The YMCA is a charitable 501(c)(3) non-profit community ...parents or guardian arising out of any medical care or dental care provided. NOTE: The YMCA requests that if the minor is

Registration Packet

CULVER-PALMS FAMILY YMCA

Welcome to the YMCA!

The YMCA is a charitable 501(c)(3) non-profit community organization. We’re here for

Youth Development, Healthy Living and Social Responsibility. Our Strength is in

Community.

ALLOW US TO REINTRODUCE OURSELVES! Our Cause Defines Us

We know that lasting personal and social change comes about when we all work together. That’s why, at

the Y, strengthening community is our cause. Every day, we work side-by-side with our neighbors to

make sure that everyone, regardless of age, income or background, has the opportunity to learn, grow

and thrive.

Our Strength is in Community

The Y is a nonprofit like no other. That’s because in 10,000 neighborhoods across the nation, we

have the presence and partnerships to not just promise, but deliver, positive change.

The Y is community centered. For nearly 160 years, we’ve been listening and responding to our

communities.

The Y brings people together. We connect people of all ages and backgrounds to bridge the gaps in

community needs.

The Y nurtures potential. We believe that everyone should have the opportunity to learn, grow and

thrive.

The Y has local presence and global reach. We mobilize local communities to effect lasting,

meaningful change.

Our Impact is Felt Every Day

With a mission to put Christian principles into practice through programs that build a healthy spirit, mind

and body for all, our impact is felt when an individual makes a healthy choice, when a mentor inspires a

child and when a community comes together for the common good.

The YMCA in the United States

Today, the Y engages more than 10,000 neighborhoods across the U.S. As the nation’s leading nonprofit

committed to helping people and communities to learn, grow and thrive, our contributions are both far-

reaching and intimate—from influencing our nation’s culture during times of profound social change to the

individual support we provide an adult learning to read.

By nurturing the potential of every child and teen, improving the nation’s health and well-being, and

supporting and serving our neighbors, the Y ensures that everyone has the opportunity to become

healthier, more confident, connected and secure.

Opportunities for All

The Y is for everyone. Our programs, services and initiatives: enable kids to realize their potential,

prepare teens for college, offer ways for families to have fun together, empower people to be healthier in

spirit, mind and body, prepare people for employment, welcome and embrace newcomers and help foster

a nationwide service ethic. And that's just the beginning.

Parents, did you know that funds raised through our Community Support Campaign helps us to provide up to 35% scholarships and assistance for families who are not able to afford to come to the Y? Would you like to donate to our Community Support

Campaign to keep program fees affordable to all and to provide these valuable scholarships?

The Y and the community are grateful for your generosity. The Y is a 501(c)(3) charitable non-profit. Tax ID: 95-1644052

- Yes, I would like to make a one-time donation. You will receive an invoice in February 2013 or you can contact the Child

Care office at 213-639-7608 to make your donation immediately.

___$10 ____$25 ____$50 ____ $100 ____ Other (please specify amount :$________________)

- Yes, I would like to make a donation and pay it in monthly installments. You will receive your first monthly invoice in

February 2013 or you can contact the Child Care office at 213-639-7608 to start making your donation immediately.

I would like to donate $_______ per month, for _______ months (12 months maximum), beginning January

2013, for a total donation of $________(total) For example: I would like to donation $10 per month for 10 months, beginning January 2013 for a total donation of $100.


IDENTIFICATION AND EMERGENCY INFORMATION

SIGN IN / OUT – EMERGENCY CONTACT INFORMATION

SIGN IN AND OUT AUTHORIZATION: The following individuals have my unrestricted permission to sign the above named child out from the YMCA program and should be contacted in an emergency when I cannot be reached. Please notify day camp director in advance in writing if an individual not listed will be picking up your child. (minimum of two names required)

ADDITIONAL PERSONS WHO MAY BE CALLED IN EMERGENCY

NAME PHONE# 1 PHONE #2 Relationship to

child Pick-Up Emergency

□ □

□ □

□ □

□ □

Restricted PICK-UP : The Following individuals are RESTRICTED from signing out my child due to a court-issued restraining order (A certified copy of the official documentation must be kept in the child’s YMCA file) Name Name

Name Name

CCIS/Cal-Works families MUST provide:

Case #:

Name of Case Manager: Telephone number:

BASIC INFORMATION

CHILD’S NAME (last Name, First Name) SEX BIRTHDATE (MONTH/DATE/YEAR)

HOME ADDRESS (INCLUDE CITY AND ZIP CODE) TELEPHONE

NAME OF SCHOOL CHILD IS ATTENDING IN THE FALL 2012: GRADE ENTERING IN FALL 2012:

1st Adult’s Name HOME PHONE

( ) MOBILE NUMBER

( )

HOME ADDRESS (If Different From Child) WORK NUMBER

( )

E-MAIL ADDRESS:

Employer Name / Address Drivers License # (ID Purposes) State of Issue

2nd Adult’s Name HOME PHONE

( )

MOBILE NUMBER

( )

HOME ADDRESS (If Different From Child) WORK NUMBER

( )

E-MAIL ADDRESS

Employer Name / Address Drivers License # (ID Purposes) State of Issue

Parent /Guardian Signature:

Date


CHILD’S PRE-ADMISSION HEALTH HISTORY

Child’s Name Sex: M F BIRTHDATE

Father’s Name Does father live in Home with child? Yes No

Mother’s Name Does mother live in Home with child? Yes No

Other Legal Guardian’s Name

Relationship to child (grandparent, stepparent, etc.)

Medical Information

Is or was your child under regular supervision of physician? Yes No

If Yes, Name of Physician: Date of Last Exam / Physical:

Does your child take Prescribed Medications? Yes No (If yes, a permission to medicate form is required)

If yes, what kind? / Side Effects:

Child’s Medical History (Does you child have any of the following)

Yes No Yes No Yes No Yes No

Diabetes Epilepsy Hay Fever Ashthma

Child’s immunization History (please have a copy on file at school) Please mark yes for all immunications that are current

Yes No Yes No Yes No Yes No

Chicken Pox Rheumatic Fever

Whooping Cough

Mumps

Poliomyelitis 10- Day Measels (Rubeola)

3-Day Measels (Rubella)

Please Sepcify Any Other Serious or Severe Illnesses or Accidents:

Does child have frequent colds? How many in the last year?

List ALLERGIES staff should be aware of (Food, medications, environemental, etc.) Describe the ALLERGIC REACTION:

Does child have allergic reaction to sunscreen? If yes, what kind?

Does child have any special device(s)? If yes, what kind?

Does child have any special device(s) at home?

If yes, what kind?

Does your child have any special needs?

If yes, please explain?

Emergency Medical Informaition (This information is required)

PHYSICIAN OR DENTIST TO BE CALLED IN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN # PHONE #

DENTIST ADDRESS MEDICAL PLAN # PHONE #

Child’s Health Statement: I, the undersigned, understand that at a YMCA day camp program, physical activity is a regular part of the program. To the best of my knowledge, my child is an excellent physical health and the needs no restrictions (except what is listed below under “special consideration”) from strenuous 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 YMCA of any restrictions on my child’s activities.

Parent/Guardian Signature: DATE


EMERGENCY TREATMENT AUTHORIZATION

Child’s Name Sex: M F BIRTHDATE

I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the YMCA Program. I hereby grant permission for my child to leave the YMCA Program premises under the supervision of a staff member for neighborhood walks or field trips in authorized vehicles. I hereby grant permission for my child to be included in evaluation and pictures connected with YMCA Program. The undersigned, as the parent(s) or legal guardian(s) of the above-named person, (the “minor”) authorize YMCA of Metropolitan Los Angeles and its employees, directors and adult volunteers (collectively “YMCA”) to consent to any x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively “dental care”) to be rendered to the minor by a dentist licensed under the law of the State or other jurisdiction in which dental care is sought. For the purpose of medical care or dental care obtained outside of California, this authorization is given with the intent that any consent given pursuant to this authorization shall be the consent of each of the undersigned. The undersigned understand and agree that YMCA shall not be legally or financially liable for any bill or medical expense incurred, or for any cause of action or claim arising from any medical care or dental care provided, or the lack of medical care or dental care. The undersigned hereby agree to indemnity, defend and hold YMCA harmless from any claim made by or on behalf of minor’s heirs or parents or guardian arising out of any medical care or dental care provided. NOTE: The YMCA requests that if the minor is in the custody of both parents or more than one legal guardian, both or all sign this authorization. The YMCA understands that the minor is in the custody only of the person(s) who have signed this authorization. If for religious reasons you cannot sign this, the branch must be contacted for a legal waiver, which must be signed for attendance SPECIAL HEALTH CONSIDERATION /ALLERGIES:

____________________________________________________________________________________________________



SUNSCREEN UTILIZATION PERMISSION FORM

Section 101226(e) (4), Health-Related Services, requires CCCs to obtain written approval or instructions from parents prior to administering Non-prescription medication to children in care. Sunscreen is considered a non-prescription medication. As the parent or guardian of the above child, I give permission for the staff at the YMCA programs, to provide a sunscreen product of SPF 30 or higher, especially during the months of April-September. I understand the YMCA staff will not be applying the sunscreen on my child.

