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2010-11 Before and After School Program

Laugh, Learn and Grow with the

Childcare Enrichment Program! The YMCA of Greater Louisville, in partnership with Jefferson County Public Schools, offers the Childcare Enrichment Program — where your child will learn, grow and have a great time!

ymcalouisville.org en kindergart through hool middle-sc

Financial assistance available.


Childcare Enrichment Program ● (502) 637-1575

We’re Everywhere The Childcare Enrichment program is available to all JCPS students from kindergarten through age 14. Transportation by JCPS school bus between your child’s school and CEP is available. We are the largest provider of childcare in the state, offering over 50 sites throughout Jefferson County.

Enrichment is our Name We pride ourselves on providing a safe environment where your child can participate in fun activities that enrich, strengthen and expand their learning. Our activities are focused around literacy, arts and humanities, recreation, science & technology, academic support, healthy actions and fitness, character development and asset building. Our goal is to help your child build a healthy spirit, mind and body.

Daily Schedule Regular program hours are 7 a.m. until the start school and close of school until 6 p.m. Continuous care is also available from 7 a.m. until 6 p.m. when school is not in session, at select locations. Spring Break, Winter Break and Summer programs require a separate registration. In addition to planned activities and programs, each child will receive healthy morning and afternoon snacks. Breakfast is served for children in the before-school program.

And for Preschoolers . . . Before- and after-school care is available for any child enrolled in one of the JCPS tuition-based preschool sites in the district (see site location list for details). Full day care is not available for preschoolers.

Trained Staff Our outstanding staff members receive extensive hours of professional development training that exceeds state licensing requirements. All staff are CPR and First Aid certified and we meet or exceed state staff-to-child ratios.

Parental Involvement All our programs have an open door policy and parents are welcome and encouraged to take part in their child’s day. Each site will host special family events. We welcome parents to join our Parent Advisory Committee, where monthly luncheon meetings give you the opportunity to provide key input, feedback and program development ideas. Throughout the year, we distribute surveys to parents and participants. Your feedback is valuable and greatly appreciated!

visit ymcalouisville.org or email us at childcareservices@ymcalouisville.org


Weekly Rates First Child

Each Additional Child

Program Members

YMCA Facility Member/ Partnership Employee Dependents

Program Members

YMCA Facility Member/ Partnership Employee Dependents

4- or 5-day Before School Only After School Only Before & After School

$45 $58 $72

$40 $53 $67

$35 $48 $62

$30 $43 $57

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

$37 $47 $59

$33 $43 $55

$29 $39 $51

$25 $35 $47

Registration Fees Per Child

Through August 9, 2010

$30 per child

August 10, 2010 throughout school year

$45 per child

In-service and snow days are included in total number of days attended for the week.

Registration Registration for the before- and after-school programs will continue throughout the school year based on space 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 2 business days prior to your child’s start date. All parents must pay the registration fees. To register submit your registration form and non-refundable registration fee one of the following ways:

• Online at ymcalouisville.org through August 9th

• Bring registration form and fee to your CEP Site Director

• Mail the registration form and fee to:

YMCA School-Age Child Care Services 2411 Bowman Avenue Louisville, KY 40217 Mail must be post-marked one week prior to start date.

Payment Options All payments are to be made by bank or credit card draft. Automatic draft payments must be set up prior to the first day of attendance in order for the child to attend the program. Drafts will occur each Wednesday for the current week, unless otherwise scheduled through our main office.

In-Service & Snow Days Full day care available during in-service and snow days from 7 a.m. until 6 p.m. Site locations may vary due to site consolidation. In addition to completing the registration form, participants must be signed up to attend these days at the site of their choice. Details available at your site or at ymcalouisville.org. In-service and snow days are included in total number of days attended for the week. Full day care is not available for preschoolers.

Financial Assistance & 3rd Party Subsidies Through the Spirit Program, we strive to turn no one away due to an inability to pay. The Spirit Program is a sliding-scale income-based financial assistance program available through the YMCA. Call (502) 637-1575 or go to ymcalouisville.org for a Spirit Application. All sites are also eligible for third-party subsidy reimbursements provided by 4-C, Foster Care, United Way, etc. Valid contracts must be on file with our main office prior to the program start date. Spirit Program assistance is only available for those that do not qualify for 4-C or other third-party subsidies.


