Dear Family,

Thank you for your interest in the Los Cerritos YMCA Before and After School Licensed Child Care

Program. We look forward to working with you and your children to meet the needs of your family. It is

important when you are filling out this pre-enrollment packet that you do the following:

One application per child

Print Clearly

Use a black or blue ink pen (no pencil or white-out)

Answer all Questions

Make sure to sign all paperwork where a signature is required

In addition, the following documents must be turned in before the enrollment of your child can begin:

2 Current pictures of your child

Immunization record

Other documentation, if applicable

It is strongly encouraged to call the Office to schedule a registration appointment once you have

completed a packet. Walk- in appointments are offered between 9:00am and 4:45pm. If you would like

to complete registration between 5:00pm-6:00pm please be advised that an appointment is necessary.

Paperwork must be turned in at the time of your appointment before enrollment can begin

Your scheduled appointment is on: Date______________________ at _______________a.m./p.m.

If you have any questions before your appointment please contact the Los Cerritos YMCA Office at (562)

925-1292. Be advised, incomplete paperwork may delay the enrollment of your child. Once again, we

would like to thank you for your interest in the Los Cerritos YMCA Before and After School Licensed

Child Care Program.

LOS CERRITOS YMCA OFFICE

15530 Woodruff Avenue, Bellflower CA 90713 P 562 925 1292 F 562 925 2192

BEFORE AND AFTER SCHOOL ACADEMIC ENRICHMENT REGISTRATION 2015/2016

PARTICIPANT INFORMATION

Participant’s First Name:

Participant’s Last Name:

YMCA Site:

Date of birth:

Age in Fall 2015

Sex:

M F

Grade Entering:

School Enrolled:

Teacher’s Name:

Class Room #:

Home address:

City:

State:

Zip Code:

Start Time:

Dismissal Time:

Home Phone Number:

Best Contact Phone Number:

Special disabilities or illnesses:

List Any Known Allergies:

Child Lives With (circle one)

Mother Father Both 50/50 Other (Explain):

PARENT OR GUARDIAN INFORMATION

(The “Responsible Party” is the parent/guardian enrolling the child and is responsible for payment of fees, signing releases, authorizing

individuals to sign out the child and making any changes to the child’s participation in the program.)

Responsible Party First and Last Name:

Date of birth:

Relationship to child:

Home address (if different from the child):

City:

State:

Zip Code:

Best Contact Number:

Employer Name:

Work Phone:

Email Address:

2nd Parent/Guardian Parent’s First and Last Name:

Date of birth:

Relationship to child:

Home address (if different from the child):

City:

State:

Zip Code:

Best Contact Number:

Employer Name:

Work Phone:

Email Address:

In order that we may protect you and your child, please indicate below who you would allow to pick up your child from YMCA programs. We will not release your

child to anyone else. If you need to add someone you must come in and personally add them to the list. If you need someone else to pick up your child not on list

below, you may fax a one day approval with the name of your child, the name of the person picking up your child, the date and your signature. This type of

authorization is only good for one day; you must come in to the Los Cerritos YMCA Child Care Offices to add them to the original form if they are to continue to

pick your child up. (Minimum of two required)

Name Phone #1 Phone #2 Relationship to child Pick-Up Emergency

□ □

□ □

□ □

The following individuals are restricted from signing out my child due to a court-issued restraining order (a certified copy of the official court

documentation must be submitted and on file with the YMCA).

BEFORE AND AFTER SCHOOL ACADEMIC ENRICHMENT REGISTRATION 2015/2016

Child’s Name:

Child’s Date of Birth:

Parental Consent to Treat

I hereby certify that the individual on this application is in good health and capable of participating in and using the camp program, equipment and facilities. I understand

that my child must comply with the camp's rules and standards for participant behavior. I agree that the YMCA of Greater Long Beach has the right to enforce appropriate

standards of conduct and that the organization may terminate my child's participation in the camp program if he/she does not maintain these standards. Further I give my

consent for the use of my son/daughter's comments and photographs to be used in promotional materials for the YMCA of Greater Long Beach. This Health History is correct

so far as I know, and the person herein described has permission to engage in all prescribed camp activities, except as noted on this health form. The undersigned, as parent

or legal guardian of the child registered on this form, hereby authorizes the YMCA and its delegated leaders and directors to consent to any medical and hospital care, (which

may include but not be limited to X-rays, anesthesia, surgery, hospital care and dental work), to be rendered to said minor upon the advice of a licensed physician or dentist.

