YMCA SCHOOL AGE CHILDCARE PROGRAM

2020-2021 ENROLLMENT FORMS

Table of Contents

Child Care Enrollment Form (Front & Back) 1-2

Parent’s Health Statement 3

CACFP Enrollment Form 4

Income Eligibility Form 5-6

Parent’s Informed Consent Agreement 7

Statements of Understanding 8

Fee Schedule 9

Third Party Responsibility (to be completed if using DFS or Voc Rehab) 10

Bank Draft Form 11

Payment Authorization/Extracurricular Activities Form 12

Change Form (to be completed when switching programs or changing schedule) 13

COVID-19 Waiver 14-15

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4

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Name of Child:________________________________________________________________________________________________

_______ 1. I give permission for my child to participate in activities, field trips, and swimming.

_______ 2. I give permission for my child to be given CPR and First Aid treatment by qualified YMCA staff as

necessary until emergency personnel arrives. In the event hospitalization is required, I give consent

for my child to be taken to a hospital and to be treated by a qualified physician. I agree to assume

financial responsibility for such treatment.

_______ 3. I give permission for my child to be transported by emergency vehicle.

_______ 4. I give permission for my child’s photograph/video to be printed and/or used in promotional

materials such as Facebook for the YMCA.

_______ 5. I’ve read the Parent Handbook and agree to abide by all rules and regulations stated. All information

is correct and current.

_______ 6. I understand that registration is not complete unless the registration fee and the payment of the

first week’s tuition accompanies this form.

_______ 7. I understand that these agreements are subject to updates and revisions.

_______ 8. I understand that a school supply list will be provided upon registration.

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PARENT INFORMED CONSENT AGREEMENT

______ Payments are due every Thursday by the end of the business day for the care provided the next week. Late

payment will result in a late fee of $20 and possible disruption of my child(ren)’s participation.

______ Any balance more than 30 days past due will be sent to our collection agency.

______ The total cost of running a 9-month program is divided equally among 9 months. The tuition remains the

same each week regardless of out of school breaks or the number of half-weeks, or school closings due to

inclement weather.

______ I will call to inform the Site Director when my child will not be attending on any day for which he or she

is signed up.

______ In the event that any of the work numbers, home numbers, or emergency contact numbers that are listed for

my child(ren) should change, I will immediately inform the Site Director. I will also make sure that the

emergency contacts I list for my child(ren) are aware that they may be called if I cannot be reached.

______ In order to change my child(ren)’s schedule, I must provide 1 week written notice, using the Change Form, to

the Youth Development Director. I understand that my account must be at a zero balance before I can make

any changes.

______ In order for this registration to be processed in accordance with the Missouri State Licensing

Department, all information requested on the following registration forms must be completed at this time.

______ I may disenroll my child earlier than May with written notice (a minimum of one week prior to child’s final

attendance). I am responsible for payment through my child’s last day.

______ Credits or refunds will not be given for days missed due to illness, school closings due to inclement weather,

family vacations (without 1 week’s written notice), or suspensions from the program.

______ A late fee of $1 per minute, per child, will be added to my account for subsequent late pick up after

6:00 pm. After the third occurrence, my child will be excused from the program.

______ I am aware I have a folder for program and billing information distribution. I will check it daily.

______ A copy of my child’s immunization record has been turned in with this packet.

______ I have read, understand, and will adhere to the policies and procedures set forth in the School Age Child

Care Program Policy and Procedures Parent Handbook.

______ I attest that my child is in good health and is able to participate in all YMCA activities. The last physical

check up date for my child was___________________________________________________________________________________________.

I, _________________________________________________________, have read, understand, and will adhere to the

(Parent’s Name)

policies and procedures set forth in the School Age Child Care Policy and Procedures Parent Handbook.