CEP Sites & Locations The before- and after-school program begins on Tuesday, August 17, 2010. Sites are conveniently located in these Jefferson County Public Schools. Northeast Area Bowen Elementary, 1601 Roosevelt Avenue Malcolm B. Chancey Jr. Elementary, 4301 Murphy Lane Chenoweth Elementary, 3622 Brownsboro Road Dunn Elementary, 2010 Rudy Lane *Field Elementary, 120 Sacred Heart Lane Greathouse Elementary, 2700 Browns Lane Hite Elementary, 12408 Old Shelbyville Road Lowe Elementary, 210 Oxfordshire Lane Middletown Elementary, 218 North Madison Avenue *Norton Elementary, 8101 Brownsboro Road St. Matthews Elementary, 601 Browns Lane *Joseph E. Stopher Elementary, 14417 Aiken Road *Wilder Elementary, 1913 Herr Lane Zachary Taylor Elementary, 9620 Westport Road Southeast Area Audubon Traditional Elementary, 1051 Hess Lane Bates Elementary, 7601 Bardstown Road Bloom Elementary, 1627 Lucia Avenue Blue Lick Elementary, 9801 Blue Lick Road Cochrane Elementary, 2511 Tregaron Avenue *James E. Farmer Elementary, 6405 Gellhaus Lane Fern Creek Elementary, 8703 Ferndale Road Goldsmith Lane Elementary, 3520 Goldsmith Lane *Hawthorne Elementary, 2301 Clarendon Avenue Highland Middle, 1700 Norris Place Jeffersontown Elementary, 3610 Cedarwood Way Klondike Elementary, 3807 Klondike Lane Laukhuf Elementary, 5100 Capewood Drive Luhr Elementary, 6900 Fegenbush Lane Price Elementary, 5001 Garden Green Way Rangeland Elementary, 1701 Rangeland Road Smyrna Traditional Elementary, 6401 Outer Loop Thomas Jefferson Middle, 1501 Rangeland Road *Tully Elementary, 3300 College Drive Watterson Elementary, 3900 Breckenridge Lane *Wheeler Elementary, 5700 Cynthia Drive Southwest Area Cane Run Elementary, 3951 Cane Run Road Conway Middle, 6300 Terry Road Doss High School, 9601 St. Andrews Church Road Fairdale Elementary, 10104 Mitchell Hill Road Frederick Law Olmsted South Middle, 5650 Southern Parkway (nationally accredited by the NSACCA) Jacob Elementary, 3701 W. Wheatmore Avenue Johnsontown Elementary, 7201 Johnsontown Road Kerrick Elementary, 2210 Upper Hunters Trace McFerran Elementary, 1900 South Seventh Street Minors Lane Elementary, 8510 Minors Lane Rutherford Elementary, 301 Southland Boulevard Shacklette Elementary, 5310 Mercury Drive Stuart Middle, 4601 Valley Station Road Downtown Area *Brandeis Elementary, 2817 W. Kentucky Street Breckinridge-Franklin Elementary, 1351 Payne Street Brown School, 546 South First Street *Carter Traditional Elementary, 3600 Bohne Avenue Coleridge-Taylor Elementary, 1115 West Chestnut Street Foster Elementary, 4020 Garland Avenue *Kennedy Montessori Elementary, 3800 Gibson Lane Noe Middle, 121 West Lee Street *Before and After School child care for 3- and 4-year olds enrolled in the host school’s tuition-based Pre-K program will be provided at these sites only. No full-day child care is available for preschoolers.

Feeder Schools Locate your child’s school. All available CEP sites are listed after the school name. Atkinson: All CEP sites available Auburndale: Fairdale, Jacob, Frederick Law Olmsted, South Middle, Rutherford Audubon: Audubon, Bates, Farmer, Goldsmith, Hawthorne, Highland, Jeffersontown, Klondike, Noe, Rangeland, Thomas Jefferson Middle, Tully, Watterson, Wheeler Barrett Traditional Middle: Bowen, Chancey, Chenoweth, Dunn, Greathouse, Lowe, Middletown, Norton, St. Matthews, Zachary Taylor Bates: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown Elementary, Luhr, Price, Rangeland, Watterson, Wheeler Blake: Blue Lick, Laukhauf, McFerran, Smyrna, Thomas Jefferson Middle Bloom: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite, Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully Blue Lick: Blue Lick, Laukhuf, McFerran, Minors Lane, Smyrna, Thomas Jefferson Middle Bowen: Bowen, Chancey, Coleridge-Taylor, Dunn, Norton, Wilder, Zachary Taylor Brandeis: All CEP sites available