□ Approve of the YMCA to provide my child with sunscreen of SPF 30 or higher □ Please do not provide my child with sunscreen, I will provide my child with specific type of sunscreen

The YMCA has sunscreen on site for children whose legal parents and/or guardian have approved. Although the YMCA has an on-site supply for days when you may forget, you are required to supply your own sunscreen for your child. Please label the bottle with your child’s name.


YMCA of METROPOLITAN LOS ANGELES

PHOTO & 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 METROPOLITAN LOS ANGELES, I hereby give my permission and consent, now and for all time, to YMCA OF METROPOLITAN LOS ANGELES, 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 METROPOLITAN LOS ANGELES 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 METROPOLITAN LOS ANGELES, 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 METROPOLITAN LOS ANGELES, I authorize, according to this Release, shall belong to YMCA OF METROPOLITAN LOS ANGELES, YMCA of the USA and third parties collaborating with YMCA OF METROPOLITAN LOS ANGELES 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 METROPOLITAN LOS ANGELES;

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

YMCA OF METROPOLITAN LOS ANGELES will not be subject to any obligation of confidentiality and may be shared with and used by YMCA OF METROPOLITAN LOS ANGELES, YMCA of the USA and third parties collaborating with YMCA OF METROPOLITAN LOS ANGELES and/or YMCA of the USA;

- YMCA OF METROPOLITAN LOS ANGELES, YMCA of the USA and third parties collaborating with YMCA OF METROPOLITAN LOS

ANGELES 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 METROPOLITAN LOS ANGELES; and

- YMCA OF METROPOLITAN LOS ANGELES, YMCA of the USA and third parties collaborating with YMCA OF METROPOLITAN LOS

ANGELES 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 METROPOLITAN LOS ANGELES for any purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge INSERT YOUR YMCA NAME HERE], YMCA of the USA and third parties collaborating with YMCA OF METROPOLITAN LOS ANGELES 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 METROPOLITAN LOS ANGELES 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: __________________


ACCEPTANCE OF POLICIES AND PROCEDURES

By signing below, I acknowledge that I have received a copy of the 2012-2013 Child Care Parent Handbook, which includes the policies and procedures for all Child Care programs: before and after school, seasonal days camps, year-around child care, etc. I acknowledge that I have read and understood the information in the Handbook. By signing below, I acknowledge that I understand the financial policy of the YMCA, including the YMCA’s refund policy, credit policy and transfer policy. I also acknowledge that I understand the late-pick-up policy. I understand that these policies and procedures will be enforced at all child care programs sponsored by the Culver-Palms Family YMCA. By signing below, I acknowledge that I fully understand the cancellation and the policies regarding changes to my account and/or billing. I acknowledge that all requests for cancellations or changes must be submitted in writing, 15-days prior to my billing or draft date, and any request made after the deadline will be denied. I also understand that if I do not make my cancellation or change request by the deadline that I will still be liable for the payment to the YMCA. I also understand that it is my (the parent/guardian’s) responsibility to preplan my schedule, and the YMCA will not issue refunds or credits due to scheduling conflicts. I acknowledge that the refund and cancellation policy for child care programs may be different than the refund policy for other programs offered at the Culver-Palms Family YMCA. I understand that the YMCA will not issue refunds, credits or transfers for missed days of program, under any circumstances. I understand that the YMCA does not prorate for missed days of program, under any circumstances. I also understand that the YMCA does not issue refunds or credits for shortened months, as this has already been calculated into the fee schedule. I also understand that if my child(ren) are dismissed from YMCA programs due to behavior issues, I will not receive a refund, credit or transfer of any kind for child care payments already made to the YMCA. By signing below, I fully understand that all payments made towards the YMCA are nonrefundable and may not be exchanged for YMCA credit. Finally, I also understand that it is my (the parent/guardian’s) responsibility to preplan my schedule, and the YMCA will not issue refunds or credits due to schedule conflicts.

I understand that if my child care program offers a day camp program, the day camp program may not be held at the child care location where my child is registered. The YMCA reserves the right to combine camp locations due to low enrollment, and the YMCA reserves the right specify specific ages or grades for our day camp programs. The YMCA agrees to notify parents 60 days prior if a program location changes their age or grade enrollment parameters. If the YMCA changes the age or grade parameters for a specific program, the YMCA will offer an alternate option at another program/camp location. By signing below, I acknowledge that I have read and understood the above statements. By signing below, I acknowledge that I have received, read and understood the 2012-2013 Child Care Parent Handbook. If this statement is true, please confirm by signing below:


Parent Name (Please print)

Name of Child being enrolled in YMCA program

YMCA OF METROPOLITAN LOS ANGELES

RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of the 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 (hereinafter referred to as “the undersigned”) 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 and/or the affiliated program. It is further warranted that such entry into the YMCA 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 IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES

AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, volunteers and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or demands on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence, active or passive, 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.

