RAF Alconbury School-Age Program CARE SELECTION SHEET 2016-2017 SCHOOL YEAR

Child’s Name: School Grade:

Please place a ✓ next to the service you request for the 2016-2017 school year:

Before and After School Care

Before School Care ONLY

After School Care ONLY

______Drop-in Care ONLY

I understand that I will be billed according to the selection made above for the 2016-2017 school year. I also understand that any changes to this selection will require a “Request for Change in Care” form no less than two weeks prior to the requested change.

Parent’s Signature Date

SAP Representative Signature Date

NOTE: The RAF Alconbury School-Age Program (SAP) provides before and after school care during the school year for children ages 5-12 (K - 6

th grade) attending Alconbury Elementary. Children from

other school districts may be accepted, but transportation to and from school will not be provided by SAP.

PRIVACY ACT INFORMATION AUTHORITY: 10 USC 8013; 44 USC 3101; EO 9397 PRINCIPAL PURPOSES: To provide the Child and Youth Programs with special needs diagnosis information, supporting documentation and, if applicable, treatment information. ROUTINE USES: Form may be furnished to Alconbury Medical Advisor and will be placed in the child's file. DISCLOSURE IS VOLUNTARY: Failure to disclose information may delay enrollment or entrance into the Child and Youth Programs.

Child Placement Questionnaire RAF Alconbury Child and Youth Programs

Child's Name: _ Date of Birth: _

Program enrollment: CDC FCC SAP TC Today's Date:. _

1. Does your child have any of the following conditions? (Please mark)

a. Intellectual Disability/Developmental Delay L Other Health Impairment:

b. Visual Impairments/Blindness Asthma

c. Hearing Impairments ADD/ADHD

d. Speech/Language Impairments Diabetes

e. Emotional Disturbances Epilepsy/Seizures

f. Autism Spectrum Disorders Heart Condition

g. Orthopedic Impairments Hemophilia

h. Learning Disability Lead Poisoning

i. Behavior/Conduct Concerns Sickle Cell Anemia

j. Allergy (medication, food, etc.) Tourette Syndrome

k. Feeding Disorder

2. Please explain any condition marked above:

3. Is your child taking any medication for his/her condition? If so, please specify.

4. Is your child receiving Physical, Occupational, Speech or any other Therapy? If so, please explain.

5. Is your child receiving services from At Risk or Developmental Preschool or Pediatric Behavioral Services? _Yes No If yes, please explain.

6. Does your child have an IFSP, IEP or Treatment/Therapy/Behavior Plan? Yes No

7. Are you enrolled in the Exceptional Family Member Program (EFMP)? _ Yes _ No

Signature of Parent/Sponsor/Guardian Home/Duty Phone

IF YOU ANSWERED YES TO ANY OF THE ABOVE, THE FORM WILL BE FORWARDED TO THE MEDICAL ADVISOR. PLEASE NOTE, WE WILL NEED MEDICAL DOCUMENTATION FOR ANY ALLERGIES OR SPECIAL NEEDS TO GUIDE STAFF TRAINING AND ENSURE YOUR

CHlLD'S IN DIVIDUAL NEEDS AUE 1\1ET.

!

Copy of Current Immunization w it h

Current Flu Vaccinat ion and up to Date

immunization in accordance w it

h https://www.cd c.gov/vacci n es/hcp/a ci p-recs/i

ndex.htm I

(YYYYMMD

)J

' '

APPLICATI ON FOR DEPARTMENT OF DEFENSE CHILD CARE FEES OMB No. 0704-0515

OMB approval expires

(Read Instructions on back before completing form.) May 31, 2017

The public reporting burden for this collection of Information is estimated to average 5 minutes per response, including the lime for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0515). Respondents should be aware that notwithstanding any other provision of law, no person shall ba subject to any penalty for failing to comply with a collection of infonnation if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO THE APPROPRIATE CHILD AND YOUTH PROGRAM REPRESENTATIVE.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 10 U.S.C. 8013, Secretary of the Air Force; DoD Instruction 6060.02, Child Developrr.ent Programs; Army Regulation 608-10, Child Development Services; OPNAV Instruction 1700.9 series, Child and Youth Programs; Marine Corps Order P1710.30E, Children, Youth, and Teen Program (CYTP); Air Force Instruction 34-248, Child Development Programs; and Air Force Instruction 34-249, Youth Programs, and 34-276, Family Child Care. PRINCIPAL PURPOSE(S): To collect total family income to determine child care fees. When completed, records are covered by one of the appropriate SORNs: Department of the Army: httg://dgclo.defease: gQv{g[jy:acJ::/SORNslndexltabidl 59j Q/article/6j 6QlaQ6Q6-10-cfsc.asg ; Department of the Navy: bttr.ril dR:!::!IQ.defense.gov/grivacJ::/SOBt h lodexltabid/5915/article/6Q2:Zl omQ1 ZQ4-3.asgx; Department of the Air Force: l:lttt;rlld!2'11Q.defense. gov/12rivac/SQB sladed'./DODwideSOB 8cticielliew/tabid/6797/.8dile/5793/f034-af-sY:a-c. asgx ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies. Department of the Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the performance of their official duties relating ta child abuse reporting and investigations. Department of the Air Force records may be disclosed to civilian health and welfare departments/agencies in emergency situations. DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional Inquiries), 6 (Required by International Agreement), 9 (Department of Justice for Litigation), 12 (National Archives and Records Administration), and 15 (Data Breach Remediation) specifically apply to this system. Other DoD Blanket Routine Uses found at http://dpclo.defense gov/prjvac\u'SORNslndex/BlanketRoutioeLJses aspx may apply to these records. Any release under a blanket routine use will be compatible with the purpose of the collection. DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in application of the highest fee range.

SECTION I- DEPENDENT CHILDREN

1. NAME OF EACH CHILD (LAST, First, Middle Initial) 2. DATE OF BIRTH

3. AGE 4. CARE REQUESTED (OR ENROLLED)

a.

b.

c.

d.

e.

