Foglia YMCA

SCHOOL AGE CHILD CARE

2016-2017 REGISTRATION PACKET

- St. Francis de Sales

- Spencer Loomis

- Sarah Adams

- Seth Paine

- May Whitney

- Isaac Fox

- Kindergarten Enrichment

Foglia YMCA

1025 N. Old McHenry Road, Lake Zurich, IL 60047

847.438.5300 | fogliaymca.org

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Before & After School Care

Dear Parents:

Attached are the Foglia YMCA’s School Age Child Care Program and the Kindergarten Enrichment Program

registration packet for the 2016-2017 school year. Please fill out all paperwork and submit a $50 non-refundable

registration fee if you are a Foglia member and $100 if you are not per family. This is valid for the entire 16-17

school year.

All of the paperwork in the packet is mandatory, including the physical, dental examination records and birth

certificate. This paperwork is required by the Department of Children and Family Services and must be completed.

If your child attended the program for the 2015-2016 school year we have retained their physical, dental

examination, and birth certificate; you are not required to submit new ones if we already have them on file.

Please be sure to write legibly when filling out the packet, as this information is vital to your child’s

registration. If we cannot read the e-mail address, we cannot communicate effectively.

The first day of Before and After School Care will be Wednesday, August 24, 2016.

There is a mandatory one week waiting period from when you hand in the FULLY COMPLETE registration packet to

when your child can start the program. Your child will not be able to start until we have all paperwork. Before Care

will be held at Isaac Fox for Isaac Fox students only and at May Whitney for all other students. Students who

attend Before Care at May Whitney that do not attend May Whitney will be bussed to their respective school by

District 95 busses. Before Care is held from 6:45 a.m. – 8:15 a.m. After School Care at every District 95

Elementary School is from 2:50-6:30 p.m. After School Care for St. Francis de Sales students runs daily from 2:15-

6:30 p.m.

If you have any questions regarding our School Age Child Care Programs, please contact me at 847-410-5379 or

mmcglauchlin@ymcachicago.org or our Program Coordinator Sarah Sidell at 847-410-5393 or

ssidell@ymcachicago.org.

Thank you for your interest in our program! We look forward to your family becoming part of ours!

Sincerely,

Mimi McGlauchlin

School Age Child Care Director

Foglia YMCA

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KINDERGARTEN ENRICHMENT

Welcome to the Foglia YMCA Kindergarten Enrichment Program. We are pleased to offer this program in collaboration with District

95. The program is open to kindergarten students in any district. If your child does not attend District 95 schools transportation

must be provided on an individual basis as we do not have busses from other districts.

*When you register for Kindergarten with District 95, let them know that your child will be attending this program so that they can

coordinate transportation.*

Our morning program (AM Enrichment) will run from 8:00am until approximately 11:30 a.m. The students will be picked up from the

Foglia YMCA at 11:30 a.m. by District 95 busses and dropped off at their respective schools. If your child is continuing on in the

afternoon with the School Age Child Care After School Program, they will walk down to the appropriate room within the school and

join the rest of the grades at the school site.

Our afternoon program (PM Enrichment) will run from 11:30 a.m. until 3 p.m. If your child is continuing on in the afternoon with the

School Age Child Care After School Program, they will remain at the Y and after care will take place on site for those participants.

NEW THIS YEAR** Before Care will be offered for students attending our AM Enrichment Program. It will be held at the Y and run

from 6:45 a.m. – 8:00 a.m. If your child is attending our PM Enrichment Program and attending AM Kindergarten at school Before

Care will be offered for them at either Isaac Fox or May Whitney. Before Care will be held at Isaac Fox for Isaac Fox students only

and at May Whitney for all other students. Students who attend Before Care at May Whitney that do not attend May Whitney will be

bussed to their respective school by District 95 busses. Before Care is held from 6:45 a.m. - 8:15 a.m.

Our Kindergarten Enrichment Program is a fully licensed DCFS program and will run under its parameters. All paperwork must be

completed before admittance into the program. We will provide a catered lunch and snack for all students. Unless your child has

specific dietary needs, which will be assessed on a case by case basis, students are NOT allowed to bring their own lunch.

The Kindergarten Program will offer a broad range of curriculum and activities based on the YMCA’s Christian principles of caring,

honesty, respect and responsibility and encourage children to achieve a healthy spirit, mind and body.

Curriculum will include, but not be limited to the following:

Independent, group and one on one

Reading Time

Weekly Swimming

Centers

Science Enrichment

Printing

Math Enrichment

Social Development

Team Building

Group Games

Arts and Crafts

Climbing Wall

Various Physical Education Units

Thank you for your interest in our program!

If you have any further questions please contact Jenna Stanonik at 847.410.5373 or at jstanonik@ymcachicago.org

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School Age Child Care & Kindergarten Enrichment

Attendance Policy and Procedures

When you turn in your completed registration packet with all required materials you will have been asked to designate what

your child’s attendance will be in our program. This is considered your confirmed schedule. Should you need to make changes

to said schedule please refer to the guidelines below.