This authorization is given pursuant to the provisions of the California Medical Practice Act. It is understood that if time and circumstances reasonably permit, the YMCA will

endeavor, but is not required, to communicate with me prior to such treatment. The undersigned further agrees that the YMCA and its designated leaders and directors are

not responsible for costs incurred for medical care or for any claim arising from any consent given in good faith in connection with such diagnosis or advised treatment. This

authorization and consent to treatment is given to the YMCA in conjunction with any authorized event.

Parent’s Signature Date

Insurance Information

I understand that I am responsible for the medical fees of my child, if he/she

should be injured or is ill at the YMCA of Greater Long Beach, or during YMCA

of Greater Long Beach activities or field trips.

Insurance Carrier:

Policy Number:

Name of Family Physician: Phone Number: Name of Dentist: Phone Number:

Department of Children’s Services (if applicable) Case Worker’s Name: Phone #: Case #:

Health History

Include Past and Present Conditions

Asthma □ Yes □ No

Heart Defects/Disease □ Yes □ No

Recent Hospitalizations □ Yes □ No

Currently Under Doctor’s Care □ Yes □ No

Seizures □ Yes □ No

Diabetes □ Yes □ No

ADD/ADHD □ Yes □ No

Head Lice (recent) □ Yes □ No

Bedwetting □ Yes □ No

Sleepwalking □ Yes □ No

Tuberculosis □ Yes □ No

Chicken Pox □ Yes □ No

Measles □ Yes □ No

German Measles □ Yes □ No

Ear Infection □ Yes □ No

Other Diseases or Conditions:

Operations or Serious Injuries:

If yes to any, please explain:

Immunization Dates

MMR (Measles, Mumps, Rubella):

DPT:

Tetanus:

Polio OPV (Sabin ):

Other:

Allergies: Hay Fever □ Yes □ No

Bee Stings □ Yes □ No

Penicillin □ Yes □ No

Oak/Ivy Poisoning □ Yes □ No

Bee Sting Kit? □ Yes □ No

Other Drugs □ Yes □ No

Foods □ Yes □ No

Other insects □ Yes □ No

Other animals □ Yes □ No

Any other allergies □ Yes □ No

If yes, please explain:

Female Participants Only Has your child started her menstruation cycle?

□ Yes □ No

If no, has she been talk to about it?

□ Yes □ No

Dietary Restrictions:

Activity Restrictions:

My child takes medication: □ Yes □ No *Please see your site director if the YMCA needs to administer medication

Medication: Dosage: Time:

Medication: Dosage: Time:

Medication: Dosage: Time:

PROGRAM PARTICIPATION PLAN

Program Plan:

□ AM Only Care

□ PM Only Care

□ AM & PM Care

□ PM Care with Breaks (September Start Only)

□ AM & PM Care with Breaks (September Start Only)

Payment Method:

□ Monthly Automatic Debit - ATS Form Require

□ Monthly over the counter payment by cash, check, debit or credit card

□ Current Agency Certificate

I authorize the verification of the information provided on this form. I acknowledge that I have received a copy of the parent handbook and are responsible for

the information it contains, including but not limited to program policies, procedures and financial obligations.

Parent/Legal Guardian Name (print):

Parent/Legal Guardian Signature:

Date:

YMCA OF GREATER LONG BEACH PHOTO

AND VIDEO/AUDIO RECORDING RELEASE

I am 18 years of age or older and, if not, my Mother/Father/Legal Guardian has also signed below.

For my participation in activities to be conducted by YMCA of Greater Long Beach, I hereby give my

permission and consent, now and for all time, to YMCA of Greater Long Beach, the National Council of Young

Men’s Christian Associations of the United States of America (YMCA of the USA) and third parties

collaborating with YMCA of Greater Long Beach and/or YMCA of the USA to make, reproduce, edit, broadcast

or rebroadcast any video film, footage, sound track recordings and photo reproductions of me and/or my

narrative account of my experience at YMCA of Greater Long Beach for publication, display, sale or exhibition

thereof in promotions, advertising and legitimate business uses without any compensation to, and/or claim,

by me. I may, or may not be, identified in such reproductions; however, I shall not be stated by name to

have endorsed any particular commercial products or commercial services.

I further agree to the following:

- Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative

account of my experience at YMCA of Greater Long Beach, I authorize, according to this Release, shall

belong to YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of

Greater Long Beach and/or YMCA of the USA. Therefore, they will have full right of disposition of any video

film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my

experience YMCA of Greater Long Beach;

- Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative

account of my experience YMCA of Greater Long Beach will not be subject to any obligation of

confidentiality and may be shared with and used by YMCA of Greater Long Beach, YMCA of the USA and

third parties collaborating with YMCA of Greater Long Beach and/or YMCA of the USA;

- YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long

Beach and/or YMCA of the USA shall not be liable for any use or disclosure to a third party of any video

film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my

experience at YMCA of Greater Long Beach; and

- YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long

Beach and/or YMCA of the USA shall exclusively own all known or later existing rights to worldwide and

shall be entitled to the unrestricted use any video film, footage, sound track recordings and photo

reproductions of me and/or my narrative account of my experience at YMCA of Greater Long Beach for any

purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge YMCA of Greater

Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long Beach and/or YMCA

of the USA from any and all claims in connection with the uses and reproductions of any video film, footage,

sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA

of Greater Long Beach as described herein.