5. SPONSOR

SECTION II - ANNUAL FAMILY INCOME

a. NAME (LAST, First, Middle Initial) b. YEARS OF MILITARY/CIVIL SERVICE

c. INCOME (1) Income Data (2) Basic Allowance for Housing (3) Basic Subsistence (4) Other Earned Income (5) Total Income - sg,onsor

(BAH) Allowance be completed y rogram Staff)

6. SPOUSE OR OTHER ADULT LIVING IN THE HOME

a. NAME (LAST, First, Middle Initial) b. INCOME

7. OTHER EARNED INCOME 8. TOTAL INCOME (Include income from Blocks 5, 6, and 7. To be completed by Program Staff.)

SECTION Ill - CERTIFICATION OF SPONSOR/DESIGNEE (Required for Category I - IX. Please read the following statement carefully before signing.)

I certify that all of the above information is true and correct and that all family income of the spouse and sponsor is reported. I understand that this information is being given in order to determine child care fees to be paid and that Federal funds are used to subsidize the cost of child care. I also understand that the installation commander may verify the information on the application; and that deliberate misrepresentation of this information may subject me to prosecution under applicable State and Federal laws. See 18 U.S.C. Section 1001.

9. SIGNATURE OF SPONSOR 10. SIGNATURE OF SPOUSE 11. DATE SIGNED (YYYYMMDD)

SECTION IV - FOR CHILD DEVELOPMENT PROGRAM USE ONLY

12. CATEGORY OF APPROVAL 13. AUTHORIZED FEES 14. DATE OF APPROVAL 15. NAME OF CHILD DEVELOPMENT (YYYYMMDD) PROGRAM OFFICIAL

' ' DD FORM 2652, MAY 2014 PREVIOUS EDITION IS OBSOLETE. Adobe Designer 9.0

INSTRUCTIONS

Per Department of Defense Instruction 6060.02, Child Development Programs, this form is utilized to determine fees for DoD Child Care Programs.

To determine child care fees for your child(ren), or and child(ren) you legally claim as dependents, this from must be completed, signed and returned to the facility for which your child is enrolling.

Fees are determined based on your Total Family Income (TFI) as defined below. If you choose not to disclose your family income, your rate for child care will be set at the highest fee level.

Total Family Income (TFI) - For the purpose of determining child care fees in DoD Child Development Programs, total family income is defined as all earned income including wages, salaries, tips, special duty pay (fiight pay, active duty demo pay, sea pay) and active duty save pay, long-term disability benefits, voluntary salary deferrals, retirement or other pension income including SSI paid to the spouse and VA benefits paid to the surviving spouse before deductions for taxes. TFI calculations must also include quarters subsistence and other allowances appropriate for the rank and status of military or civilian personnel whether received in cash or in kind.

DO NOT INCLUDE alimony, and child support received by the custodial parent, SSI received on behalf of the dependent child, reimbursements for educational expenses or health and wellness benefits, cost of living (COLA) received in high cost areas, temporary duty allowances, or reenlistment bonuses.

For households in which unmarried couples or pairs are living as a family, the income for both adults should be used to determine Total Family Income (TFI).

Sections I, II, and Ill are to be completed by the sponsor or their designee.

Section I.

1. Provide the last name, first name and middle initial for each child who is receiving care in a DoD child care program.

2. Provide the date of birth for each child who is receiving care in a DoD child care program.

3. Provide the age of each child on the date of application who is receiving care in a DoD child care program.

4. Provide the type of care being request or in which each child is currently enrolled.

Section II.

When completing Section II, include all military and civilian income for both the sponsor and spouse or other adult living in the home.

5.a. Provide the sponsor's last name, first name and middle initial.

5.b. Provide the total years of military/civilian service as applicable.

5.c.(1) Provide your most recent income data and indicate if income is received weekly, biweekly, monthly or twice per month.

5.c.(2) Provide the current year BAH RT/C. For dual military living in government quarters include BAH RC/T of the senior member only; in locations where military members receive less than the BAH RC/T allowance, use the local BAH rate; for Defense civilian OCONUS include either the housing allowance or the value of the in-kind housing.

5.c.(3). Provide the basic subsistence allowance or in-kind equivalent. 5.c.(4)

Provide any other earned income.

5.c.(5) To be completed by program staff.

a. Provide the last name, first name and middle initial of the spouse or other adult living in the home, who contributes to the welfare of the child.

b. Provide the income of the spouse or other adult living in the home, who contributes to the welfare of the child.

7. Provide any additional income.

8.To be completed by program staff.

Section Ill.

9. Provide the sponsor's signature.

10. Provide the spouse's or other resident adult's signature.

11. Provide the date of signatures.

DD FORM 2652 (BACK), MAY 2014

(YYYYMMDD)

DEPARTMENT OF DEFENSE CHILD DEVELOPMENT PROGRAM OMB No. 0704-0515 REQUEST FOR CARE RECORD OMB approval

expires (Read Privacy Act Statement and Instructions on back before completing form.) May 31, 2017

The public reporting burden for tl11s collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Jnformation Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0515). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE APPROPRIATE CHILD AND YOUTH PROGRAM REPRESENTATIVE.