Parent Signature _____________________________________________________________________________________Date _______________________ 8

SCHOOL AGE CHILD CARE PROGRAM

STATEMENTS OF UNDERSTANDING

Please

Check One Part Time

(1-2 Days)

Members

Part Time

(1-2 Days)

Community

Participant

Full Time

(3 Days or

more)

Members

Full Time

(3 Days or

more)

Community

Participant

Mornings $19.00 $34.00 $24.00 $39.00

Afternoons $29.00 $44.00 $34.00 $49.00

Both $44.00 $59.00 $49.00 $64.00

Childs Name: ________________________________________________________________________________ DOB: _____________________________

School Attending: _______________________________________________________________________________________________________________

FEES ARE SUBJECT TO CHANGE.

SJSD Corporate Program MOSAIC Corporate Program 2nd Child Discount

Only one discount per family.

Fees and Extra Charges:

Registration Fee: $30 per family, due at registration, along with first week’s tuition.

Tuition is due on THURSDAY for following week of services. Late payment will result in a late fee

of $20 and possible disruption of my child(ren)’s participation.

Due to the weekly changes in the State payments, participants who receive DFS assistance

will not be able to do bank draft. You can pay every Thursday via money order or check at

the school site or either YMCA Facility.

Return Check Fee: $10 per check.

Late Pick Up Fee: $1 per minute, per child after closing time (6 pm).

Cash is only received at the Downtown YMCA or the Campus Family YMCA.

__________________________________________________________________________________ ______________________________________

Parent Signature Date

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SCHOOL AGE CHILD CARE PROGRAM

FEE SCHEDULE

The YMCA of St. Joseph accepts payment from DFS (Division of Family Services)/Voc Rehab. It is important that you read

the fee schedule so you are aware of the rates you will be charged for any YMCA services used which are not covered by

your third party funding. This agreement is REQUIRED for all families who are subsidized by DFS/Voc Rehab, Third Party

agencies, or other individuals. Please read the following carefully.

As a parent or legal guardian of (child’s name), I understand and agree to the following:

Initially I am responsible for payment of the full weekly tuition fee, due every Thursday for the following week of

service. Due to the weekly changes in the state payment, participants that receive DFS assistance will not be

able to do weekly bank draft. You can pay every Thursday via money order or check at the sites or either

YMCA Facility. I have read the Parent Handbook and Fee Schedule, including payment policies, and understand that

I am responsible for any fees not covered by DFS/Voc Rehab or third party, including the $30 per family

registration fee.

Initially I am responsible for payment at the full fee for any care I use that is not authorized by DFS/Voc Rehab.

This includes, but is not limited to:

1. Any care that occurs before or after the dates authorized by DFS/Voc Rehab.

2. Care used on days/times not authorized by DFS/Voc Rehab.

3. Late pick-up fees

4. Late payment fees

5. ANY other fees as indicated in YMCA documents including the Parent Handbook.

I am responsible for contacting DFS/Voc Rehab and the YMCA immediately, in writing if my situation changes

(employment status, hours of work or enrollment in school, class schedule, custody issues, living

arrangements, change of address).

I am responsible for providing my caseworker with documentation at least two weeks before my contract

expiration date. This gives your caseworker time to process your information and get a new authorization to us

before your current contract expires.

Cancellation/Expiration of DFS/Voc Rehab funds does not automatically cancel, enroll, or change my childcare with

the YMCA. I am responsible for completing registration and change/cancellation forms according to YMCA

policies. If your DFS/Voc Rehab expires, we assume you want to continue childcare as a full paying family until you

notify us otherwise.

I understand that YMCA financial assistance may be available if I do not qualify for DFS/Voc Rehab . Financial

assistance is not retroactive so it is important to apply 2 weeks before your DFS/Voc Rehab expires.

I understand that failure to make payments as scheduled can/will result in termination of my care and will

result in lack of DFS/Voc Rehab benefits for future providers. Failure to pay all fees in a timely manner may

result in dis-enrollment from the program and your account being sent to collection.