CHANGE OF PERMANENT SCHEDULE

In order to make a change to your child’s confirmed schedule, such as decreasing or increasing the amount of days they

attend, we require a written notice by the 15th of the month, to be effective on the following month. This allows us to make

the necessary changes to your billing as well as our attendance rosters.

ADDING DAYS

If you would like to add a day for a particular week you may do so depending on space availability for an additional fee. There

is a $15.00 cost per day to add a morning and a $25.00 cost per day to add an afternoon. If there is an early release day

that your child is not regularly scheduled for and you would like them to attend the program an additional cost of $30.00

must be paid.

SWITCHING DAYS

Switching the days of the week your child attends is not permitted. For example, if your child’s confirmed schedule states that

they attend Monday, Wednesday, and Friday you may not “switch” Friday for Thursday one week even though it is still the

same amount of days. You would need to add Thursday for an additional cost even if your child will not be attending Friday.

Unfortunately, we cannot refund or issue credit for missed days.

WITHDRAWAL FROM PROGRAM

If you would like to withdraw your child from our program a two week notice must be given in order to make the necessary

changes to your billing as well as our attendance rosters. There is NO cancellation fee provided you give us two weeks’ notice.

ABSENCES

If your child is absent from school, or not attending our program that day, you must notify us of the absence by

1:00pm. Please call the site cell phone for the school that your child attends and leave a message if the phone is not turned

on.

Kindergarten Enrichment 224.725.8840

Isaac Fox 224.725.8193

May Whitney 224.725.8192

St. Francis 224.725.8197

Sarah Adams 224.725.8196

Seth Paine 224.725.8194 | Land Line: 847.726.2327

Spencer Loomis 224.725.8195 | Land Line: 847.719.3618

** To make any of the above changes (besides reporting an absence) please contact Debbie Siedlecki, our business secretary,

at 847.410.5368 or dsiedlecki@ymcachicago.org. Debbie is the only one who handles payments! **

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SCHOOL AGE CHILD CARE AND KINDERGARTEN

ENRICHMENT ORIENTATION FUN NIGHT *MANDATORY FOR ALL NEW PARTICIPANTS* Returning participants are welcome and encouraged to attend!

WHEN

Thursday, August 4th, 2016 from 6:30 p.m. - 8:30 p.m.

6:30 p.m. - 7:30 p.m.

- Informational Meeting in multipurpose room 1 for the parents whose child(ren) attends the following

schools: Sarah Adams, Seth Paine and Spencer Loomis

- Meet and Greet with the Staff in multipurpose room 2 for the parents whose child(ren) attends the

following schools: Isaac Fox, May Whitney, and St. Francis

7:30 p.m. - 8:30 p.m.

- Informational Meeting in multipurpose room 1 for the parents whose child(ren) attends the following

schools: Isaac Fox, May Whitney, and St. Francis

- Meet and Greet with the Staff in multipurpose room 2 for the parents whose child (ren) attends the

following schools: Sarah Adams, Seth Paine, and Spencer Loomis

WHERE

Foglia YMCA – Multipurpose Rooms 1 & 2

Gymnasium (Rock Wall)

WHY

Because we want you to become part of our family!

If you cannot make it or want more information please contact:

May Whitney Before Care, Sarah Adams, Seth Paine, & Spencer Loomis:

Mimi McGlauchlin, 847.410.5379, or mmcglauchlin@ymcachicago.org

Isaac Fox, May Whitney, St. Francis:

Sarah Sidell, 847.410.5393, or ssidell@ymcachicago.org

Kindergarten Enrichment:

Jenna Stanonik, 847.410.5373, or jstanonik@ymcachicago.org

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SCHOOL AGE CHILD CARE & KINDERGARTEN ENRICHMENT PROGRAM 2016-2017 SCHOOL YEAR

Participant’s Name: __________________________________________________________________________________________________________

School Name: ________________________________________________________________________ Grade: ________________________________

Circle One: New Participant Returning Participant

**Please turn in with completed packet, so School Age Child Care Staff can sign off on and place in child’s folder.

ALL PAPERWORK MUST BE COMPLETED BEFORE CHILD WILL BE ALLOWED TO ATTEND THE PROGRAM. **

REQUIRED INFORMATION COMPLETED

Participant/Parent Information ____________________

Emergency Contacts/Authorized Pick-Up (at least 3) ____________________

Pick Up Consent (bottom of page 7) ____________________

Days Needed ____________________

Insurance Information/Health History/Medical Release/ADA Compliance ____________________

YMCA Character Contract ____________________

Facility User/Field Trip Agreement ____________________

Developmental History/Talent Release ____________________

Pick Up Agreement ____________________

Parent Consent for Assessment ____________________

Draft Agreement ____________________

Payment Agreement ____________________

Health Exam Form w/ Doctor Signature ____________________

Lead Risk Questionnaire/TB Test Verification ____________________

Developmental History/Allergies (yes/no questions located on physical form) ____________________

Dental Exam Record w/ Doctor Signature ____________________

Birth Certificate ____________________

DCFS Standards (Receive and sign on first day of program for new participants) ____________________

SCHOOL AGE CHILD CARE STAFF ONLY

Initials _______________ Date ________________________

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SCHOOL AGE CHILD CARE & KINDERGARTEN ENRICHMENT

2016-2017 PROGRAM REGISTRATION Please complete for EACH CHILD. Return with your $50 member/$100 non-member NON-REFUNDABLE REGISTRATION FEE

(per family). Check, Money Order, and Major Credit Cards accepted.