Breckinridge-Franklin: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor Brown: Brown Byck: All CEP sites available Camp Taylor: Audubon, Blue Lick, Laukhauf, McFerran, Noe, Smyrna Cane Run: Cane Run, Carter, Conway, Foster, Johnsontown, Kennedy, Kerrick, Shacklette, Stuart Carrithers Middle: Tully Carter Traditional Elementary: Audubon, Bloom, Brandeis, Cane Run, Coleridge-Taylor, Conway, Doss, Fairdale, Field, Highland, Johnsontown, Kerrick, Noe, Shacklette, Stuart Chancey: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor Chenoweth: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor Cochran: Blue Lick, Kennedy, Laukhauf, McFerran, Minors Lane, Noe, Stuart Cochrane: Bloom, Cochrane, Hawthorne, Hite, Klondike, Lowe, Middletown, Smyrna, St. Matthews, Stopher, Tully Coleridge-Taylor: Bloom, Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Highland, Jeffersontown, Lowe, Middletown, Noe, Norton, St. Matthews, Tully, Wilder, Zachary Taylor Conway Middle: Cane Run, Conway, Shacklette Coral Ridge: Fairdale Elementary, Jacob, Rutherford Crosby Middle: Lowe, Middletown Crums Lane: Cane Run, Carter, Conway, Foster, Johnsontown, Kennedy, Kerrick, Shacklette, Stuart Dixie: Cane Run, Foster, Johnsontown, Kennedy, Kerrick, Shacklette, Stuart Dunn: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Greathouse, Norton, Wilder, Zachary Taylor Eisenhower: Cane Run, Conway, Foster, Johnsontown, Kennedy, Kerrick, Shacklette Engelhard: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite, Klondike, Lowe, Middletown, Noe, St. Matthews, Stopher, Tully Fairdale Elementary: Fairdale, Frederick Law Olmsted South Middle, Jacob, Rutherford Farnsley Middle: Cane Run, Conway, Frederick Law Olmsted South Middle, Kerrick, Shacklette Farmer Elementary: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Fern Creek Elementary: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Field: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Highland, Norton, Wilder, Zachary Taylor Foster: All CEP sites available Frayser: Blue Lick, Laukhauf, McFerran, Minors Lane, Smyrna Frederick Law Olmsted North: Frederick Law Olmsted South Frederick Law Olmsted South: Frederick Law Olmsted South Gilmore Lane: Blue Lick, Laukhauf, McFerran, Minors Lane, Smyrna, Thomas Jefferson Middle Goldsmith Lane: Bates, Coleridge-Taylor, Farmer, Fern Creek Elementary, Jeffersontown, Goldsmith, Luhr, Price, Rangeland, Watterson, Wheeler Greathouse/Shyrock: Bowen, Chancey, Coleridge-Taylor, Dunn, Greathouse, Lowe, Middletown, Norton, St. Matthews, Wilder, Zachary Taylor Greenwood: Cane Run, Conway, Doss, Foster, Johnsontown, Kennedy, Shacklette Gutermuth: Cane Run, Foster, Frederick Law Olmsted South, Johnsontown, Shacklette Hartstern: Blue Lick, Laukhauf, Minors Lane, Smyrna, Thomas Jefferson Middle Hawthorne: Bloom, Cochrane, Hawthorne, Highland, Hite, Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully Hazelwood: Fairdale, Frederick Law Olmsted South, Jacob, Rutherford Highland Middle: Audubon, Bates, Bowen, Chenoweth, Coleridge-Taylor, Dunn, Field, Frederick Law Olmsted South, Hawthorne, Highland, Noe, Norton, Zachary Taylor Hite: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite, Klondike, Lowe, Middletown, Stopher, Tully Indian Trail: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Jacob: Cane Run, Fairdale, Jacob, Rutherford, Stuart Jefferson County Traditional Middle: Bates, Brandeis, Hawthorne, Highland, Klondike, Laukhauf, Price Jeffersontown Elementary: Bates, Farmer, Fern Creek, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Johnson Traditional Middle: Blue Lick, Carter, Conway, Frederick Law Olmsted South, McFerran, Shacklette, Stuart Johnsontown Road: Cane Run, Foster, Frederick Law Olmsted South, Kennedy, Kerrick, Shacklette, Stuart Kammerer Middle: Chancey, Chenoweth, Dunn, Johnsontown, Norton, Wilder, Zachary Taylor Kennedy Montessori: Audubon, Bates, Bloom, Blue Lick, Brandeis, Cane Run, Carter, Chancey, Chenoweth, Cochrane, Coleridge-Taylor, Conway, Doss, Dunn, Fairdale Elementary, Farmer, Field, Foster, Frederick Law Olmsted South, Goldsmith, Hawthorne, Highland, Johnsontown, Jeffersontown, Kennedy, Kerrick, Klondike, Laukhauf, Lowe, Luhr, Middletown, Noe, Rangeland, Shacklette, St. Matthews, Stuart, Thomas Jefferson Middle, Tully, Watterson, Wheeler, Wilder, Zachary Taylor Kenwood: Fairdale, Frederick Law Olmsted South, Jacob, Rutherford Kerrick: Cane Run, Conway, Foster, Johnsontown, Kennedy, Kerrick, Shacklette