1. DATE OF REQUEST (YYYYMMDD) 2. EXPIRATION DATE (YYYYMMDD) (To be completed by Facility)

3. FAMILY INFORMATION

k. SIBLING CARE

(1) NAME (Last, First, Middle Initial) (2) DATE OF BIRTH

(1) NAME (Last, First, Middle Initial) (2) DATE OF BIRTH

a. SINGLE MILITARY e. SINGLE DOD CIVILIAN i. MILITARYIUNEMPLOYED SPOUSE

b. DUAL MILITARY f. RETIRED MILITARY j. MILITARY/OTHER THAN DOD SPOUSE

c. MILITARY/DOD SPOUSE g. MILITARY RESERVE k. OTHER (Specify)d. DUAL DOD CIVILIANS h. NATIONAL GUARD

a. FCC ON-INSTALLATION d. CIVILIAN CDC g. IN-HOME CARE

b. FCC OFF-INSTALLATION e. MILITARY ALTERNATE CARE h. NO PRESENT CARE

c. OTHER MILITARY CHILD DEVELOPMENT CENTER {CDC)

f. NON-MILITARY ALTERNATE CARE

i. OTHER (Specify)

a. SPONSOR'S NAME (Last, First, Middle Initial) b. SPOUSE'S NAME (Last First, Middle lnitiaQ

c. CHILD'S NAME (Last, First, Middle Initial) d. CHILD'S DATE OF BIRTH (YYYYMMDD) e. CHILD'S AGE

f. HOME ADDRESS (Street, City, State, Zip Code) g. SPONSOR'S BRANCH OF SERVICE

h, DUTY ORGANIZATION

I. HOME TELEPHONE NUMBER (Include Area Code) j. DUTY TELEPHONE NUMBER (Include Area Code)

4. PROGRAM($) DESIRED (X as applicable)

5. AGE GROUP (X one)a. FULL-DAY CARE d. FAMILY DAY CARE (FDC) a. INFANTS (0 - 12 months)b. PART·DAY CARE e. PART-DAY ENRICHMENT b. TODDLERS (13 - 35 months)c. SCHOOL-AGE f. PRE-SCHOOL c. PRESCHOOL (3 - 5 years)

d. SCHOOL AGE (5+ years)

6. SPONSOR STATUS (X one)

7. PRESENT CHILD CARE ARRANGEMENTS (X as applicable)

8. GENERAL INFORMATION (X and complete as applicable)YES NO a. IF CHILD JS NOT PRESENTLY IN CARE, IS

EMPLOYMENT OF SPOUSE IMPACTED? (If Yes, estimate average annual income lost)

YES NO c. IS CHILD ON OTHER MILITARY WAITING LIST? (If Yes, name installation)

b. HAS CHILD BEEN IDENTIFIED FOR SPECIAL NEEDS CARE?

d. CURRENT COST OF CARE PER WEEK (If child is currently in care)

9. ACCOMMODATI ON UPDATES/REVERIFICATION (For Office Use Only)

DD FORM 2606, MAY 2014 PREVIOUS EDITION IS OBSOLETE. Adobe Designer 9,0

- (1) (2) (3) (4) (5)

a. DATE CALLED (YYYYMMDD)

b. DECLINED/

c. COMMENTS/

d. PLACEMENT TIME • (In months) '

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; 1O U.S.C. 8013, Secretary of the Air Force; DoD Instruction 6060.02, Child Development Programs; Army Regulation 608-10, Child Development Services; OPNAV Instruction 1700.9 series, Child and Youth Programs; Marine Corps Order P1710.30E, Children, Youth, and Teen Program (CYTP); Air Force Instruction 34-248, Child Development Programs; and Air Force Instruction 34-249, Youth Programs, and 34-276, Family Child Care.

PRINCIPAL PURPOSE($): To collect applicant information for Child Development Programs and establish waiting lists for program services. This information may also be used for statistical analysis, tracking, reporting, and evaluat1ng program effectiveness. When completed, records are covered by one of the appropriate SORNS: Department of the Army: http://dpc!o defense.gov/pr jyacy/SORNslndex/1abid/591S/article16160/a0608-10-cfsc.asQx; Department of the Navy: http://dpclo.defense.gov/pr jyacy/SORNslndexttabid/591 S/article/6527 /nm01754-3 aspx; Department of the Air Force; http·//dpclo.defense.govlprivacy/SORNslndex/DODwjdeSORNArticleView/tabjd/6797/Article/5793/f034-af-sva-c.aspx

ROUTINE USE(S): Department of the Army records may be disclosed to civilian health and welfare departments/agencies in emergencies. Department of the Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the performance of their official duties relating to child abuse reporting and investigations. Department of the Air Force records may be disclosed to civilian health and welfare departments/agencies in emergency situations. DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional Inquiries), 6 (Required by International Agreement), 9 (Department of Justice for Litigation), 12 (National Archives and Records Administration), and 15 {Data Breach Remediation) specifically apply to this system. Other DoD Blanket Routine Uses found at http·//dpclo defense.goytprivacy/SORNs!ndex/BlanketRoutineUses.aspx may apply to these records. Any release under a blanket routine use will be compatible with the purpose of the collection.

DISCLOSURE: Voluntary; however, if you fail to furnish the needed information, you might not be added to a waiting list or notified when there is space for your child.

INSTRUCTIONS

This form is to be completed by authorized patrons (per Department of Defense Instruction 6060.02, Child Development Programs) and serves as the Official Request for Care for use of Department of Defense operated Child Development Programs. Providing this information is voluntary, but failure to complete the form may result in a denial of care.

1. Provide the date the request is completed.

2. To be completed by facility where care is requested. This form expires one year from the initial date of request.

3. Family Information. 3.a. Provide the sponsor's last name, first name and middle initial. 3.b. Provide the spouse's last name, first name and middle initial (when applicable). 3.c. Provide the last name, first name and middle initial of the chlld for whom care is being requested. 3.d. Provide the date of birth of the child for whom care is being requested. 3.e. Provide the age of the child for whom care is being requested at the time of application. 3.f. Provide the residential address of the child for whom care is being requested. 3.g. Provide the sponsor's branch of service. For DoD civilians, provide the service or agency of employment. lf this is not applicable, enter NA. 3.h. Provide the organization to which the sponsor is employed. If this is not applicable, enter NA. 3.i. Provide the home telephone number of the sponsor. 3.j. Provide the work telephone number of the sponsor. 3.k. If the family is requesting care for additional children, enter their last name, first name, middle initial and date of birth, and complete a

separate form for each child when applicable.

4. Program(s) Desired. - Place an "X" to indicate the family's desire for where the child's need for care may be accommodated.