PARTICIPANT INFORMATION

Name: _______________________________________________________________ Birth Date: ______________________ Grade: _____________

Nickname: ________________________________ Male ________ Female ________

Address ___________________________________________________________________________________________________________________________

Street City State/Zip

PARENT/LEGAL GUARDIAN INFORMATION

Mother (Guardian) ____________________________________________________________ Home Phone: ______________________________

Address ___________________________________________________________________________________________________________________________

Employer _______________________________________________________________________ Work Phone _______________________________

Address ________________________________________________________________________ Cell Phone _________________________________

E-mail ______________________________________________________________________________________________________________________________

Father (Guardian) _____________________________________________________________ Home Phone ______________________________

Address ___________________________________________________________________________________________________________________________

Employer _______________________________________________________________________ Work Phone _______________________________

Address ________________________________________________________________________ Cell Phone _________________________________

E-mail ______________________________________________________________________________________________________________________________

Child Lives With: o Both Parents o Mother o Father o Other __________________________________________________

EMERGENCY CONTACTS/AUTHORIZED PICK-UP Parents are always called first. If unavailable, AT LEAST THREE (3) LOCAL NAMES ARE REQUIRED.

NAME RELATIONSHIP PHONE ADDRESS (CITY, ST)

1.

2.

3.

4.

5.

I, ________________________________ authorize the people listed above to pick up my child and be contacted in the event of an emergency from the

FOGLIA YMCA. In doing so, I relieve the YMCA of Metropolitan Chicago, its centers and employees of all responsibilities for my child after

he/she has been released from the program. Attempts will be made to reach the parent/legal guardian first. Initials ___________

UNAUTHORIZED PICK-UP: People who CANNOT pick up your child from our program:

1. Name _______________________________________________________________________ Relationship ___________________________________

2. Name _______________________________________________________________________ Relationship ___________________________________

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SCHOOL AGE CHILD CARE RATES Rates per Month

DISTRICT 95 BEFORE CARE AFTER CARE BOTH ST. FRANCIS

1 Day per Week $59 $82 $131 $98

3 Days per Week $162 $221 $368 $267

4 Days per Week $173 $254 $409 $307

5 Days per Week $198 $306 $485 $369

School Enrolled: _________________________________________________________________________________

Days Enrolled – Please Circle

AM: M T W TH F Start date: _____________________________

PM: M T W TH F The first day of Before and After Care is Wednesday, August 24th

KINDERGARTEN ENRICHMENT (with Before and After Care Options)

Rates per Month

NUMBER OF DAYS BEFORE CARE KINDERGARTEN BOTH

(Kindergarten and after care)

1 Day per Week Add $52 $155 $211

3 Days per Week Add $155 $310 $503

4 Days per Week Add $165 $350 $571

5 Days per Week Add $185 $412 $678

School Enrolled: _________________________________________________________________________________

Days Enrolled – Please Circle

AM Enrichment: M T W TH F Start date: _________________________

PM Enrichment: M T W TH F The first day of Kindergarten Enrichment Program is Wednesday, August 24th

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INSURANCE INFORMATION Is the participant covered by family medical/hospital insurance? CIRCLE ONE: Yes No

If yes, indicate carrier or plan name ___________________________________________ Group # _______________________________________________

Carrier Address ______________________________________________________ City/State/Zip _____________________________________________________

Name of insured _______________________________________________ Relationship to Participant ___________________________________________

HEALTH HISTORY Describe any of your child’s current health conditions requiring medical attention, treatment or special restrictions

or considerations while at our program _________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Does your child take any medications? __________________________________________________________________________________________________

Does your child have any allergies, including food? _________ if so, please list ___________________________________________________

____________________________________________________________________________________________________________________________________________________

Reaction to allergy/management of allergy _____________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Are there any activities that your child should be exempted from for health reasons? ________ if yes, please describe

____________________________________________________________________________________________________________________________________________________

MEDICAL RELEASE I do hereby give permission for the YMCA of Metropolitan Chicago staff to transfer child named above off property

for purpose of medical care as deemed appropriate by the Director and in the event that I cannot be reached in an

EMERGENCY, I hereby give my permission to the physician selected by the Director, to hospitalize, secure proper

treatment for and to order injection, anesthesia or surgery for my child named above. Initials ___________

AMERICANS WITH DISABILITIES ACT In accordance with the Americans with Disabilities Act, The YMCA of Metropolitan Chicago does not discriminate

against persons with disabilities. The YMCA will make every effort to include members with disabilities in its

programs, and will work together with the parent or caregiver to determine what reasonable modifications will be

effective for the member with a disability.