2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each of them, from

any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, 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.

3. 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, active or passive, 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 the YMCA.

THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY 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 inducement apart from the foregoing written agreement have been made.

THIS AGREEMENT DOES NOT APPLY TO LICENSED CHILD CARE SERVICES. I HAVE READ THIS RELEASE

Date: ________________________________________ ___________________________________________ Printed Name

___________________________________________ Signature of Applicant/Guardian

____________________________________________________________________________________________________ Name(s) of Child(ren) in Program and/or YMCA Facility

Revised 5/22/08


PARENT PROFILE AND INTEREST QUESTIONAIRE

FAMILY INFORMATION

How many people live in the home? ______

How many children live in the home? ______

What are the ages of your children? ______, ______, ______

WORK INFORMATION

Does the mother or legal female guardian work? ____ Yes ____ No

Occupation __________________________

Does the father or legal male guardian work? ____ Yes ____ No

Occupation__________________________

LANGUAGE

Other than English, what language is spoken at home? _______________

SOCIAL ACTIVITIES

What type of social activities would you enjoy participating in with other parents and staff in our program? ____ Family game night ____ Pot luck dinner ____Other:

____ Family picnic ____ Sport event

Would you help to plan social activities for parents and staff?

____ Yes ____ No

How often would you attend social activities at the center?

____ Weekly ____ Monthly ____ Every other month

Do you or any family member have any particular skill like those listed above that you would teach to other parents or children? ____ Yes ____ No

What skills? ____________________________________________________________________________________

In which other YMCA programs (besides child care) does your school-age child participate?

____ Y-Guides ____ Swim lessons ____ Youth sports

____ Day camp ____ Camp ____ Other:

In what other YMCA programs do other family members participate?

____ Y-Guides ____ swim lessons ____ youth sports

____ Day camp/camp ____ senior programs

PARENTING EDUCATION/FAMILY SUPPORT

On which of these topics would you like to receive information? (Please check)

____ Child growth and development (understanding child development, discipline and other problem areas, activities to do at home to enhance children’s development, other)

____ Adult education (classes and courses available, GED, junior college, college, scholarship information, other) ____ Employment (how to complete a job application, how to succeed in job interviews, job opportunities in the area, other) ____ Health education (recognizing and treating common childhood diseases, emergency first aid, safety in the home, family

planning, pregnancy and childbirth, drug abuse and alcoholism, other) ____ Nutrition education (preparing inexpensive, nutritious meals; growing foods at home; how to get food stamps; weight control; forming food co-ops; other)

____ Resource management and use of community agencies (budgeting and stretching your dollar, services provided by community agencies, comparative shopping, other)

Can you provide printed information to other parents on any of the topics listed above?

____ Yes ____ No

Which topics? __________________________________________________________________________________

Would you be willing to present a workshop or know someone who could on any of the topics listed above? ____ Yes ____ No

Name Phone #

Which topics? __________________________________________________________________________________


DISCIPLINE GUIDELINES AND POLICIES

Discipline Guidelines

The following is our discipline procedures followed by the staff here at the YMCA. Please take a few minutes to read the procedures and sign, date and return this form with your enrollment papers. Breaking Program Rules

If a child is not following the rules, he/she will be reminded of the rules. If the child continues to break the rules, he/she will be asked to leave that area and find another area to play in. If the child still fails to follow the rules, the teacher will assign an area for the child. If the behavior has not improved by this time, the child will be removed from the group and placed directly beside a teacher or

staff member. Threatening the Safety of the Staff and/or Children in the Program

If a child threatens the safety or health of anyone in our program by hitting, kicking, biting, pushing, spitting or any other dangerous act they will receive a verbal warning.

If the behavior continues after the verbal warning has been given, the parent will be called to pick the child up within a half an hour. Credit will not be reimbursed for this day.

After returning to school, if the child continues this behavior, the parents will be called to pick the child up within a half an hour and the child will be suspended for one (1) school day. Credit will not be reimbursed for these days. A parent conference with the director will be mandatory at this time.

The next time the child is required to be picked up for inappropriate behavior, they will again need to be picked up within a half an hour and this time the child will be suspended for three (3) school days. Credit will not be reimbursed for these days.

