Bullitt County School-Age Child Care Program at the Y!

MAKING LEARNING FUN

Bullitt County School-Age Child Care Program YMCA OF GREATER LOUISVILLE 2011-12 SCHOOL YEAR REGISTRATION ymcalouisville.org

BULLITT COUNTY SCHOOL-AGE CHILD CARE PROGRAM 2011-2012 School Year

LEARN, GROW, THRIVE

SCHOOL SITES

The Y makes strengthening communities our cause. Through our affordable child care programs we create a nurturing environment to engage children and help them develop skills that will serve them throughout their lives. We focus on ensuring that your child’s time is spent creatively and constructively in the critical hours before and after school and during school breaks.

BEFORE AND AFTER SCHOOL CARE (GRADES K-8)

HELPING BUILD CONFIDENCE With values of caring, honesty, respect and responsibility as our guide, we work with you every day to ensure your children have fun while helping them realize their potential. You can feel confident knowing your child is safe and well cared for by our qualified staff.

Every staff member receives extensive hours of training and professional development and is CPR and First Aid certified. We are licensed child care and meet or exceed state licensing requirements.

BUILDING THE WHOLE CHILD Your child will experience academic support, self-esteem building and character development through activities designed to enrich, strengthen and expand their learning. We offer homework assistance through our Homework Club and maintain a strong focus on literacy. We also encourage healthy eating habits, provide opportunities for physical activity, and provide nutritious morning and afternoon snacks daily.

ALWAYS HERE FOR YOU Our before school program is from 6 am until the start of your child’s school day. Our after school program is from the close of the school day until 6 pm. Continuous care is also available 6 am - 6 pm during school breaks, including in-service days, snow days and early dismissal days. Spring Break, Winter Break, and Summer Camps require separate registrations.

CONNECTING WITH OUR FAMILIES Our programs have an open door policy and parents are welcome and encouraged to take part in your child’s day. Each site hosts special family events throughout the year and our Program Committee offers parents an opportunity to volunteer and give valuable feedback towards program enhancements. Parent surveys will also be distributed throughout the year, so we can receive your feedback and continuously improve your experience.

SIGN UP TODAY!

• Cedar Grove Elementary • Crossroads Elementary • Freedom Elementary • Mt. Washington Elementary • Old Mill Elementary • Overdale Elementary • Pleasant Grove Elementary • Roby Elementary • Shepherdsville Elementary Site locations may vary due to consolidations.

All sites have minimum and maximum enrollment numbers.

FEEDER SCHOOLS Before and after school care is available at the site listed after your child’s school.

• Brooks Elementary: Freedom Elementary • Lebanon Junction Elementary: Cedar Grove Elementary • Maryville Elementary: Overdale Elementary • Bernheim Middle: Cedar Grove Elementary • Bullitt Lick Middle: Shepherdsville Elementary • Hebron Middle: Freedom Elementary • Zoneton Middle: Maryville Elementary • Mt. Washington Middle: Crossroads Elementary • Eastside Middle: Pleasant Grove Elementary Transportation provided by Bullitt County Public Schools and is subject to change.

All sites have minimum and maximum enrollment numbers.

REGISTER TODAY

PAYMENT OPTIONS

Registration for the before and after school programs will continue throughout the school year based on availability. All sites have minimum and maximum enrollment numbers and registrations are processed on a first-come, first-served basis. Completed registrations must be received at least two business days prior to your child’s start date.

Payments can be made by bank or credit card draft. Automatic draft payments must be set up prior to the first day of attendance for your child to attend our program. Drafts occur each Wednesday for the current week, unless otherwise scheduled through our main office.

ACCESS FOR ALL

You can register one of the following ways: • Online at ymcalouisville.org through August 4

th

• Bring registration form and fee to your Site Director or to the Bullitt County Family YMCA at 409 Joe B. Hall Avenue • Mail the registration form and fee to: Bullitt County Family YMCA P. O. Box 846 Shepherdsville, KY 40165 Mail must be post-marked one week prior to start date. Please do not fax registration forms. If you have additional questions, call 502 543 3985 or 502 955 6433, or visit ymcalouisville.org.

WEEKLY RATES 2011-12 Bullitt County YMCA School-Age Child Care Program First Child

Each Additional

$50

$35

Before & After School

$62

$40

1-, 2- or 3-day Before or After School Only

$35

$25

Before & After School

$46

$31

$30 per child through August 4

$45 per child starting August 5

4- or 5-day Before or After School Only

Registration Fees Per Child

In-service and snow days are included in total number of days attended for the week. In-service and snow day only rate is $25 per day, per child.

At the Y, we believe everyone should have the opportunity to grow up healthy, happy, confident and secure. That’s why we strive to make our programs and services available to everyone, even if they are unable to pay the full fee. Families can apply for financial assistance with the cost of Y programs and membership. Assistance is on an income-based sliding scale.

All sites are also eligible for 4-C and other third-party subsidy reimbursements. Valid contracts must be on file with our office prior to the program start date. Applicants who qualify for 4-C or other child care subsidies will not be eligible for additional assistance through the Y.