5. Age Group. - Place an "X" to indicate the age group that the child falls on the date of application.

6. Sponsor Status. - Place an "X" to indicate the status of the sponsor on the date of application. - For "Other'', specify the sponsor's status.

7. Present Child Care Arrangements. - Place an "X" to indicate the present arrangement for child care of the child for whom care is being requested. - For "Other'', specify the sponsor's status.

8. General Information. 8.a. Indicate "Yes" or "No" if the lack of child care is impacting the ability of the spouse (where applicable) ta find employment. 8.b. Indicate "Yes" or "No" if the child has been identified for special needs care. 8.c. Indicate "Yes" or "No" if the child is on other military waiting lists for child care. If, "yes", provide the name of the installation where the child

is on a waiting list. 8.d. If the child is currently accommodated in non-DoD child care, indicate the weekly cost for care.

9. To be completed by the facility only.

DD FORM 2606 (BACK), MAY 2014

RAF Alconbury School-Age Program

Parent Agreement for School Year 2016-2017

Child(ren)'s Name: ---------------------- Date: _

Sponsor's Name and Rank: _

Sponsor's Squadron or Organization:, _

Duty Phone: --------------- Home Phone:

First Sergeant/Su pervisor's Name & Phone Number: _

Please initial in the space provided next to each statement.

1. PURPOSE: The mission of the RAF Alconbury School-Age Program (SAP) is to provide quality, available, and affordable programs and activities that foster resilience in youth and improve their quality of life. Activities and field trips are age appropriate, educational, and entertaining for youth needing care during the out-of-school time (before/after school, school breaks, winter camp, spring DODEA School Calendar 2016-2017 calendar school breaks and days out. This agreement is provided to explain the procedures and scope of the School-Age Program. For the purposes of this agreement, the RAF Alconbury School-Age Program will be herein referred to as SAP.

2. PROGRAM ELIGIBILITY: Family members of full-time employed, active duty, and DoD civilians and contractors assigned to RAF Alconbury are eligible for care in the SAP Summer Camp program. NAF employees are considered DoD Civilians.

a. Once a waiting list is established and there are higher priority parents on the list (either single, dual military or dual DoD employees), families in Priority 4 may be given a letter of termination. Priority 4 includes DoD contractors, Alcnbury Elementary School employees, or active duty military/DoD Civilian with a non-working spouse. Enrollment will be terminated after a 90-day grace period. The 90 day notice will only be issued one time. Subsequent notices will be issued in two-week increments. A non working spouse with a child in the program will be asked to show proof that they are actively seeking employment in order to continue receiving care. Within the first two weeks of the spouse's new employment, a pay statement must be provided to the program. If a spouse cannot show proof of employment or actively seeking employment, a letter of termination will be issued. Enrollment will be terminated after a 90-day grace period. The 90 day notice will only be issued one time. Subsequent notices will be issued in two-week increments.

b. A parent is considered a full-time student if he/she is enrolled for a minimum of 12 semester hours during the school year and 6 semester hours during the summer. A copy of a current class schedule will be required to verify program eligibility.

3. ENROLLMENT: Enrollment in the SAP includes completion of the following documents: AF Form 1181, DD Form 2652, USDA Enrollment Form, SAP Parent Agreement (this document), a care selection form, and verification of total family income. A registration packet will not be considered

complete and will not be processed until all forms have been turned in and reviewed. Likewise, children will not be placed in the program until all forms are complete, turned in and reviewed. Failure by families to maintain current and complete documents may result in denial of care until forms are brought up-to-date. Additional forms are required depending on the following circumstances:

a. Children with Special Needs, to include dietary restrictions and allergies, are required to have the child's physician complete an Inclusion Action Plan - Child Care Ratio Recommendation for Children Identified with Special Needs and/or Authorized Medical Action Plan. Once received, all documents are reviewed by the program's Medical Advisor prior to admittance. Enrollment into the program may be delayed while the recommendations are reviewed and/or accomplished.

b. In some cases, special needs documents may be reviewed by the Inclusion Action Team to assist in developing reasonable accommodations to aid the SAP in meeting the youth's needs.

4. FEE INFORMATION: The Military Child Care Act of 1989 (Public Law 1809, Section 1504) requires the Department of Defense (DoD) establish uniform fees for childcare based upon total family income (TFI). Parents enrolling their child in care are required to bring a copy of their sponsor's Leave and Earnings Statement (LES) and a copy of the spouse's pay statement to verify TFI, whether taxable or not. Total Family Income is defined as all earned income such as wages, salaries, tips, long-term disability benefits, combat pay, fly pay, assignment incentive pay, voluntary salary deferrals, quarters allowance and subsistence allowances retirement or other pension income. Quarters allowances are defined as the Basic Allowance for Housing type II (BAH) and Basic Allowance for Subsistence (BAS) received by military personnel. The senior members information, if dual military, whether living on or off base is taken into consideration when configuring the BAH fees.

a. An Application for Department of Defense Fees, DD Form 2652, is required to determine which fee category will be charged. Fees are determined by completion of DD Form 2652 and are based on a sliding scale. Fee charts can be obtained from the front desk at any time.

b. For households in which unmarried couples or pairs are living as a family, the total household income of the family unit will be used to determine TFI.

c. Fee categories for individual families may be adjusted only once annually except in the event of financial hardship. In these instances, families may submit a request to the 423 ABG Commander through the Airman and Family Services Flight Chief to have their fee category adjusted.

d. Families who do not present an LES and/or pay stub to verify total family income by the date first weekly payment is due will be defaulted to the highest fee category.

e. All fees are due in advance of care received. Weekly fees are due the COB on Friday before the week of care and no later than 1730 (5:30pm) on Monday the week of care. A payment is considered late if it is paid after the COB on Monday. In the event that the first day of the week is a holiday, payment will be due the following business day.

f. On no school days such as, parent teacher conferences/teacher training day/Etc. The School Age Program will automatically offer care for those who are enrolled in Before & After care. If your child will not be attending that day you need to give us 1 Week notice or an all-day fee will be calculated into you weekly charge.