Signature: ________________________________Printed Name: _____________________________

Age: _________ Address: ______________________________________________

I am the Mother/Father/Legal Guardian of (child’s name). For the

consideration contained herein, I hereby consent to the foregoing on behalf of my minor child.

Signature of Mother/Father/Legal Guardian: ___________________________________

Date: __________________

PERMISO PARA GRABACIÓN

EN VIDEO/AUDIO Y FOTOGRAFÍAS

Tengo 18 años o más y, en caso contrario, mi madre/padre/tutor legal también firmó abajo.

Para participar en las actividades que llevará a cabo el Consejo Nacional de la Asociación Cristiana de

Jóvenes de Estados Unidos (Young Men’s Christian Associations, YMCA), por la presente doy mi

consentimiento y permiso, ahora y para siempre, a la YMCA de Estados Unidos y a los terceros que colaboran

para hacer, reproducir, editar, transmitir o retransmitir toda película en video, imágenes, grabaciones de

pistas de sonido y reproducciones de fotos de mi persona y/o mi descripción narrativa de mi experiencia

dentro de dichas actividades, para publicación, muestra, venta o exhibición de éstas en promociones,

publicidades y usos comerciales legítimos sin ninguna remuneración a cambio o ninguna reclamación de mi

parte. Puedo, o no puedo, ser identificado en dichas reproducciones; sin embargo, no seré indicado por

nombre para promocionar cualquier producto comercial o servicio comercial en particular.

Asimismo acepto lo siguiente:

- Toda película en video, imágenes, grabaciones de pistas de sonido y reproducciones de fotos de mi

persona y/o mi descripción narrativa de mi experiencia durante dichas actividades, que autorizo

conforme a este permiso, pertenecerán a YMCA de Estados Unidos y a los terceros que colaboran. Por

lo tanto, tendrán plenos derechos de la disposición de las películas en video, imágenes, grabaciones

de pistas de sonido y reproducciones de fotos de mi persona y/o mi descripción narrativa de mi

experiencia dentro de dichas actividades.

- Toda película en video, imágenes, grabaciones de pistas de sonido y reproducciones de fotos de mi

persona y/o mi descripción narrativa de mi experiencia dentro de dichas actividades no quedará

sujeta a ninguna obligación de confidencialidad y se podrá compartir con la YMCA de Estados Unidos y

ser utilizada por ésta y los terceros que colaboran.

- La YMCA de Estados Unidos ni los terceros que colaboran serán responsables del uso o la divulgación

a terceros de las películas en video, imágenes, grabaciones de pistas de sonido y reproducciones de

fotos de mi persona y/o mi descripción narrativa de mi experiencia.

- La YMCA de Estados Unidos y los terceros que colaboran poseerán exclusivamente todos los derechos

conocidos o que existan más adelante en el mundo y tendrán derecho al uso ilimitado de las películas

en video, imágenes, grabaciones de pistas de sonido y reproducciones de fotos de mi persona y/o mi

descripción narrativa de mi experiencia para cualquier fin sin ningún tipo de remuneración a cambio.

Acepto que este consentimiento y permiso son irrevocables. Por medio de la presente libero y eximo a YMCA

de Estados Unidos y a los terceros que colaboran de toda reclamación relativa al uso y la reproducción de las

películas en video, imágenes, grabaciones de pistas de sonido y reproducciones de fotos de mi persona y/o

mi descripción narrativa de mi experiencia como se describe aquí.

Firma: _______________________________________

Nombre en imprenta: ___________________________

Edad: ________________________________________

Dirección: ____________________________________

Soy la madre/el padre/tutor legal de ______________________ (nombre del niño). Para la consideración

que se incluye aquí, doy mi consentimiento para lo precedente en representación de mi hijo menor de edad.

Firma de la madre/del padre/tutor legal: ____________________

Fecha: _______________________________________________

Electronic Funds Transfer (EFT) Authorization Form - Child Care

Account Holder Information:

Last Name:________________________________________________________ First Name: ____________________________________________ Middle Initial: _____

Home Address: _____________________________________________________________________________________________________________________________________________ Street Unit# City State Zip Code

Home Phone: _____________________________________________________ Work/Cell Phone: ________________________________________________________________

Financial Information (choose one):

Program Participant Policies and Authorization

Electronic Funds Transfer (EFT) is the automated monthly deduction from your credit card, checking or savings account to pay for

your Y Program. To authorize the deduction you must complete this Authorization Form. The Y will process your paperwork and

notify your bank.