Expiration Date: ________________________ Weekly Amount due from parent $___________________

Child’s Name: _____________________________________________________________________ Program Location: _______________________ ________________________

Parent/Guardian Name (please print):

_______________________________________________________________________________________________________________

YMCA OF ST. JOSEPH

THIRD PARTY RESPONSIBILITY AGREEMENT

This form must be signed and submitted at time of registration.

Only parents with third party billing of DFS/Voc Rehab need to fill out this form.

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Payment Terms & Conditions

In order to provide for convenient monthly payments to the YMCA of St. Joseph, the member authorizes

electronic funds transfer (EFT) from specified checking/savings account, charge card or debit card in the amount

of and on or after the date specified. The YMCA is authorized to change the payment date or amount by giving

the member thirty (30) days written notice, the member's EFT or credit charge will reflect this change. EFT's are

subject to the rules of the Mid-America Payment Exchange and the member agrees to be bound thereby. The

member may cancel this authorization with thirty (30) days WRITTEN notice and surrender of membership cards

to the YMCA. In no event shall a revocation of authority be effective with respect to entries the bank honors

EFT by charging the specified amount or when the charge is made to the specified charge card, the funds

transfer or charge shall constitute the receipt of payment. Please Initial ________________

Should any EFT or charge not be honored, then it is understood that payment is to be made by the member in

the amount of said payment, plus a $5 service charge. This agreement also allows the YMCA to initiate a

reversing entry to a member's account in the event that an error occurs. Memberships changing from Youth to

Adult (age 19) and from Adult to AOA (age 50) will automatically renew to the appropriate monthly rates during

the first draft at which the member has reached the aforementioned age. Please Initial ________________

Payment Options

$ . 1. Automatic Transfer System (ATS): beginning (MMYY)

A. Checking Savings Bank Name:________________________________________________

Account Number

Routing Number

B. Debit/Credit Card: □ Visa □ MC □ Discover □ AMEX

Expire Date

2. Fixed Term Payment (pay ahead): 12 months

(Statements are mailed prior to expiration)

Signature of Responsible Party Date

I have read and agree to all terms of the YMCA Childcare

Street City State Zip

Billing Address

First Name MI Last Name M/F Birth Date

Billing Party

Telephone Cell Email

BANK DRAFT FORM

Please attach a voided check

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I authorize the following to have access to my child(ren)’s account in the event that the named person(s)

is paying the account. I understand by listing the person(s), that they will have access to the account

balance for my child(ren). If a person has not been authorized, information about my child(ren)’s

account will not be provided.

____________________________________________________________________________________________

Name

____________________________________________________________________________________________

Name

I give my permission for my child. __________________________________________________, to participate in

Name of Child

________________________________________________________. The program will run from_____________________ Name of Program Start Date

to ____________________, and they will meet every ______________________. My child will report to End Date Day of the Week

SACC before going to their program. I understand that if my child does not report to SACC then my

child will be reported absent for the day. If my child continues to not report to SACC, I understand my

child will not be allowed to leave the SACC site for any extra curricular activities.

____________________________________________________________________________________________________________________

Parent Signature Date

____________________________________________________________________________________________________________________

Child’s Signature Date

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PAYMENT AUTHORIZATION

EXTRA CURRICULAR ACTIVITIES

YMCA of St. Joseph

315 S. 6th St.

St. Joseph, MO 64501

816-233-YMCA

www.stjoymca.org

2020-2021 CHANGE FORM

SCHOOL AGE CHILD CARE PROGRAM

Child’s Name: _________________________________________________________ Birthdate: ________________________

IMPORTANT!!!! One Week Notice must be given.

Change my child’s enrollment for

the remainder of the school year:

Effective Date:

__________________________ Please elaborate below:

______________________________________

______________________________________

______________________________________

______________________________________

______________________________________

Current Schedule

Before School

After School

Before & After School

New Schedule

Before School

After School

Before & After School

New Schedule

REGULAR MONTHLY SCHEDULE CHANGE

DISENROLL - ONE-WEEK NOTICE

Disenroll my child for the remainder of the school year: (My child will be disenrolled from all childcare programs in which they are currently enrolled unless otherwise noted.)