g. On no school days such as, parent teacher conferences/teacher training day/Etc. The School Age Program will offer care to Before or After children but you must sign up I week in advance. If you request care and don't show up, you will be charged an all day care fee for that day.

h. A late fee of $5.00 per day, per child will be imposed for each day that the childcare fee is late. Youth Programs will make a reasonable effort to remind parents of payments that are due before a late fee

2

is imposed either verbally or via email. However, there may be times when a reminder is not possible. Ultimately, it is responsibility of each parent to pay their childcare fees on time. In the event that a reminder notice is not given, late fees will still be imposed.

i. Families whose fees become delinquent by over two weeks will be refused service until all fees are brought up-to-date and paid in full. If fees are not brought up-to-date within seven days, the child's slot in the program will be forfeited and/or filled by a patron on the waiting list. The SAP will attempt to work with families experiencing financial hardship.

j. Cash, personal checks, Visa or MasterCard are accepted as forms of payment. Payments must be made in person, or have a completed form to allow automatic credit card payments (see clerk for form). Checks must contain the following information: name, rank, address, assigned unit, duty phone, and home phone. Cash register is open 0700-1730.

k. Parents of children left after closing time will be assessed a late fee pick-up charge of $2.00 per minute per child for any late pick up after 1745. The clock in the Youth Center will be used for determining the time of pick-up.

1. The fee guidelines are established once per year and are subject to an increase each year.

6. Drop-In/Hourly Care: Drop-in/Hourly care is available for families on a space available basis. Drop-in/Hourly care youth must have a completed contract, registration, AF Form 1181, special needs paperwork, immunization, and DD Form 2652 on file before care can start. Drop in care fee rate is $4.00 per hour. Drop-in care times are 0730-0830 and afternoon is 1500-1700. Drop in care must be requested the day of, and is on a space available basis. Call the Youth Center at DSN 268-3604 or 01480843604 after 0700 to request care. Care will not be authorized until 0700 the day of. Fees for drop-in/hourly care must be paid at time of drop off. If drop in care is frequent you may be asked to pay for a regular spot.

a. If Drop-in/Hourly care is used 3 times during one week, a regular fee will be applied. If TFI is not on file, Fee category will be Cat 9. Once enrolled in regular care two week withdrawal notice in writing is needed.

b. Drop-in/Hourly care more than two days a week for two consecutive weeks will result in regular enrollment. If TFI is not on file, fee category will be Cat 9.

5. HOURS: Hours of operation for the SAP are 0630-1745, Monday through Friday. There will be no credit or refunds given for illness, family days, inclement weather, disciplinary suspensions, federal holidays or days that parents choose not to bring their child to the program for personal reasons. Credit may be given for hardship, and/or extreme, atypical circumstances only as determined by the 423d ABG Commander. Please see the front desk staff for a copy of the Hardship Waiver request if this applies. The SAP will be closed on all Federal holidays. USAFE Family Days will be will be dealt with on a case by case basis.

a. USAFE Family Days: A survey will be conducted at least one week in advanced of any family day. Parents requesting care will be required to list direct supervisor for verification off-time required for work. At least 12 youth must be sign up for care to be provided on family day.

3

b. Children must be picked up by 1745 daily. Parents are asked to contact the program if they are running late. The program staff will notify the parent/emergency contact beginning at 1745 if the parent has not arrived. The sponsor's first sergeant or commander will be called to pick up the child if the child has not been picked up 15 minutes after closing or if the parent/emergency contact cannot be reached by phone. At 1815 if no contact with parents or emergency contact has been made, and arrangements have not been made to pick up the child, Security Forces will be notified.

6. INCLEMENT WEATHER/BASE CLOSURES: The SAP follows any announcements regarding inclement weather made by RAF Alconbury. The program will not offer care during base closures as indicated by the command. Credit for childcare fees will not be given in the event of a base wide closure authorized by the command.

7. WITHDRAWAL: Families wishing to withdraw from the program must submit a written two week notice to the program. Families who withdraw their child without a two-week notice will be financially responsible for the two weeks. The weekly fee must be paid regardless of whether the child attends the program.

8. PRIORITY REGISTRATION: Children enrolled in the SAP for before and/or after school care are given priority status when registering for SAP winter, spring break, and summer camps.

a. Children enrolled in the SAP for summer camp are given priority status when registering their children in the SAP for before and/or after school care for the upcoming school year. Youth must be enrolled and attend a minimum of 2 weeks during the summer to receive priority status. Parents who enroll children into the summer program and then withdraw their child without completing the 2-week minimum will not receive the priority enrollment status.

b. Families in Priority 4, who are currently enrolled in the SAP, are given the opportunity for priority registration. However, should a waiting list develop with families of higher priority, families in Priority 4 may be given a letter of termination.

9. SIGNING IN/OUT: Families must designate on the AF Form 1181 those adults authorized to sign their child out of the SAP. Children 9 years and older may arrive and/or depart from the program with written permission on file from the parent(s). Children under 14years of age will not be authorized to sign children in/out of the program.

a. The AF Form 1930 must be signed by an authorized individual each day as the child enters and/or leaves the program. Children responsible for signing themselves in/out of the program will lose this privilege if unable to complete the daily AF Form 1930 as required. SAP personnel have the right to revoke a child's sign in/out privilege at any time.

b. The person signing the child in/out must be listed on AF Form 1181 and must present proper identification upon request. Families are asked to contact the SAP when someone other than a parent or guardian is picking up a child.

c. SAP personnel will sign children in/out of the AF Form 1930 to take them to school and on field trips.

10. ACCOUNTABILITY: The SAP uses a Locator board system to account for and locate youth within the program. Children use nametags to select their activity room of choice and can freely move throughout the program based on their interests. Children are responsible for moving their nametag to the correct choice board while in the program and to their locker before going to school or home. These measures ensure accurate accountability of all children. SAP personnel provide training to children on how

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to use the locator board. If a child repeatedly forgets to move his/her nametag, activity choices may be limited for a time period for retraining.