Please Initial:

____ Drafting Date: EFT deductions will only be taken out on the 1st of each month.

____ Cancellations: Program participants may cancel at any time provided that you notify the Y, in writing, 2 weeks prior of

the requested cancellation date. Cancellations may NOT be processed over the phone. I further understand that

canceling and/or leaving the program does not relieve me of the responsibility of paying my account in full.

____ Absenteeism: There is no credit for absences or vacations. The program payment is required whether your child is in

attendance or not.

____ Account Changes, Insufficient Funds, Declined and/or Closed Accounts: You must notify the Y of any bank account or

credit card changes, submit the new information and pay any outstanding balances. All bank drafts or credit cards

returned due to insufficient funds or any other reason will be charged a $20 processing fee.

____ YMCA Child Care Changes: YMCA Child Care fees are subject to change. The Y will make attempts to notify all program

participants in advance of any adjustments/changes made.

I understand the above information and agree to the terms. I understand that I am responsible for delinquent payments and

additional charges made to the Y for returned drafts, declined credit cards, insufficient funds, change in account or closed

account.

I hereby authorize the YMCA of Greater Long Beach to initiate debits to my checking/savings or credit card account as indicated. I

understand it will take 2 weeks to cancel and/or leave the program. All program fees are NON-REFUNDABLE and NON-

TRANSFERABLE.

___________________________________________________________ __________________________________

Signature of Account Holder Date

Checking / Savings Financial Institution: _______________________________________________ Account Number (last 4): _________________________________________ Routing Number (last 4):__________________________________________ Date of Draft: 1st

Credit Card Card Type: Visa / MasterCard / AmEx / Discover Last 4 of Card Number: __________________________________________ Expiration Date: __________/____________ Date of Draft: 1st

Office Use Draft Amount: _____________

Draft Start: _______________ Draft End: ________________ Staff I.N.: _________________

Dear School Office,

My child, ______________________________, is enrolled in the Los Cerritos YMCA Before and After School Child Care Program.

He/she will (circle one): be picked up each day the YMCA van /walk over to the YMCA classroom promptly when school

is dismissed. Please dismiss him/her promptly and remind him/her to go directly to the area indicated above. If any

disciplinary problems arise, please do not keep my child after school. The YMCA is willing to work with you at his/her

after school site if you wish to pursue disciplinary measures after school.

Thank you,

_______________________________________

Parent/Guardian Signature

(OFFICE COPY)

LOS CERRITOS YMCA

15530 Woodruff Avenue, Bellflower CA 90706 P 562 925 1292 F 562 925 2191

Dear Teacher,

My child, ______________________________, is enrolled in the Los Cerritos YMCA Before and After School Child Care Program.

He/she will (circle one): be picked up each day the YMCA van / walk over to the YMCA classroom promptly when school

is dismissed. Please dismiss him/her promptly and remind him/her to go directly to the area indicated above. If any

disciplinary problems arise, please do not keep my child after school. The YMCA is willing to work with you at his/her

after school site if you wish to pursue disciplinary measures after school.

Thank you,

_______________________________________

Parent/Guardian Signature

(TEACHER COPY)

LOS CERRITOS YMCA

15530 Woodruff Avenue, Bellflower CA 90706 P 562 925 1292 F 562 925 2191

LOS CERRITOS YMCA CHILD CARE LOCATIONS

Los Cerritos YMCA Site Hours of Operation

servicing ABC, Paramount, BUSD Before and After School

15530 Woodruff Ave. 6:30 am until school starts

Bellflower, CA 90706 School Dismissal until 6pm

Ph: 562-925-1292 Los Cerritos Site open until 6:30pm

Fax: 562-925-2191

License # 198017013

Stephen Foster Elementary School Intensive Learning Center

Servicing Foster students Servicing ILC Students

5223 E. Bigelow Street 4718 E. Michelson Street

Lakewood, CA 90712 Lakewood, CA 90712

Ph: 562-455-5226 Ph: 562-233-7748

License # 198015310 License # 198015673

Esther Lindstrom Elementary School

Servicing Lindstrom Students

5900 North Canehill Avenue

Lakewood, CA 90713

Ph: 562-916-5814

License # 198015674

2015/2016 PROGRAM FEES

Monthly Rate Monthly Rate Including Breaks, September start only

Before & After $423 $488

After School

Only

$268 $333

Before School

Only

$155

Non School Day $36/day

$180/week

Registration Fee $35