For more information about the YMCA Inclusion process, contact Brian Barnes

at bbarnes@ymcachicago.org or inclusion@ymca.org.

My child needs a modification because of disability to enjoy this program. Please circle one: Yes No

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YMCA CHARACTER CONTRACT At Y Before and After Care, it is our goal to create an exciting and safe learning environment for all! We ask

everyone in our program to agree to certain safety and behavioral guidelines so all of our participants are able to

have an enjoyable experience. As a family, please read, discuss and sign the Character Contract together.

Be Kind – Children will not be allowed to discuss inappropriate topics or contribute to demeaning conversations

about other children or staff.

One way I will be kind is to_________________________________________________________________________________________________________________ (Please have your child share how they will be kind at before/after care- ie. sharing, smiling etc.)

Be Safe – At the Y we maintain an emotionally and physically safe environment. We stay with our group and follow

staff’s directions. We use equipment and materials in the way they are intended to be used. We use appropriate

and productive words to settle our differences and keep our hands and feet to ourselves.

One way I will be safe is to ________________________________________________________________________________________________________________ (Please have your child share how they will be safe at at before/after care - ie. keeping their hands to themselves, using

walking feet etc.)

Be Honest – At the Y we tell the truth and are able to be our genuine self.

I will be honest when ________________________________________________________________________________________________________________________ (Please have child your child share an example of when they will be honest at before/after care - ie. when they get out in tag,

when they make a mistake etc.)

Be Respectful – At the Y we listen to each other, follow directions and use appropriate language/communication.

One way I will be respectful is to _________________________________________________________________________________________________________ (Please have your child share how they will be respectful at before/after care - ie. following directions, use appropriate

language etc.)

Have Fun – At the Y we are open to new experiences! We try new things and make new friends! We have fun in

ways that do not harm others physically or emotionally:

I have fun when I am: ________________________________________________________________________________________________________________________ (Please have your child share what they like to do to have fun!)

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If this contract is broken or if there is a conflict/interaction that involves strong feelings or

serious negative behaviors the following steps will be taken:

Step 1: YMCA staff will talk with students in order to acknowledge feelings, gather information and create a plan

to repair any harm that has been caused. This will be documented in the behavior log.

Step 2: If negative behavior persists or the plan to repair harm is not followed, parents will be asked to come to

the program as a partner to discuss the issues and work toward a solution together with their child and YMCA

staff. A written plan will be created and signed by parent, youth and staff.

Step 3: YMCA staff will monitor behavior closely and provide regular feedback to the student and his/her parents.

Step 4: If the problem persists or the students does not follow the plan created and agreed upon, the parent may

be contacted immediately to pick up their child from the program. The following day, parents, staff and the child

will meet to discuss any additional supports that the child might need to be successful in the program.

Step 5: If the prior interventions are not successful AND youth behavior is impacting the physical or emotional

safety of themselves, Y staff or other students an alternative placement will be discussed and the child may be

dismissed from the program for the remainder of the school year.

*We reserve the right to dismiss your child from the program immediately in extreme circumstances where physical,

emotional or other harm is occurring or may occur to themselves, other children, staff or members.

I have read and understand the expectations in the character contract to ensure a safe school year for all!

Child Signature: ____________________________________________________________________________________________________________________________

Parent Signature: _____________________________________________________________________________________________________________________________

Y Staff Signature: ____________________________________________________________________________________________________________________________

Page 12 of 18

FACILITY USER/FIELD TRIP AGREEMENT

I agree to follow all rules and regulations of the YMCA of Metropolitan Chicago (“YMCA”) while in, upon or about the premises or while using

or observing the premises or any facilities or equipment, or participating in any program affiliated with the YMCA without respect as to

location, and understand to agree hat I may be expelled at any time, with no refund of any monies paid, for failure to abide by such rules

and regulations.

IN CONSIDERATION OF BEING PERMITTED TO UTILIZE THE FACILITIES, SERVICES AND PROGRAMS OF THE YMCA FOR ANY PURPOSE,

INCUDING BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT OR PARTICIPATION IN ANY PROGRAM AFFILIATED

WITH THE YMCA WITHOUT RESPECT AS TO LOCATION, I HEREBY AGREE TO THE FOLLOWING:

1. I UNDERSTAND THAT ACTIVITIES AT THE FACILITY OR ELSEWHERE, INCLUDING USE OF EQUIPMENT AND PARTICIPATION IN PROGRAMS,

CAN INVOLVE MOVEMENT, STRAIN AND OTHER ELEMENTS THAT CREATE RISK OF SERIOUS INJURY OR DEATH. I ALSO UNDERSTAND THAT

PROGRAM ACTIVITIES INCLUDE FIELDTRIPS TO LOCATIONS OUTSIDE THE YMCA PREMISES, AS DESCRIBED IN DETAIL IN THE PROGRAM

MATERIALS, AND THAT PUBLIC OR PRIVATE TRANSPORTATION MAY BE UTILIZED TO TRANSPORT PARTICIPANTS TO AND FROM THESE

FIELD TRIP LOCATIONS. I HEREBY, ASSUME FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE OR

LOSS, regardless of severity, that I or my minor child/ward may sustain from my or my minor child/ ward’s presence in, upon or about the

premises or while using or observing the premises or any facilities or equipment, or participating in any programs affiliated with he YMCA

without respect to location, or while being transported to and from field trip locations outside the YMCA premises, except for any injury,

damage or loss that is caused solely by the YMCA’s gross negligence.