Upon returning to school after a three day suspension and the child’s behavior continues, the parent will be called to pick their child up within a half an hour and the child will receive his/her final suspension of one school week. Credit will not be reimbursed for these days.

After the final suspension, if the inappropriate behavior has not stopped, the parent will be called to pick the child up within half an hour and the child will be expelled from the program thereafter. There will not be any reimbursements of any kind.

There are extreme cases where a child will be sent home and/or suspended on the first violation. This is left to the Director’s discretion.

I have read and understand the discipline procedures of the YMCA.





FINANCIAL POLICY AGREEMENT 2012-2013 Page 1 of 2 Payment Policies and Procedures Below you will find our payment policies and procedures for our child care and youth programs. Please read carefully. FINANCIAL POLICY: HOW DO I PAY? Payments may not be made at our child care centers. You may walk in payments to our branch location or you may mail in your payments to: Mailing Address: Culver-Palms Family YMCA 4500 Sepulveda Blvd. Culver City, CA 90230 Attn: Christopher Jefferson If you feel that mailing or walking in payments will cause an inconvenience, then we strongly encourage you to enroll in our ATS payment plan.

PAYMENT PLAN ATS Payment Plan: Pay automatically through your checking, savings or credit card and receive the ATS rate. Payments are drafted monthly on the 2nd or twice per month on the 2nd and 16th (where applicable). If enrolling on the ATS program, an ATS enrollment form, a void check, savings account statement or credit card information is required. A $25 service fee will be applied to each returned item (declined credit cards, NSF drafts, etc.). If more than 3 items are returned, you will be taken off of ATS, placed on the Billing Plan and only allowed to pay by cash or credit card. Some options do not permit Split Payments. Please see the fee schedule for information on options that permit a split payment. Billing Plan: Bills are sent out on the 19th of each month prior to the month they are due. Monthly fees must be paid in full on the 2nd of each month or you can split your payments and pay half on the 2nd and the remaining half on the 16th. If monthly fees are not paid within the 5 day grace period of the 5th and the 20th of each month then you will be charged a $25 late fee. Failure to pay by the end of the grace period will result in suspension of child care. A $25 service fee will be applied to each returned check. If more than 3 checks are returned you will only be allowed to make your payment by cash or credit card. Families are still responsible for payment, even if they do not receive a physical invoice via mail or e-mail. Late Fees: There is a $1 charge for every 1 minute you are late after 6:00p.m per child. Emergencies called in will be taken into account. When late you are required to sign and date the late pick-up form. The late charge needs to be paid at the branch via cash or credit. Due to our own staff evening school schedules and family responsibilities we ask for your respect at all times in promptly picking up your child from program by the closing hour of 6:00 p.m. If you are late more than 3 times in a rolling 30 days, you may be asked out of the program. PAYMENT SCHEDULE Our School Year Child Care Plan and School Year plus Plan is based on 10 months of child care for the school year, with the first payment due August 2012 and the final payment May 2012. Your bill is divided into equal monthly payments. The fees have been averaged into monthly rates including the total weeks of after school care and 4.3 weeks of full day care for winter break, spring break and 3 days of fall break care, if you have the plus plan (care for winter, spring and fall breaks is only included if you have the school year plus plan). Seeing as how this matter can be confusing, so to clarify, our School Year Child Care Plan and School Year plus Plan covers care from Monday, September 3, 2012 through Friday, May 31, 2013 and monthly fees are of equal amounts. June 3, 2013 is the first week of our summer camp program and a separate weekly fee will need to be made if you desire to enroll your child into summer day camp. The YMCA does not prorate for shortened months, as your fees for child care have been broken-down into 10 equal payments. THERE IS NO PRORATING.