King: All CEP sites available Klondike: Bloom, Cochrane, Hawthorne, Hite, Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully Knight Middle: Thomas Jefferson Middle Lassiter Middle: Fairdale, Frederick Law Olmsted South, Kennedy, Minors Lane Laukhuf: Blue Lick, Laukhauf, Minors Lane, Rangeland, Smyrna, Thomas Jefferson Middle Layne: Carter, Fairdale, Jacob, Kennedy, Rutherford, Stuart Lincoln: Chancey, Chenoweth, Cochrane, Coleridge-Taylor, Dunn, Field, Goldsmith, Hawthorne, Lowe, Middletown, Norton, St. Matthews, Wilder, Zachary Taylor Lowe: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite, Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully Luhr: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Maupin: All CEP sites available McFerran: Blue Lick, Laukhuf, McFerran, Minors Lane, Smyrna, Stuart Medora: Fairdale, Jacob, Rutherford, Stuart Meyzeek Middle: Bloom, Bowen, Brandeis, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Highland, Noe, Norton, Wilder, Zachary Taylor Middletown: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite, Klondike, Middletown, Lowe, Stopher, Tully Mill Creek: Fairdale Elementary, Frederick Law Olmsted South, Jacob, Rutherford Minors Lane: Minors Lane, Smyrna, Moore Middle: Bates, Frederick Law Olmsted South, Luhr, Thomas Jefferson Middle Myers Middle: Bowen, Brandeis, Chancey, Frederick Law Olmsted South, Hawthorne, Klondike, Zachary Taylor Newburg Middle: Bates, Blue Lick, Highland, Laukhuf Noe Middle: Bates, Bloom, Blue Lick, Bowen, Brandeis, Carter, Chancey, Chenoweth, Conway, Dunn, Frederick Law Olmsted South, Hawthorne, Highland, Laukhuf, Norton, Noe, Price, Shacklette, Wilder, Zachary Taylor Norton: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor Okolona: Blue Lick, Laukhuf, Minors Lane, Rangeland, Smyrna, Thomas Jefferson Middle Portland: Bowen, Breckinridge-Franklin, Carter, Chancey, Chenoweth, Coleridge-Taylor, Conway, Dunn, Field, Frederick Law Olmsted South, Norton, Wilder, Zachary Taylor Price: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Ramsey Middle: Wheeler Rangeland: Bates, Farmer, Fern Creek, Goldsmith, Jeffersontown, Laukhuf, Luhr, Price, Rangeland, Watterson, Wheeler Roosevelt-Perry: All CEP sites available Rutherford: Fairdale, Frederick Law Olmsted South, Jacob, Rutherford St. Matthews: Bloom, Cochrane, Coleridge-Taylor, Greathouse, Hawthorne, Hite, Klondike, Lowe, Middletown, Stopher, St. Matthews, Tully Sanders: Cane Run, Conway, Foster, Johnsontown, Kennedy, Kerrick, Shacklette Schaffner Traditional Elementary: Bates, Blue Lick, Cane Run, Doss, Farmer, Frederick Law Olmsted South, Laukhuf, Luhr, McFerran, Watterson, Wheeler Semple: Fairdale, Frederick Law Olmsted South, Jacob, Rutherford Shacklette: Cane Run, Carter, Conway, Foster, Johnsontown, Kennedy, Kerrick, Shacklette, Stuart Shelby: All CEP sites available Slaughter: Bates, Farmer, Fern Creek, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Thomas Jefferson Middle, Watterson, Wheeler Smyrna: Blue Lick, Laukhuf, Minors Lane, Smyrna Stonestreet: Carter, Fairdale, Jacob, Kennedy, Rutherford, Stuart Stopher: Bloom, Cochrane, Hawthorne, Hite, Klondike, Middletown, Rangeland, Stopher, Thomas Jefferson Middle Stuart Middle: Kennedy, Stuart Thomas Jefferson Middle: Bates, Bowen, Chenoweth, Dunn, Frederick Law Olmsted South, Norton, Thomas Jefferson Middle, Zachary Taylor Trunnel: Fairdale, Frederick Law Olmsted South, Jacob, Rutherford, Stuart Tully: Bloom, Cochrane, Coleridge-Taylor, Hawthorne, Hite, Klondike, Lowe, Middletown, St. Matthews, Stopher, Tully Watson Lane: Cane Run, Carter, Foster, Johnsontown, Kennedy, Kerrick, Shacklette, Stuart Watterson: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Wellington: Cane Run, Carter, Conway, Foster, Johnsontown, Kennedy, Kerrick, Shacklette, Stuart Western Middle: Coleridge-Taylor Westport Middle: Brandeis, Chancey, St. Matthews, Zachary Taylor Wheatley: All CEP sites available Wheeler: Bates, Farmer, Fern Creek Elementary, Goldsmith, Jeffersontown, Luhr, Price, Rangeland, Watterson, Wheeler Wilder: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Greathouse, Norton, Wilder, Zachary Taylor Wilkerson: Cane Run, Foster, Johnsontown Road, Kennedy, Kerrick, Shacklette, Stuart Wilt: Blue Lick, Laukhuf, Minors Lane, Rangeland, Smyrna, Thomas Jefferson Middle Whitney Young: All CEP sites available Zachary Taylor: Bowen, Breckinridge-Franklin, Chancey, Chenoweth, Coleridge-Taylor, Dunn, Field, Norton, Wilder, Zachary Taylor