2. I, FOR MYSELF, ANY PERSONAL REPRESENTATIVES, ASSIGNS, HEIRS AND NEXT OF KIN, HEREBY FULLY RELEASE, WAIVE, DISCHARGE AND

COVENANT NOT TO SUE the YMCA of Metropolitan Chicago, its operating centers, their respective officers, directors, Board of managers,

Trustees, members, volunteers, employees or agents (the “Releasees”) and each of them from any and all claims for injuries, damage or loss

that I or my minor child/ward may have or which may accrue to me or my minor child/ward from my and/or my minor child/ward’s presence

in, upon or about the premises or while using or observing the premises or any facilities or equipment, or participating in any program

affiliated with the YMCA without respect as to locations, or while being transported to and from field trip locations outside the YMCA

premises, except for any injury, damage or loss that is caused solely by the YMCA’s gross negligence.

3. I HEREBYAGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Releasees and each of them from any loss, liability, damage or cost

they may incur from me or my minor child/ward’s presence in, upon or about the premises or while using or observing the premises or any

facilities or equipment, or participating in any program affiliated with the YMCA without respect as to location, or while being transported

to and from field trip locations outside the YMCA premises, except for any loss, liability, damage or cost that is caused by the YMCA’s gross

negligence.

I further expressly agree that the forgoing ASSUMPTION OF RISK, RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as

broad and inclusive as is permitted by the law of the State of Illinois and if any portion thereof is held invalid, it is agreed that the balance

shall, notwithstanding, continue in full legal force and effect.

THIS AGREEMENT APPLIES TO ALL PAST, PRESENT AND FUTURE VISITS AND USES BY ME TO ANY YMCA FACILITY OR PROPERTY.

I HAVE READ AND VOLUNTARILY SIGNED THIS ASSUMPTION OF RISK, RELEASE WAIVER AND INDEMNITY AGREEMENT, and further agree

that no oral representation, statements or inducements apart from the foregoing written agreement have been made.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE AGREEMENT. THIS AGREEMENT CONTAINS A WAIVER AND RELEASE.

Signature of Parent/Legal Guardian ____________________________________________________________ Date ______________________

Printed Name of Parent/Legal Guardian _____________________________________________________________________________________

Page 13 of 18

DEVELOPMENTAL HISTORY OF CHILD Please describe your child’s interaction with children of the same age: _________________________________________________________

____________________________________________________________________________________________________________________________________________________

How would you describe your child’s personality? ____________________________________________________________________________________

Does your child have and special fears that we should be aware of? ____________________________________________________________

____________________________________________________________________________________________________________________________________________________

Does your child have any special needs that we should be aware of to better understand your child and be able to

work with your child? (Please be specific) ______________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

TALENT RELEASE FORM In consideration of my participation in activities to be conducted and/or sponsored by the YMCA, the receipt and

sufficiency of which is hereby acknowledged, I hereby freely and with our restraint consent to and grant the YMCA

of Metropolitan Chicago and its agents, successors, licensees, assigns, and affiliated entities (collectively, the

“YMCA”) the right to publish, print, photograph, videotape, record or otherwise reproduce my voice, appearance,

opinions, statements, biographical information, name, place of residence (city and state) and other personal

information concerning me, to own all the results thereof as a work for hire for copyright purposes, and to exhibit,

display, distribute, transmit and/or otherwise exploit any and all such reproductions containing my voice, opinions,

statements, appearance, and/or other contributions, altered as the YMCA may see fit, in any and all media now or

hereafter known, including without limitation by means of internet, email, still photography, billboard, radio,

television, video, soundtrack recordings, printing, merchandising, public displays, exhibitions, and in advertising

and/or publicity in connection therewith, and the right to use my name, city and state of residence in any

connection with any of the foregoing. The rights granted by my hereunder are granted for the entire universe and

shall inure in perpetuity and no further compensation shall be payable to me at any time in connection there with.

I hereby release the YMCA from any and all claims and demands arising out of or in connection with the uses

stated above, including without limitation any and all claims for libel, slander, invasion of privacy, infringement of

my right of publicity, defamation, copyright or trademark violation, and any other personal and/or proprietary

rights, and I agree that I shall not now or in the future assert or maintain any such claim against YMCA with

respect to the subject matter herein. This release shall be governed by Illinois lay without regards to its conflict of

laws principles.

Signature of Parent/Legal Guardian: ___________________________________________________ Date: _____________________________

Page 14 of 18

PICK UP AGREEMENT The following agreement is made between __________________________________ and The Foglia YMCA After Care Staff for the

pick-up of their child/children _______________________ from the day care home/group day care home/day care center.