The Year Round Plan is a continuous fee based on 12 months of care. Payments start August 14, 2012 with the final invoice being billed on August 2, 2013. Coverage of care begins Tuesday, August 14, 2012 until the last day of summer care, which is tentatively scheduled for August 9, 2013 (subject to change). If you feel that you will not be using the YMCA summer camp program then you may want to consider the School Year Plan or School Year plus Plan. **If you enroll in the Year Round Plan and decide not to participate in our summer program it is your responsibility to drop from program or you will be charged. The YMCA will not refund you funds paid towards the Year Round Plan. Once you cancel from the Year Round Plan, you will not be able to readmit into that option and will be required to register for another available option. The deadline for the Year Round Plan is October 5th, 2012. The YMCA does not refund or credit funds paid towards any plan if you decide to upgrade or downgrade your plan. 2-day Plan- The 2-day plan covers after school days only that fall on Tuesday and Thursday. This also includes early dismissal days that fall on a Tuesday or Thursday. The 2-day plan does not cover All-Day care that falls on Tuesday or Thursday. It also does not include summer, spring, fall or winter day camp break. The two-day plan is for after school care twice a week only. The days are non-negotiable. ATS is the only acceptable payment method for this plan. The payment system for the two-day plan has been balanced to include 10-even months of payments. Credit will not be issued for short months or days when the YMCA is closed. Your fee schedule has been adjusted to accommodate allotted days. 3-day Plan- The 3-day plan covers after school days only that fall on Monday, Wednesday and Friday only. This also includes early dismissal days that fall on a Monday, Wednesday and Friday. The 3-day plan does not cover All-Day care that falls on Monday, Wednesday, and Friday. It also does not include summer, spring, fall or winter day camp break. The three-day plan is for after school care three days a week only. The days are non-negotiable. ATS is the only acceptable payment method for this plan. The payment system for the three-day plan has been balanced to include 10-even months of payments. Credit will not be issued for short months or days when the YMCA is closed. Your fee schedule has been adjusted to accommodate allotted days. There IS NO PRORATING for any of the options listed above, unless those months where noted.

Page 2 of 2 ABSENCES, CHANGES AND DROPS Absence: Three-week leave allowance is built in for absence for year round and two-week leave allowance is built in for absence for the School Year and School Year plus Plan. We do not credit for time missed. If your child is ill, please call your child care site before 10:00 a.m. Please call each day of absence. You are not charged if you choose not to use your absence allowance or if you exceed the absence allowance. Changes: 15-days written notice is required for all changes to program. Notice must be submitted in written 15 days prior to the billing and draft date. Without proper written notice, changes to your account will not be made. Change forms can be picked up at the YMCA Main Facility. A signature is required to make any changes and you must fill out the change form yourself. It is not the site director’s responsibility to fill out a change form on your behalf.

Cancellations: A 15 day notice is required for all changes to program. Without proper written notice, your child will not be dropped from program. If you are on ATS you will be charged and if you are on billing you will be liable for payment. Drop forms can be picked up at the Main YMCA on Sepulveda. A signature is required to drop a child from program; you must fill out a drop form yourself. Please make sure all cancellation are dealt with our child care office directly, this is not handled by the site director. The YMCA will not grant cancellations without a 15 day written notice.

HOLIDAYS: The YMCA will be closed on the day of the legal observance of the following holidays: New Year’s Day President’s Day Memorial Day Fourth of July Labor Day Thanksgiving Day Christmas Day Veterans Day Day after Thanksgiving Martin Luther King Day

***The YMCA reserves to right to close the site for the day or close the site early. Notice will be given. For all holidays, off track days, and student free days, the YMCA reserves the right to consolidate sites due to low enrollment. The YMCA offers care on the LAUSD school calendar and may not be able to make accommodations for children who do not follow the LAUSD schedule. The YMCA child care also follows the bell schedule of our hosting school, and may not be able to accommodate children who come from schools with different bell schedules. The YMCA reserves the right to change the age and grade parameters for any program. The YMCA will offer arrangements if the age parameters are reduced. For example, if the YMCA changes summer camp from K-5th to K-2nd, the YMCA will offer families an option for 3rd – 5th graders, which may not be at your home site. DOWNGRADING/UPGRADING: You have the right to upgrade or downgrade your option at any time during the school year if the YMCA has a 15-day notice of change, in writing, and if the option is still available for enrollment. When upgrading, you are responsible for paying the difference accrued between the greater option and the lesser option. When downgrading, the YMCA offers no credits and will not prorate. Once you downgrade from an option, the YMCA will not offer credits or refunds towards our other YMCA programs. 3RD PARTY FUNDING: The YMCA accepts third party funding from Connections for Children and from the Department of Children and Family Services. The YMCA will also accept some Cal-Works 3rd party funding as well as funding from the Westside Regional Center. The YMCA does not accept all 3rd party funding, so please check with the child care office if there is a 3rd party funding source that you prefer to use. Some third party families do not pay the full fee of the YMCA. Parents/guardians are responsible for any and all fees not paid by their third party funder. FINANCIAL ASSISTANCE: The YMCA provides financial assistance, at a maximum of 35%. Please complete a financial assistance application if you wish to apply for an award from the YMCA. If your financial situation changes and you require financial assistance and are awarded, the awarded may only be applied 15-days prior to the billing date. If after the billing date, the award will be applied to the following months invoice. FURLOUGH DAYS: The LAUSD Furlough days for November 2012 will only be included in your child care if listed under the option you have selected. The YMCA has branded these furlough days as “Fall Day Camp.” The LAUSD Furlough days for June 2013 have been removed from the fee schedule. The YMCA considers the last day of school to be May 31, 2013. The first day of Summer Day Camp for the 2013 season will be June 3, 2013. By signing below you are acknowledging you understand and will follow all policies and procedures stated above.