If your child’s school is not a host site, JCPS will provide transportation for before- and after-school program students. Transportation is dependent upon JCPS routing and is subject to change.


2010-11 School Year Childcare Enrichment Program Registration Form

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

Please print legibly and include your registration fee. Register Online through August 9th at ymcalouisville.org. Program Start Date_ _____________________________________

E-mail Address to receive confirmation_ ______________________________________________________________

1st Child’s Name First _____________________________ Middle _____________________________ Last_____________________________ Date of Birth _ _____/______ /______ Gender:  African American/Black

Race:

 Alaskan

 Native Asian/Pacific Islander

 Caucasian/White

 Hispanic

 Native American

 M

 F

Age_ ________

 Other

Physical Conditions/Special Needs_________________________________________________________ Medications/Allergies___________________________________________________________________ To better serve your child, please indicate if he/she has been diagnosed with any of the following:  ADD/ADHD

 Convulsions

 Rhett Syndrome

 Bleeding/Clotting Disorders

 Down Syndrome  Yes

Does this child have an IEP?

 Autism

 Chronic Health Problems

 Aspergers

 Fragile X

 Asthma/Severe Allergies

 Cerebral Palsy

 Diabetes

 Bipolar Disorder

 Heart defect/disease

 Tourettes

 Other______________________________

 No

Childcare Enrichment Program Site_ _____________________________________________________ School Attending_ ____________________________________________________________________ Attendance:

 1-3 Days

Participation:

 Before-School Care

 4-5 Days

Grade in School (2010-11)_ ______________________________________________________________________  After-School Care

 Before & After-School Care

 In-Service Day Care

 Snow Day Care

2nd Child’s Name First _____________________________ Middle _____________________________ Last_____________________________ Date of Birth _ _____/______ /______ Gender:  African American/Black

Race:

 Alaskan

 Native Asian/Pacific Islander

 Caucasian/White

 Hispanic

 Native American

 M

 F

Age_ ________

 Other

Physical Conditions/Special Needs_________________________________________________________ Medications/Allergies___________________________________________________________________ To better serve your child, please indicate if he/she has been diagnosed with any of the following:  ADD/ADHD

 Convulsions

 Rhett Syndrome

 Bleeding/Clotting Disorders

 Down Syndrome  Yes

Does this child have an IEP?