I/We agree to pick up the above named child/children before 6:30 o’clock p.m. every day he/she/they are in child

care except for early release days when the program ends at 6:00 o’clock p.m.

If I/We fail to pick up our child/children by the appointed time, I/we understand that a late fee of $15.00 per

quarter hour (or portion thereof) will begin to accrue after the above stated pick up time.

If I/We fail, without notice, to pick up my/our child/children at the above stated time, or arrange for someone else

to pick them up, the provider will make 3 attempts to contact me/us. If the provider is unable to contact me/us,

the provider should contact the emergency person listed on the Application/Record of Child Information sheet, or

persons on the contingency list, to advise them my/our child/children are still in their care without notice from me/

us. If, for any reason, there is no telephone service the provider will contact police to request assistance in

contacting me/us or my/our emergency persons.

Provider agrees to keep my/our child/children for 1 hour after the above stated pick-up time, with late fees

accruing, before contacting the local police and/or the Child Abuse Hotline if contact cannot be made with parents/

guardians or emergency persons.

Provider will continue normal responsibilities for the child’s protection and well being and agrees not to discuss

your tardiness in arriving with your child/children beyond reassuring them you, or someone known to them will be

there soon to pick them up.

Parents/Guardians agree to advise provider immediately of any changes regarding their personal contact

information, including addresses and phone numbers for home and work and cell phone numbers. Parents/

Guardians also agree to provide immediate notice to the provider of any changes for their emergency contact or

contingency persons.

________________________________ ________________________________

Parent/guardian Provider A

________________________________ ________________________________

Parent/guardian Provider B

____________________ ____________________

Date signed Date signed

This form meets the requirements of Rule 406.12 (h) and Rule 408.60 (j)

Page 15 of 18

PARENT CONSENT FOR ASSESSMENT

Dear Parents,

The YMCA of Metropolitan Chicago (“YMCA” or “we”) is asking to collect assessments (i.e. surveys) from your child

during the program day. We use these measures to evaluate how our programs currently serve the academic and

social needs of your child and to plan ways to continue nurturing their development. Assessments often happen in

the beginning and the end of the programming session, this way we can measure the growth of your child's

development. The results of the assessment will be used to inform how YMCA staff trains and plans to best

support your child. We will use assessments widely used in child and youth programming that can provide reliable,

valid scores to tell us more about a child’s development across our mission’s anchors: Academic Readiness,

Character Development, Violence Prevention, and Fitness and Healthy Living. To allow your child to participate in

the assessment, please fill in the form below. Results will be stored anonymously with the YMCA. Your child’s name

and any other identifying information will never be shared with parties outside the YMCA or published with

information identifying your child. Results will not impact your child’s participation or enrollment in YMCA

programs.

Thank you for your participation!

I (Print your name) _______________________________________________________________________________, the parent/guardian of

(Print child’s name) __________________________________________________________________ give my consent to YMCA Learning &

Evaluation staff and other professionals secured by the YMCA to conduct the assessments:

Parent/Guardian Signature: ________________________________________ Date: ________________________________

Staff Signature: _______________________________________________________ Date: ________________________________

Program Staff: Please return to Learning and Evaluation at lande@ymcachicago.org

Page 16 of 18

DRAFT AGREEMENT

Dear Parents,

In years past we have sent out billing coupons that you received at the beginning of the school year and you would

make your monthly payments using those. This year we are moving away from that and ask that you participate in

our payment drafting program. If you are unable to participate in automatic draft you will receive monthly invoices

which will represent one-ninth of the total fees due, plus any additions or any past due balances (the entire school

year is divided into nine equal payments). Your monthly payment is due by the 1st of each month. Your last

payment for the school year will be due May 1, 2017.

If you are interested in participating in our payment drafting program please complete the bottom portion of this

letter and return it to the attention of Debbie Siedlecki no later than August 15th. You will be authorizing a

monthly charge to your Visa, MasterCard, Discover, American Express, or checking account. If electing a draft from

a checking account, please attach a voided check. Your first auto draft will be on 9/1/16.

Credit Card Payment Drafting Agreement

I, ___________________________________________________ , (parent) agree to participate in the payment drafting program for the

2016-2017 school year for fees due for my child/children named below:

Name of Child ____________________________________________________________________________________________

Name of Child ____________________________________________________________________________________________

Name of Child ____________________________________________________________________________________________

$ ______________ Monthly amount to be drafted the first of each month, September 2016 - May 2017

Credit Card # _________________________________________________________ Exp Date ____________ 3 Digit Code _________

Signature ____________________________________________________________________________________ Date ___________________

Page 17 of 18

PAYMENT AGREEMENT

We are thrilled that you have chosen to enroll your child in our child care program at the YMCA! To ensure proper

communication, we have outlined our policy related to child care payments. If you have questions, please feel free to contact

Debbie Siedlecki at (847) 410-5368.