GOAL SETTING CONFERENCE Child's Name:_____________________________________ Age________ 1. DAILY ROUTINES:

A. When does your child do homework? _______________________________________________

B. Does your child have daily chores? ____Yes ____No

What? ______________________________________________________

C. Has your child experienced any major change in his/her daily routine in the past month? ____Yes ____No

What? _______________________________________________________

D. Has there been a major change in your child’s daily routine that we should be aware of?

____Yes ____No What? _______________________________________________________

2. HEALTH:

A. Has your child's health changed significantly in the past three months? If yes? ____Improved ____Declined ____No Change

B. Does your child participate in outside school activities?

____Yes ____No

What? _______________________________________________________

C. Does your child participate in any organized fitness activity?

____Yes ____No

What? ______________________________________________________

3. FAMILY:

A. If child does not live with both parents, how often does he/she have contact with the other parent?

___________________________________________________________________

B. What kinds of activities do you share as a family? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

4. SOCIAL:

A. Does your child make friends easily? ____Yes ____No

B. What are some of his/her personal interests? ____________________________________________________________________

____________________________________________________________________

C. Do you think your child feels good about himself/herself? Comments:

____________________________________________________________________

____________________________________________________________________

Is there anything else we should know about your child that will help us care for him/her?

____________________________________________________________________

____________________________________________________________________

We know that all parents want a safe, enjoyable and caring environment for their children. We also know that you want your child to have fun at the YMCA. How else can we create a positive experience for your child?

____________________________________________________________________

____________________________________________________________________ Our staff is committed to your child's success. Please identify one or two personal goals where we can assist your child. Goal #1: ____________________________________________________________________

____________________________________________________________________ Goal #2: ____________________________________________________________________

____________________________________________________________________ How else may we meet any additional needs of your family?

____________________________________________________________________

____________________________________________________________________ Is there anything else you would like to share with us?

____________________________________________________________________

____________________________________________________________________ Thank you


PARENT/FAMILY VOLUNTEER AGREEMENT (OPTIONAL) The YMCA will no longer be providing child care programs for children but rather developing child care programs with families. It is our goal to work in partnership with the families and schools in our community. Research supports the idea that children do better in school and later as adults if their parents have been involved with them. We want to help make that happen.

As part of this philosophy, each family will have an opportunity to be involved with the YMCA to plan and implement programs for our children. Each family enrolled in one of our child care sites will be asked to be involved in one of several areas. Our goal is that every parent will be involved in some way. The areas of involvement are varied in an effort to fit our families’ interests and time considerations. If you have suggestions for expanding the list, please let us know. Your input is valuable to us.

Please name your first (1) and second (2) choice for involvement in the upcoming school year:

Completion and return of this form is required to complete the enrollment process. Family Nights/Events

Leadership role in coordinating refreshments as needed for various events/functions

Parent Advisory Council

Site Newsletter

Annual Parent Recognition

Phone Tree Committee

Set up for meetings/Clean up for meetings

YMCA Annual Support Campaign Leader

Tutoring

Liaison between PTA and YMCA Child Care

Bulletin Board Assistant

Friend Raising Coordinator

Birthday Coordinator

Member Satisfaction Council

Field Trips

Other – Suggestions are welcomed! I understand that I am making a commitment as a partner working with other YMCA parents in an effort to strengthen YMCA child care families and the community.




Culver-Palms Family YMCA

Admissions Agreement AWKNOLEDGEMENT / AGGREEMENT – As the parent or legal guardian of the above named child I understand agree to and/or acknowledge the following:

A. I acknowledge that I have received a copy of the YMCA School Age Child Care Parent Handbook and will comply with the policies set forth. I further acknowledge that I have received copies of the following documents required by the State of California Community Care Licensing: “Parents Right”, “Personal Rights”, “Parent Handbook”, “Fee’s Page” and “Acknowledgment of Receipt of Licensing Reports”

B. Those field trips, either by walking or in YMCA vehicles or chartered buses are a part of the Child Care program

activities. No additional permission slips will be required.