BULLITT COUNTY SCHOOL-AGE CHILD CARE PROGRAM 2011-12 SCHOOL YEAR REGISTRATION FORM PLEASE PRINT LEGIBLY and include your registration fee. Register Online through August 4 at ymcalouisville.org. th

Program start date

Please attach a recent wallet size photo and immunization certificate for each child.

Email address

(To receive important program updates and registration information)

1st CHILD First name Race

Middle initial

African American/Black

Alaskan

Last name

Native Asian/Pacific Islander

Date of birth Caucasian/White

Physical conditions/special needs

Hispanic

/

Native American

/

Gender

Yes

Participation

Age

Tourettes

Rhett Syndrome

No

YMCA Childcare Site Attendance

F

Medications/allergies

To better serve your child, please indicate if he/she has been diagnosed with any of the following: ADD/ADHD Convulsions Bleeding/Clotting Disorders Autism Aspergers Fragile X Cerebral Palsy Bipolar Disorder Down Syndrome Chronic Health Problems Asthma/Severe Allergies Diabetes Heart defect/disease Other Does this child have an IEP?

M

Other

School Attending

1-3 Days

4-5 Days

Before-School Care

Grade in School (2011-12) After-School Care

Before- & After-School Care

In-Service Day Care

Snow Day Care

2 CHILD nd

First name Race

Middle initial

African American/Black

Alaskan

Last name

Native Asian/Pacific Islander

Date of birth Caucasian/White

Physical conditions/special needs

Hispanic

/

Native American

/

Gender

Yes

Participation

Age

Tourettes

Rhett Syndrome

No

YMCA Childcare Site Attendance

F

Medications/allergies

To better serve your child, please indicate if he/she has been diagnosed with any of the following: ADD/ADHD Convulsions Bleeding/Clotting Disorders Autism Aspergers Fragile X Cerebral Palsy Bipolar Disorder Down Syndrome Chronic Health Problems Asthma/Severe Allergies Diabetes Heart defect/disease Other Does this child have an IEP?

M

Other

School Attending

1-3 Days

4-5 Days

Before-School Care

Grade in School (2011-12) After-School Care

Before- & After-School Care

In-Service Day Care

Snow Day Care

1 PARENT/GUARDIAN st

Name

Relationship to child

Address Home phone

City

Cell phone

Date of birth

State Work phone

/

/

/

/

Zip

Employer

2nd PARENT/GUARDIAN Name

Relationship to child

Address Home phone

City

Cell phone

Date of birth

State Work phone

Zip

Employer

INSURANCE INFORMATION Policy number

Health insurance company Name of physician

Physician phone

PLEASE LIST ANY ADULT OTHER THAN THE ABOVE THAT MAY BE PICKING UP THIS CHILD OR THAT MAY BE CONTACTED IN AN EMERGENCY.

Anyone picking up your child must be at least 18 years of age or older. A picture ID is required at pick-up. .

Name

Relationship to child

Phone 1

Phone 2

Name

Relationship to child

Phone 1

Phone 2

The YMCA has permission for my children to be photographed and/or interviewed for promotional purposes Yes Yes No My child(ren) have permission to participate in basic health and fitness evaluations Yes, I would like to make a charitable donation to The Spirit Campaign $10 $25 $50 $100 Check here if either parent is YMCA employee Spirit recipient 4-C recipient YES! I would like to learn more about FREE or LOW-COST health insurance for my children and teens.

No Other/please contact me

You must choose one option below to process your registration. Drafts will occur each Wednesday for the current week unless otherwise scheduled through our main office.

I am currently on draft. Please use the account on file ending in ___ ___ ___ ___. Authorized account holder signature __________________________________________________________________________ I am authorizing a NEW bank draft from my checking account and I have attached a voided check.

I am authorizing a NEW credit card draft and I have provided all the information below: Credit Card Type:

Visa

MasterCard

Discover

Name on card

Authorized cc signature

Card number

Expiration date

Billing street address

Billing zip code

I have the legal authority to sign up the child/children named on this form and to the best of my knowledge the information on this application form is complete and accurate. I understand that my application will not be processed unless it includes the full fee or automatic draft authorization. I understand that the YMCA prohibits staff members from being alone with children they meet in YMCA programs outside of the YMCA. This includes but is not limited to baby-sitting, tutoring, sleep-overs, etc. In the event I cannot be reached in an emergency, I hereby give permission to the director of the program or designee to secure emergency medical services, including transportation and medical care. I also give permission for the attending physician to order injections, anesthesia or surgery for this child as named above. I understand that medical and accident insurance is the responsibility of the parent or guardian. There may also be times when the YMCA may take photographs (or other digital images) of students participating in activities. Those images may appear in the YMCA’s or publications, including electronic publications.

By signing this form, I am giving permission to the YMCA to use my child(s) image for the purposes listed above. I understand that this release may be revoked by me at any time by written request.

Signature

Date Signed