PLEASE READ CAREFULLY, SIGN AND RETURN WITH YOUR FIRST PAYMENT

1. A registration fee is due at the time of registration to reserve your spot if you wish to enroll your child. The amount of the

fee is dependent upon the program and YMCA membership status. This fee is good for the 2016-2017 school year.

2. Registration fees are non-refundable or transferable.

3. We ask that you sign up for automatic draft payments. You will be provided a draft letter with your first billing. Fees are

drafted the 1st of each month of service. There will be 9 monthly drafts with the first being September 1 and the last draft

being May 1.

4. If for some reason you cannot do automatic draft, you will be billed on approximately the 15th of each month for the

following month and your payment is due on or before the 1st of that month. For example, you will receive on approximately

October 15 your bill for the month of November, with payment due on or before November 1. There is a $15 late payment fee

if the payment is not paid on or before the 1st. If fees are not paid by the end of the month before the new month begins,

your child will not be allowed to attend until fees for that month are paid in full.

5. School Day Off school programming is not included in the price but we do offer School Days Off on most days school is not

open. Those days need to be registered and paid for in full at member services.

6. If you wish to cancel your child’s enrollment you must give two weeks paid notice.

7. Once you have enrolled in our program, we allow you to put a hold on your child's enrollment up to two times throughout

the school year.

8. There is a $25.00 fee due for all NSF checks. The missed payment and the NSF fee must be made with cash, credit or a

money order. After two NSF checks, personal checks will no longer be accepted for payments.

9. There are no credits or refunds for missed days except for medical absences of one week or more and must be accompanied

by a doctor’s note.

I have read and understand the above statements. I fully understand my responsibility for payment of my child’s fees. I also

understand that my child may be released from the program if I have not met my financial obligations.

Child’s Name _______________________________________________________________________________

Parent’s Signature __________________________________________________________________ Date _________________________________

Page 18 of 18

DISTRICT 95 TRANSPORTATION FORMS When you enroll your child in our program, you must fill out the transportation form(s) attached and submit to the

transportation office to notify them of what days your child will/will not need bussing. Any changes to your child's

schedule require a new form to be submitted reflecting the change. (See example attached)

PLEASE ATTACH THE FOLLOWING

- Most recent physical exam with doctor’s signature and the following:

Lead Risk Questionnaire filled out completely (that questionnaire was administered and if

blood test indicated)

a TB Test Verification (if your child does not need a TB test please have the doctor note

that on the exam)

Health History answered and signed by the parent (these are the yes/no questions on the

form)

- Most recent dental exam with dentist's signature

- Birth Certificate (this is a DCFS requirement. We only need a copy. We only accept county certified

certificates.)

If you need any of these blank forms please contact the Program Coordinators or Director and they can provide

them for you.

FOR RETURNING PARTICIPANTS

- We keep these documents on file from year to year

- You do not need to attach them if we already have them on file

- If you would like to give us updated ones please do attach them and make sure they are completely

filled out

District 95 Transportation Department – 66 Church Street - Lake Zurich IL 60047-2459

Phone: (847) 438-2834 FAX: (847) 438-9618 www.lz95.org

TRANSPORTATION CHILDCARE FORM – GRADES 1-5

Student Name_________________________________________________ Grade ______________________ School_______________________________________________________ School Year ___________________ CHILDCARE PROVIDER INFORMATION Name______________________________________________________ Phone Number ____________________ Address_______________________________________________________________________________________ Childcare addresses will be considered only if the stop is on an existing bus route located in the school attendance area to which the student is assigned. A listing of Subdivisions by School (and childcare providers within your school’s boundaries) is available on the back of the Transportation Information Form and on the District 95 website at www.lz95.org. Requests for transportation to childcare providers must be made annually. FOR STUDENTS IN GRADES 1-5 Who will provide transportation? District 95 Childcare Other______________________________

Circle days District 95 will supply transportation:

To School: M T W TH F Start Date___________________________ From School: M T W TH F Start Date___________________________

Pick-up & Drop-off Address_______________________________________________________________________

(Pickup and drop-off address must be identical)

PARENT/GUARDIAN SIGNATURE I understand that it is the school district’s policy for students to use the same bus stop every day and that my student will be assigned to a specific route with a limited capacity. These rules are enforced to ensure safe and orderly transportation of our students. I understand that pick-up and drop-off addresses must qualify for transportation to my child’s school. The pick-up and drop-off address must be the same, five days per week. If my student will not be using the same pick-up address and/or drop-off address consistently five days per week, I will be responsible for supplying transportation for my student on the days they will use an alternate address.