11. ABSENCES: Parents are asked to contact the SAP in advance if their child will not be in attendance for the morning, the afternoon, or the entire day. Parents can contact the Front Desk staff in person, via email, or by contacting the Youth Center at 268-3604.

12. ILLNESS/DISEASE: The SAP will not accept children into care who are exhibiting signs of illness listed on RAF Alconbury CYP Exclusion Policy (The American Academy of Pediatrics Managing Infectious Diseases in Child Care and School) until exposure period has passed. Families must not bring children to the program if they are exhibiting signs of a contagious disease. Parents must also contact the program if their child has a contagious illness so that other families can be informed of the exposure. Children who become ill while in the program will be removed from the classroom until a parent/guardian picks them up.

a. The child must be picked up within one hour from the time the parent is called. The SAP will contact a family's Emergency Contact and/or Sponsor's Supervisor if the child remains in the program for two hours after the initial contact. Depending upon the nature of the illness, a child may be issued a medical referral to seek medical evaluation before readmission. This request will be made to prevent the spread of disease and to protect children and staff from possible exposure to a contagious disease.

13. MEDICATIONS: Medications can be administered in the program with proper documentation only. Children may not keep prescription or over-the-counter medications on their person or in their cubbies. All medications must be kept at the front desk and administered by medication trained staff members. Parents must complete an AF Form 1055 and initial the form daily, indicating when medications are to be administered. Medications will not be administered if the AF Form 1055 has not been initialed for that day.

a. "As needed" and emergency medication must be initialed monthly by the parent/guardian. If it is necessary to use them, the program will contact the parent and receive phone or fax confirmation to administer the medication.

b. Medications must arrive to the Youth Center in the original container. All medications must have the following information on the prescription label: name of physician, date filled, prescription number, child's name, dosage amount and frequency, ending date (ex: use for 10 days or until completed). Prescriptions must be current within 10 days of the date filled. Please label all items clearly with child's first and last names. c. Immunizations: All children attending the youth center must have all required immunizations, to include an annual influenza vaccine before they will be admitted into the programs d. Enrolled children requiring immunizations must bring documentation of immunizations within 5 working days of notification date. Failure to provide documentation will result in denial of care until documentation is provided. No credit is given for the days of missed care.

14. MEALS: During the school year, children will be served breakfast and snack. During school days out, winter camp, spring break camp, and summer camp, children will be served breakfast, lunch, and snack. Meals are balanced and healthy, following strict USDA Guidelines. Menus are posted and changes may occur due to non-availability of items. All children will be served meals according to the menu unless a physician's statement has been provided indicating dietary restrictions, appropriate substitutions and length of special diet. Alternative food items will be served for children with special dietary requirements as certified by a medical professional. In certain circumstances, it may be the responsibility of the parent to provide specific dietary food items for youth on restrictive diets. No outside foods (to include foods from home, fast food restaurants, baked goods, etc.) are permitted in the program. Parents who wish to take their child to lunch must ensure that food is not brought into the center when the child re-enters the program. Families are encouraged to attend meals with their child. If you wish to join your child for lunch, please inform the front desk in the morning so that adequate arrangements can be made.

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15. SUNSCREEN: Sunscreen will be purchased and offered to children in the program before outside activities occur. Sunscreen must be at least 15 SPF. Spray-on sunscreens are encouraged to assist your child with easy application.

16. FIELD TRIPS: Parents will be notified of any field trips requiring parent/guardian permission at the beginning of the week. The program will utilize permission forms, personal communication, and email to ensure parents are aware of any and all trips. Providing permission is the responsibility of the parent/guardian. Children without permission will not attend field trips. The program staff will make all reasonable attempts to contact a parent in advance to obtain permission.

a. Occasionally, additional fees may be assessed for field trips. Parents will be notified of these fees well in advance.

b. School Age field trips are program wide. Parents will be responsible for finding alternate care if their child cannot attend. c. Childcare fees will not be pro-rated or refunded in the event that a parent must make alternate care arrangements when not participating in a program-wide field trip. Any additional fees are the responsibility of the parent.

d. Field trip transportation schedules will be posted and parents will be informed of these schedules in advance. All transportation schedules are approximations, especially return times. Be aware that certain conditions exist that are beyond the control of the Youth Center, such as traffic, road closures, etc. These factors could delay the return of Youth Center field trips. In the event that a trip is delayed, staff will notify the front desk so that the updated information is available to parents.

e. Failure to comply with appropriate behavior on field trip may result in exclusion from future field trips or require a parent chaperone on the field trip

17. PERSONAL ITEMS: Personal items such as toys, money, cell phones, and valuables are not allowed at the SAP. Other personal items including jackets, towels, goggles, etc - should be clearly marked with the child's name in permanent ink. Children are encouraged to keep all personal items in their cubby. The program has a lost and found for missing items. The lost and found will be emptied periodically & notices will be made to parents in advance. The SAP will not be held accountable for lost or stolen money, personal items, and/or clothing, regardless of circumstance.

18. DRESS CODE: For safety reasons it is recommended children wear closed-toe shoes while in the program. Open toe shoes or flip flops should not be worn to the program. Children go outside regularly and participate in messy activities. A change of clothes is also recommended and may be kept in a child's cubby. Label all items with first and last name. Parents of children wearing clothing deemed inappropriate may be called to bring a change of clothing for their child. Inappropriate clothing includes, but is not limited to: shorts/skirts that are too short, tube tops, spaghetti strapped tops or dresses, clothing with excessive holes, shirts with inappropriate or profane advertisements or writing.