C. Authorization for the YMCA to take photographs, videos, motion pictures and /or sound recordings of the child care participant of members of the participant’s family. I further grant the YCMA permission to use the photographs video. Motion pictures or sound recordings in its general publicity materials. See attached waiver

D. The YMCA staff and volunteers are not allowed to babysit or transport children at anytime outside of the YMCA program (The YMCA will take immediate staff and volunteer disciplinary action if a violation occurs)

E. That I am not allowed to leave my child at the YMCA program center unless a YMCA staff or volunteer is there to receive and supervise my child.

F. 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.)

G. That the YMCA is mandated by state law to report any suspected child abuse or neglect to the appropriate authorities for investigation.

H. That per Department of Social Services, Community Care Licensing, Title 22 regulations, and my child’s file is available for review by the Department of Social Services and representatives from these agencies may interview my child without prior parental/guardian permission. In addition Law Enforcement personnel may request the information listed in your file and may interview your child if necessary.

I. That the YMCA may terminate my child’s enrollment for any of the following reasons: Emergency names and phone numbers are incorrect Parent is late picking up child after program center closes Non/late/ATS payment fees Failure to adhere to the sign in and out policy Failure to notify the YMCA that the child is absent Child leaving the program center without authorized permission Behavior that is continually disruptive or dangerous to others and/or self Behavior that is disruptive to property and/or refusal to replace said property Any single incident that is deemed by the program center director to be dangerous, harmful or disruptive Harassment, violent behavior or threat of such behaviors against a staff person or other member by parent/guardian or

persons associated to the child (family member, family friend, etc.)

J. That Program participation requires a YMCA school based membership in good standing and that non-payment

of membership fees will result in my child not being allowed to participate in the program and could result in legal referral with the additional costs to myself. I further understand there is an administrative processing fee for any payment returned by my bank or credit account.

K. The YMCA and the staff employed by the YMCA will not become involved in custodial disputes between

parent/guardian. If YMCA documents are requested, the court must request them. The staff’s responsibility is to provide a safe environment for children.

L. I understand I am required to give 15 days’ written notice when terminating my child from YMCA child care programs. If 15 days is not provided I will not receive a refund or credit. Registration Fees are non-refundable.

Parent/Guardian Signature Date

YMCA Child Care Representative Date

PLEASE REMOVE AND KEEP THIS PAGE TO PLACE

INSIDE EARTHQUAKE KIT

SEE REVERSE

YMCA of METROPOLITAN LOS ANGELES

EARTHQUAKE PREPAREDNESS/EARTHQUAKE KITS

DUE: October 1, 2012 – for students who start child care in August 2012

DUE: Within 30 days of enrollment – for students who start child care after October 2012 As part of our safety and risk management plan, each child in the YMCA After-School or Preschool Programs are required to have an earthquake kit. As much as we hope an earthquake doesn’t happen, we want to be prepared if it does. The YMCA will store your child’s individual kit and return it to you at the end of the school year. Each September the earthquake kit will need to be replaced by the child’s parent. If you leave before June, please remember to ask for your kit to be returned to you. To maintain freshness of the food supplies, parents of Year Round participants should replace contents in kits every August. Earthquake kits are required to have an emergency information sheet as well as the articles on the following list. These items should be put into a large Ziploc bag with your child’s name on it. Every child in our program must have a kit within 30 DAYS of their start date. We would appreciate your cooperation in returning the kit as soon as possible. Thank you for help and understanding in making YMCA a safe place. Earthquake Kit Should Contain:

Emergency Information Card (see attached)

2 high fiber bars

2 small canned juice (with pop tops)

2 small packages of raisins, nuts or trail mix

2 small cans of tuna, Vienna sausage or other protein source (with pop tops)

1 Mylar blanket (available at R.E.I. or most sporting goods stores)

1 small First Aid Kit

A picture of the child’s family

Medication supply for two days (only if necessary)

1 small pack of wet wipes

1 small toy, book, etc.

A short note of encouragement to your child.

EMERGENCY INFORMATION SHEET

For Earthquake Kit – Place inside EQ Kit

My name is: ____________________________________ Phone (_____)___________________

Address_______________________________________________________________________

City___________________________________________ Zip____________________________

IN CASE OF EMERGENCY CONTACT:

Name_________________________________________ Phone (_____)___________________

Name_________________________________________ Phone (_____)___________________

______________________________________________________________________________

(Fold Here)

Special Medical :________________________________________________________________

Known Drug Allergies:___________________________________________________________

Family Doctor: _________________________________________________________________

Phone: (_____)___________________

Out of State Contact:

_________________________________ (______)________________ ___________________

Name Phone # Relationship

Relationship

Documents

The YMCA is a charitable 501(c)(3) non-profit community ...parents or guardian arising out of any medical care or dental care provided. NOTE: The YMCA requests that if the minor is