______________________________________________ ______________________ Parent/Guardian Name (please print) Date ______________________________________________ Parent/Guardian Signature ___________________________ _____________________ ______________________ Home Phone Cell Phone Work Phone Rev. 2/2012

District 95 Transportation Department – 66 Church Street - Lake Zurich IL 60047-2459

Phone: (847) 438-2834 FAX: (847) 438-9618 www.lz95.org

TRANSPORTATION CHILDCARE FORM – KINDERGARTEN

For transportation to and/or from a childcare provider, please fill out BOTH SIDES of this form and sign it. Student Name_________________________________________________ Grade ______________________ School_______________________________________________________ School Year ___________________ CHILDCARE PROVIDER INFORMATION Name______________________________________________________ Phone Number __________________________ Address_____________________________________________________________________________________________ Childcare addresses will be considered only if the stop is on an existing bus route located in the school attendance area to which the student is assigned. A listing of Subdivisions by School (and childcare providers within your school’s boundaries) is available on the back of the Transportation Information Form and on the District 95 website at www.lz95.org. Requests for transportation to childcare providers must be made annually. IF YOUR CHILD IS ASSIGNED AM (MORNING) KINDERGARTEN

Who will provide transportation TO SCHOOL? District 95 Childcare Other______________________

If District 95, provide the following: Days of week: M T W TH F

Start Date_________________________Pick-up Address____________________________________________________ Who will provide transportation FROM SCHOOL? District 95 Childcare Other______________________

If District 95, provide the following: Days of week: M T W TH F

Start Date_________________________Drop-off Address___________________________________________________ Additional information, if any:_________________________________________________________________________

__________________________________________________________________________________________________

IF YOUR CHILD IS ASSIGNED PM (AFTERNOON) KINDERGARTEN Same as above

Who will provide transportation TO SCHOOL? District 95 Childcare Other______________________

If District 95, provide the following: Days of week: M T W TH F

Start Date_________________________Pick-up Address____________________________________________________ Who will provide transportation FROM SCHOOL? District 95 Childcare Other______________________

If District 95, provide the following: Days of week: M T W TH F

Start Date_________________________Drop-off Address___________________________________________________ Additional information, if any:_________________________________________________________________________

__________________________________________________________________________________________________

continued on back->

District 95 Transportation Department – 66 Church Street - Lake Zurich IL 60047-2459

Phone: (847) 438-2834 FAX: (847) 438-9618 www.lz95.org

IF YOUR CHILD IS ASSIGNED ALL DAY KINDERGARTEN Who will provide transportation? District 95 Childcare Other___________________________________

Circle days District 95 will supply transportation:

To School: M T W TH F Start Date___________________________ From School: M T W TH F Start Date___________________________

Pick-up & Drop-off Address___________________________________________________________________________

(Pickup and drop-off address must be identical)

Additional information, if any:_________________________________________________________________________

__________________________________________________________________________________________________

PARENT/GUARDIAN SIGNATURE I understand that it is the school district’s policy for students to use the same bus stop every day and that my student will be assigned to a specific route with a limited capacity. These rules are enforced to ensure safe and orderly transportation of our students. I understand that pick-up and drop-off addresses must qualify for transportation to my child’s school. The pick-up and drop-off address may be different for HALF DAY KINDERGARTEN ONLY. If my student will not be using the same pick-up address and/or drop-off address consistently five days per week, I will be responsible for supplying transportation for my student on the days they will use an alternate address.

______________________________________________ ______________________ Parent/Guardian Name (please print) Date ______________________________________________ Parent/Guardian Signature ___________________________ _____________________ ______________________ Home Phone Cell Phone Work Phone Rev. 2/2012

District 95 Transportation Department – 66 Church Street - Lake Zurich IL 60047-2459

Phone: (847) 438-2834 FAX: (847) 438-9618 www.lz95.org

TRANSPORTATION CHILDCARE FORM – GRADES 1-5

Student Name_________________________________________________ Grade ______________________ School_______________________________________________________ School Year ___________________ CHILDCARE PROVIDER INFORMATION Name______________________________________________________ Phone Number ____________________ Address_______________________________________________________________________________________ Childcare addresses will be considered only if the stop is on an existing bus route located in the school attendance area to which the student is assigned. A listing of Subdivisions by School (and childcare providers within your school’s boundaries) is available on the back of the Transportation Information Form and on the District 95 website at www.lz95.org. Requests for transportation to childcare providers must be made annually. FOR STUDENTS IN GRADES 1-5 Who will provide transportation? District 95 Childcare Other______________________________

Circle days District 95 will supply transportation:

To School: M T W TH F Start Date___________________________ From School: M T W TH F Start Date___________________________

Pick-up & Drop-off Address_______________________________________________________________________

(Pickup and drop-off address must be identical)

PARENT/GUARDIAN SIGNATURE I understand that it is the school district’s policy for students to use the same bus stop every day and that my student will be assigned to a specific route with a limited capacity. These rules are enforced to ensure safe and orderly transportation of our students. I understand that pick-up and drop-off addresses must qualify for transportation to my child’s school. The pick-up and drop-off address must be the same, five days per week. If my student will not be using the same pick-up address and/or drop-off address consistently five days per week, I will be responsible for supplying transportation for my student on the days they will use an alternate address.

______________________________________________ ______________________ Parent/Guardian Name (please print) Date ______________________________________________ Parent/Guardian Signature ___________________________ _____________________ ______________________ Home Phone Cell Phone Work Phone Rev. 2/2012