A. The program coordinator or supervisor on duty will have sole discretion on the appropriateness of clothing.

19. INJURIES: Accidents that involve the application of First Aid will be reported on AF Form 1187, Youth Flight Accident Report. Parents will be required to read, sign, and return the report. Depending on the nature of the accident, parents may be given a courtesy call regarding the accident. Forms will be available for signature at the Front Desk. In the event that a parent takes a child to receive medical attention following an accident at the Youth Center, parents are required to notify the Youth Center immediately. Air Force regulations require Youth Programs to notify the chain of command within 24 hours if a child's injury requires medical attention beyond first aid.

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20. BEHAVIOR MANAGEMENT: Program staff will work closely with parents to monitor behavior. Program personnel will adhere to the Behavior Management Policy and Procedures for addressing inappropriate behaviors. Program personnel must utilize the Positive Guidance and Appropriate Touch Policy and cannot enforce corporal punishments, punitive punishments, time-outs, or similar techniques. Parents can review Behavior Management information with program personnel at any time.

a. If inappropriate behavior is repeated during the same week, the program coordinator will schedule a conference with parents and implement a Behavior Improvement Plan if necessary. If the behavior is repeated within a 4 week period after the parent conference, the child may be suspended from the program for a designated time period (rest of the day, 24 hours, etc.) or restriction from participating on field trips.

b. If a child receives a suspension from the program for behavior, parents are responsible for child care fees during the suspension.

21. BEHAVIOR MANAGEMENT IN EXTREME SITUATIONS: A child may be restrained in extreme situations where the safety of the child or others is endangered to include but not limited to physically assaulting another child or staff member or running into vehicle traffic.

a. If a child's behavior negatively affects the safety and welfare of children and staff, parents will be called by the program coordinator or supervisor on duty to immediately pick-up their child.

b. If a child's behavior negatively affects the safety and welfare of children and staff, during a field trip, parents will be called by the program coordinator or supervisor on duty to immediately travel to the field trip location to pick up their child.

22. TRANSPORTATION AGREEMENT: Program staff will transport children using the program bus and/or passenger van(s) to and from field trip locations. All children must wear seat belts and/or use booster seats correctly at any time they are being transported in Youth Center vehicles that have these safety devices.

A. Children who are unable to behave in a safe manner during transportation could be temporarily or permanently denied transportation rights by the program staff. Parents will be required to provide their own transportation in these circumstances.

23. COMMUNICATION: The SAP will communicate with parents regarding the behavior of child/children enrolled in the program when deemed necessary by program personnel. Personnel will not disclose confidential information during such communication(s). In addition, staff will may communicate similar information to other SAP staff and management. Occasionally, it may be necessary to conduct group meetings with staff, parents, and managements. This is a part of the overall Guidance, Discipline, and Behavior policies within the SAP and the "teamwork" approach to these policies.

24. CHILD AND YOUTH BEHAVIORIAL-MILITARY AND FAMILY LIFE CONSULTANT (CYB-MFLC): I understand that my child may interact with the Child and Youth Behavioral-Military and Family Life Consultant (CYB-MFLC). The CYB-MFLC is available to observe, participate, and engage in activities with children. In addition, the CYB-MFLC can meet with patrons who might need parenting support. I understand all information will remain confidential.

25. RELEASE OF CONFIDENTIAL INFORMATION: The SAP works closely with base agencies throughout the course of the school year. Communication with agencies such as Family Advocacy and the Airman and Family Readiness Center may occur. The program will also communicate with local 4- H representatives, BGCA Representatives, USDA representatives, and MFLC personnel. Confidential information protected by the Privacy Act will not be released without informed, written consent from a parent or legal guardian, when not otherwise required by law, regulation, or court order.

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26. RIGHTS AND RESPONSIBILITIES: Parents and guardians of children enrolled in the SAP have the right to fair and equal treatment, non-discrimination on the basis of race, ethnicity, national origin, gender, age, or disability, the right to information about their child, the right to be involved in the program, and the right to express grievances.

27. SCHOOL-AGE PROGRAM AGREEMENT 2016-2017: This agreement supersedes all other agreements and will be valid from the September 2016 through June 2017. This agreement is subject to revisions and modifications. Notification of all changes will be made available to parents. This agreement may be cancelled within two weeks written notice by the parents or the program.

I have read and initialed as required to indicate that I understand this agreement.

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Sponsor's Signature/Date Spouse's Signature/Date

To be completed at time of Orientation for new families

Please initial the statement below that applies.

I am a new family and have received a program tour and program orientation regarding the programs' policies and procedures addressed above.

I am a returning family and am aware of the program's policies and procedures addressed above.

I have an older child in the program and am aware of the program's policies and procedures addressed above.

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Sponsor's Signature/Date Spouse's Signature/Date

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Release Form Parental Photo & Videotaping Release I hereby give permission for my child to be videotaped/photographed while participating in the School-Age Programs. I understand that any pictures/videos may be used by the School Age Program for training, documentation, and/or recognition of the program. I understand that these photographs may be displayed in the Youth Center and/or used for publicity purposes to include newspapers, newsletters, and the internet.

Parent's Signature: ------------- Date: _

Please sign here if you would like to be notified prior to a photograph or your child being used for publicity purposes outside of the School Age Program. Parent's Signature: Date: _

Youth Photo & Videotaping Release School Age Program staff has my permission to take photos of me and/or video tape me while am playing in the Youth Center, on field trips, and/or during special events. The School Age Program will use the photos and video tapes to display in the Youth Center, to advertise the program, as part of the program record-keeping, and/or for training purposes. I have the right to see the photos and video tapes and ask that they not be used for these reasons.

Child's Signature: _

I have reviewed this agreement with (child's name) and agree that the child/youth has made an informed decision and understands what they are signing. Please note: A youth's permission to use a photo for the purposes stated above DOES NOT supersede a parent's decision as noted above. The Youth Center will honor the parent's request. Parent's Signature: Date: ---------

Face Paint During various events and activities in the School Age Program, children will have the opportunity to have their faces painted. Please initial by your face painting preference below. My child is allowed to participate in face painting activities without. My child IS NOT allowed to participate in face painting activities without.