 Autism

 Chronic Health Problems

 Aspergers

 Fragile X

 Asthma/Severe Allergies

 Cerebral Palsy

 Diabetes

 Bipolar Disorder

 Heart defect/disease

 Tourettes

 Other______________________________

 No

Childcare Enrichment Program Site_ _____________________________________________________ School Attending_ ____________________________________________________________________ Attendance:

 1-3 Days

Participation:

 Before-School Care

 4-5 Days

Grade in School (2010-11)_ ______________________________________________________________________  After-School Care

 Before & After-School Care

 In-Service Day Care

 Snow Day Care

1st Parent/Guardian Name______________________________________________________________ Relationship to Child_____________________________________ Date of Birth ______ /______ /_ _____ Mailing Address_ _______________________________________________________________________ City_______________________________________ State_____________ Zip_______________________ Home Phone___________________________ Cell Phone_ _________________________ Work Phone __________________________ Employer_____________________________________________________ 2nd Parent/Guardian Name_ ____________________________________________________________ Relationship to Child_____________________________________ Date of Birth ______ /______ /_ _____ Mailing Address_ _______________________________________________________________________ City_______________________________________ State_____________ Zip_______________________ Home Phone___________________________ Cell Phone_ _________________________ Work Phone __________________________ Employer_____________________________________________________ Insurance Company _________________________________________________________________________________________ Policy Number_ __________________________________________________ Name of Physician_ _________________________________________________________________________________________ Physician Phone__________________________________________________  Yes! I would like to learn more about FREE or LOW-COST health insurance for my children and teens. Emergency Contact and Authorized Pick-Up Information Please give the names and phone numbers of people to contact in an emergency and/or names of persons authorized to pick up your child/children. Anyone picking up your child/children must be 18 years of age or older. A Photo ID is required at pick-up. Name_______________________________________________ Relation to child_ __________________________________ Phone 1_____________________________Phone 2____________________________ Name_______________________________________________ Relation to child_ __________________________________ Phone 1_____________________________Phone 2____________________________ The YMCA has permission for my child(ren) to be photographed and/or interviewed for promotional purposes: 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: Check here if either parent is: I currently receive a:

 YMCA Employee

 Spirit Program discount

 Yes

 $10

 $25

 School Partnership Employee  4-C

 Yes

 $50

 No I am registering a tuition-based Pre-K student:

 No  $100

 Yes

 No

 Other/please contact me

 YMCA Family Facility Member

 Other 3rd party subsidy discount

You must choose one of the three options below in order to process your registration. Drafts will occur each Wednesday for the current week unless otherwise scheduled through our main office.  I am currently on automatic draft. Please use the information on file to draft my account for my registration fee(s) and to set up my weekly payments. Account ending in ____ ____ ____ ____.

 EFT

 Credit Card

 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:

Name as it appears on card ____________________________________________________________ Card Number_ _______________________________________ Expiration Date_ _______________

Billing Street Address_____________________________________________________________________________ _ _____________________________________________Billing Zip_ _______________

 Visa

 MasterCard

 Discover

I have the legal authority to sign up my child/children named on this form. I understand that this is an application and the named child’s/children’s participation is contingent upon space being available in this program. I also understand that once my application is confirmed, I must complete payment by the deadline. 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-over’s, etc. This health history is correct as far as I know and the child/children herein described have my permission to engage in all activities and field trips except as noted by me. A photo of each child and a copy of each child’s current immunization certificate will be on file with the YMCA prior to my child/children attending the program. Failure to comply with the above could result in the loss of child care space. 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 a physician. I also give permission to the attending physician to order injection, anesthesia or surgery for my child/children as named above. Medical and accident insurance is the responsibility of the parent or guardian. My child/children attend Jefferson County Public Schools and by signing this form I am giving the YMCA permission to communicate and exchange information with JCPS for the purposes of providing and enhancing services to my child/children. I understand this specific release may be revoked by me at any time by written request. To the best of my knowledge; the information on this form is complete and accurate. I have read and agree to these terms and conditions.

Signature_______________________________________________________________________________________ Date Signed________________________


Fall 2010 CEP