Last Attendance Date: _______________________________________

SIGNATURE REQUIRED

I have received a parent handbook and agree to all of the payment procedures.

I realize that my Credit/Debit or EFT account on file at the YMCA will be charged automatically.

Responsible Party Name: ______________________________________________________________________________________________

Responsible Party Signature: _________________________________________________________________________________________

Please return form to one of the following:

1. Hand deliver to: Site Director

2. Fax to: 816-233-8288

3. Email to: jryan@stjoymca.org or

ahassler@stjoymca.org

4. Mail to: 315 S 6th St., St. Joseph, MO 64501

OFFICE USE ONLY

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YMCA OF ST. JOSEPH, MO

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19

is extremely contagious and is believed to spread mainly from person-to-person contact. YMCA of St. Joseph, MO has

put in place preventative measures to reduce the spread of COVID-19; however, YMCA of St. Joseph, MO cannot guaran-

tee that you will not become infected with COVID-19. Further, participation could increase your risk of contracting

COVID-19.

READ CAREFULLY BEFORE SIGNING – INITIAL EACH PARAGRAPH

____ INITIALS By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the

risk that I may be exposed to or infected by COVID-19 by participation; and that such exposure or infection may

result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed

to or infected by COVID-19 at YMCA of St. Joseph, MO may result from the actions, omissions, or negligence of

myself and others, including, but not limited to, YMCA of St. Joseph, MO’s employees, volunteers, and program

participants and their families.

____ INITIALS I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to

myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or

expense, of any kind, that I may experience or incur in connection with my participation at YMCA of St. Joseph,

MO. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless YMCA of St. Joseph, MO, its

employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages,

costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes

any Claims based on the actions, omissions, or negligence of YMCA of St. Joseph, MO, its employees, agents, and

representatives, whether a COVID-19 infection occurs before, during, or after participation at YMCA of St. Joseph,

MO.

____ INITIALS I represent that I have adequate insurance to cover any injury or illness I may suffer or cause while

participating in this activity, or else I agree to bear the costs of such injury or illness myself. I further represent

that I have no medical or physical condition which could interfere with my safety in this activity, or else I am

willing to assume – and bear the costs of – all risks that may be created, directly or indirectly, by any such

condition.

____ INITIALS In the event that I file a lawsuit, I agree to do so in the state where YMCA of St. Joseph, MO is located,

and I further agree that the substantive law of that state shall apply. I agree that if any portion of this agreement

is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

____ INITIALS By signing this document, I agree that if I am exposed or infected by COVID-19 during my participation

in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the

parties being released on the basis of any claim for negligence.

____ INITIALS I have had sufficient time to read this entire document and, should I choose to do so, consult with legal

counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost

to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that

the opportunity to participate at the stated cost in return for the execution of this release is a reasonable

bargain. I have read and understood this document and I agree to be bound by its terms.

____ INITIALS If I have signed a separate general waiver of liability connected to my participation at YMCA of St.

Joseph, MO, I agree that the terms of that waiver are wholly incorporated into this document and that the terms

of this document are incorporated into the separate general waiver.

____ INITIALS I agree that I will practice safe social distancing and clean hygiene during my participation at YMCA of

St. Joseph, MO.

Signature on back page…. 14

Signature Print Name

Address City State Zip

Telephone ( ) _____________ Date _______________________

PARENT OR GUARDIAN ADDITIONAL AGREEMENT

YMCA of St. Joseph, MO

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

PARENT OR GUARDIAN ADDITIONAL AGREEMENT

(Must be completed for participants under the age of 18)

In consideration of minor’s name being permitted to participate in this activity, I further agree to indemnify and hold

harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way

connected with such participation by minor.

Minors’ Names

Print Name

Print Name

Print Name

Print Name

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