Parent's Signature Date: _

MEMORANDUM·FOR: FROM:

SUBJECT: Child and Youth Behavioral Military & Family Life Counseling (CYB-MFLC)

I) This letter is to inform you about the Child and Youth Behavioral Military & Family Life Counseling (CYB-MFLC) Program services. Due to the unique challenges faced by military families, the Department of Defense is offering this private and confidential non-medical counseling service to Service members, families, children, and staff of Child and Youth Programs (CYP), Department of Defense Education Activity (DoDEA) Schools, Local Education Agencies (LEA), DoDEA/CYP Summer programs, National Military Family Association Operation Purple Camps, Guard/Reserve Camps, and Operation Military Kids Camps.

2) The CYB-MFLC may support staff and work with children and families in the following ways: • Observe, participate, and engage in activities with children and youth • Provide direct intervention with children • Model behavioral management techniques and provide feedback to staff • Suggest courses of age appropriate behavioral interventions to enhance coping and behavioral skills. • Outreach to parents • Facilitate psycho-educational groups • Conduct training for staff and parents • Recommend referrals to military social services and other resources as needed.

3) CYB MFLCs may assist parents, teachers, staff, and children with the following issues: • Communication • Resolving conflicts • Managing anger • Bullying • Self-esteem/self-confidence • Behavioral management techniques • Sibling/parental relationships • Deployment and reintegration issues

The counselor is available to accommodate appointments and meetings/activities after hours and on the weekend with advance notice.

At no time will the consultant meet individually with a child without being in line of sight of a CYP, DoDEA, LEA, or camp employee or a parent/guardian.

• The counselor may use only materials for trainings, groups, and other activities that have been approved by DoD.

I acknowledge that a CYB-MFLC is available and authorize my child. , to receive CYB-MFLC support.

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Parent or Guardian Signature

I acknowledge that a CYB-MFLC is available and DO NOT authorize my child , to receive CYB-MFLC support

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Parent or Guardian Signature

School Age Program Gym/Outdoor Agreement

Gym/Outdoor Rules: 1. Be Respectful of others and Youth Center property 2. Listen and follow directions 3. Stay on your feet

I agree to follow the rules of the gym. If I am unable to follow any of the gym rules I understand the following steps will occur:

1. I will be given a verbal warning to help remind me of the rules. 2. After my verbal warning will be asked to talk with the group leader. This will

give me and the group leader a chance to go over the rules of the activity again. 3. If after steps 1 and 2 have occurred and I continue to not follow directions, I

will be ask to choose a new activity in the Gym. 4. If after I have chosen a new activity, I continue to be unable to follow the rules of

the gym I will be asked to pick a new room.

I agree to follow the gym/outdoor agreement. If I do not follow it, I will lose my gym/outdoor privileges.

My Name My Age Today's Date

Computer Lab Agreement

PARENT/GUARDIAN

1. I understand that my child will be limited to 30 minutes of computer time in AM and 30 minutes of computer time in the PM.

2. I understand that if my child does not follow their Computer Lab contract the School-Age Program staff may take away my child's computer privileges.

3. I understand that children completing homework assignments and School-Age Program projects have a priority on the computers over children using them for recreation.

4. I understand that I can be held financially responsible should my child cause damage to the Computer Lab property through misuse.

5. I understand that the computers are subject to monitoring because they are official US Government property.

6. I understand that my child must follow all items outlined in their Computer Lab Agreement. I have .reviewed this agreement with my child and have ensured that they understand the agreement.

7.

I understand and agree to the Computer Lab Contract for my child enrolled in the SAP.

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Parent Signature Date

Youth

1. I will sign in and sign out of the Computer Lab binder. I will write my first and last name so that it -can be read. 2. I understand that I will be limited to 30 minutes of computer time in AM and 30 minutes of computer time

in the PM. 3. If I argue with the Group Leader about my computer time, I will lose my computer privileges. 4. I will only play designated computer activities, which have been chosen by the Group Leaders. 5. Watching someone else play on the computer counts as my computer time too. 6. I will not touch the computer screen with my fingers. 7. I will keep the mouse on the mouse pad. 8. If I want to listen to sound at my computer, I will need to wear headphones. 9. I am responsible for saving my computer activities. I will only play under my name and games that are

MME.

I agree to follow the computer lab agreement. If do not follow it, I will lose my computer privileges.

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My Name My Age Date

Internet Use Agreement

PARENT/GUARDIAN 1. I understand that I may opt that my child not have internet access at any time. 2. I understand that my child may not visit social networking websites, video sharing

websites, or email websites while using the internet at the School-Age Program. 3. I understand that the computers use NetNanny software to restrict access to

inappropriate materials. I understand that the NetNanny software may not prevent my child from accessing something inappropriate.

4. I understand that my child will only have access to the internet while supervised by School Age Program personnel.

5. I understand that my child must follow all items outlined in their Internet Use Agreement. I have reviewed this agreement with my child and have ensured that they understand the agreement.

Please initial one option:

My child has my permission to use the internet on the School Age Program computers.

I do not wish for my child to use the internet in the School Age Program.

I understand and agree to the Internet Use Contract for my child enrolled in the SAP.

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Parent Signature Date YOUTH

1. I will not play any games on the internet that use weapons or violence. 2. I will not visit Facebook, My Space, Twitter, Club Penguin, You Tube, music video

websites, video sharing websites, and chat rooms. 3. I will not download games onto the computer. 4. I will not send or check my email on the computer. 5. If a website has been blocked, I will not try to access it 6. I will not give out my address, phone number, age, or school while on the internet. 7. I will stay on the websites approved by the Group Leaders. 8. If I accidently see a website that has things that scare me or worry me, I will get the

Group Leader to help me. 9. I will not take someone else's ideas from a website and pretend that they are my ideas. 10. I understand that my choices on the internet are limited to keep me safe and I will not

argue with the Group Leader about this. I agree to follow the internet use agreement. If I do not follow it, I will lose my internet and even my computer privileges.

My Name My Age Date