos programas ó escuelas trabajando
en una comunidad donde las normas de salida temprano no cumplen con las necesidades específicas de la comunidad ó de la
escuela ó de ambas, podrá someterse evidencia documentada al departamento para una excepción y una solicitud para la
aprobación de un plan alternativo.
Normas de Entrada Tarde y Salida Temprano
Los fondos del programa ASES requieren que los programas después de clases comiencen a la hora de la salida de un día
regular de instrucción y se mantenga abierto hasta las 6:00 p.m. cada día que la escuela este en sesión. Se requiere que los
estudiantes de escuela primaria asistan cada día por un mínimo de 15 horas por semana y los estudiantes de escuela
intermedia asistan un mínimo de 9 horas por semana. Sin embargo, los estudiantes podrán salir temprano del programa ó
entrar tarde como se indica a continuación.
Los estudiantes que estén ausentes del programa ASES y no aparezcan ausentes en la lista escolar de ausencias deberán
traer una nota al Coordinador Escolar del programa ASES al día siguiente para explicar la razón de la ausencia.
Cualquier estudiante que no cumpla con la cantidad de horas mínimas y con asistir 5 dias por semana podrá ser dado de baja
del programa ASES. Si el estudiante es dado de baja, el padre tendrá que volver a aplicar y puede que el estudiante sea
asignado a una lista de espera.
Un estudiante que salga temprano ó llegue tarde puede ser registrado por un padre, un adulto asignado por el padre/apoderado
legal que este indicado en la tarjeta de emergencia ó por un miembro del personal del Programa ASES y deberán asegurarse
de incluir la hora de la salida ó entrada en el registro.
Un estudiante puede salir temprano de ASES antes del final del programa a las 6 p.m. de acuerdo a las siguientes
condiciones:

Emergencias Familiares (tal como fallecimiento de algún familiar cercano ó incidentes de gravedad)

Citas medicas

Condiciones del clima, particularmente si el estudiante camina a casa durante los meses que se obscurece
más temprano

Accidentes de los estudiantes que ocurran durante el programa ASES

Actividades religiosas

Deportes, Eventos de la Comunidad y otras actividades
Un estudiante puede llegar tarde al programa por las siguientes razones solamente:

Tutoría Académica

Clases de liderazgo

Deportes
Cada padre tendrá que firmar un formulario de salida temprano si su estudiante saldrá antes de las 5:15 pm para los
estudiantes de escuela intermedia y 5:15 pm para los estudiantes de escuela primaria.
Los estudiantes podrán salir
después de ese periodo de tiempo cuando sea necesario sin tener que firmar un formulario de salida temprano. Los estudiantes
AUN tienen el requisito de cumplir las horas necesarias (asistir 5 dias por semana) para permanecer inscritos en el programa
ASES.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------Estoy de acuerdo en seguir las Normas de Entrada Tarde y Salida Temprano como son indicadas anteriormente. Entiendo que
soy responsable por los requisitos de asistencia de mi estudiante y que mi estudiante puede ser dado de baja del programa
ASES si no cumple con el requisito mínimo de las horas necesarias del programa ASES.
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Firma del Padre/Apoderado Legal: __________________________________________ Fecha: _____________________
CHANNEL ISLANDS YMCA
Branches:
Camarillo – Lompoc – Montecito -Santa Barbara
Stuart C. Gildred – Ventura - Youth & Family Services
PARENT STATEMENT OF UNDERSTANDING
The following information is important for the safety and protection of your child. Please read the
information, sign this form and return it to the YMCA.
I understand that YMCA staff are not allowed to babysit or transport children at any time outside
of the YMCA program. Immediate disciplinary action will be taken by the YMCA toward staff and
volunteers if a violation is discovered.
I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff or
volunteer is there to receive and supervise my child.
I understand that my child will not be allowed to leave the program with an unauthorized person.
Any person authorized to pick up my child must either be listed with the YMCA or other
arrangements must be made by calling the YMCA office to inform them of a change.
I understand that should a person arrive to pick up my child who appears to be under the
influence of drugs or alcohol, for the child's safety, staff may have no recourse but to contact the
police. Please do not put staff in a position where they have to make this judgment call.
I understand that the YMCA is mandated, by state law, to report any suspected cases of child
abuse or neglect to the appropriate authorities for investigation.
I have received a copy of the YMCA Handbook. I have read and understand the statements
above and in the YMCA Handbook:
(Please check one)
Preschool
Handbook
Afterschool
Handbook
Camp
Handbook
______________________________________________________
___________________
Parent or Legal Guardian’s Signature
Date
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