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Vineland School District
Before & After School Program
STEM ACHIEVEMENT
GAP
SERVICE
LEARNING
Only $2.75
per hour!
Cumberland Cape Atlantic YMCA | www.ccaymca.org | (856) 691-0030
2019-2020 School Year
Cumberland Cape Atlantic YMCA 2019-2020 School Aged Child Care
VPS Registration Packet
Child’s Last Name: _________________________First Name: _____________________________
Address: _________________________________________________________________________________
City, State, Zip: ___________________________________________________________________________
Birth Date: ________/________/________ Home Phone:___________________________________
Cell Phone:________________________________ Male Female Grade Entering Sept. ’19 ________________________
Convenient, easy payment scheduling for you!
Locations - Elementary Schools:
Barse Elementary School Mennies Elementary School Sabater Elementary School
D’Ippolito Elementary School Petway Elementary School Winslow Elementary School
Durand Elementary School Rossi Elementary School
Semi-Monthly Payment: (Must enroll in automatic bank draft for this option)
Before $49.50
After $66.83
Both $116.33
Twice a month automatic bank draft
Payment amounts are located to the left; amount will be deducted on the 5th and 20th of the month prior to care
Late fees will be applied after the 20th if payment is returned
Monthly Payments:
Before $99.00
After $133.66
Both $232.66
Once a month payment
Payment can be made in-person (at the YMCA), over the phone, mail, automatic draft or online by setting your online portal prior to the 20th of each month
Late fees will be applied after the 20th if payment is not received
Locations - Middle Schools:
Johnstone School (AMSA) Pilla Middle School Wallace Middle School
*Children attending Memorial Middle School would enroll in the YMCA Before and After School program held at the YMCA (Please ask for
the registration packet for the YMCA Site)
Semi-Monthly Payment: (Must enroll in automatic bank draft for this option)
Before $30.94
After $85.11
Both $116.05
Twice a month automatic bank draft
Payment amounts are located to the left; amount will be deducted on the 5th and 20th of the month prior to care
Late fees will be applied after the 20th if payment is returned
Monthly Payments:
Before $61.88
After $170.23
Both $232.10
Once a month payment
Payment can be made in-person (at the YMCA), over the phone, mail, automatic draft or online by setting your online portal prior to the 20th of each month
Late fees will be applied after the 20th if payment is not received
PLEASE
ATTACH PHOTO
Child’s Name ____________________________________________________
Parent 1 or Legal Guardian Information Parent 2 or Legal Guardian Information
Last Name: ___________________________________
First Name: ___________________________________
Relationship: __________________________________
Address: _____________________________________
Home Phone: _________________________________
Cell Phone: ___________________________________
Work Phone: __________________________________
Employer: ____________________________________
Email: ______________________________________
Last Name: ____________________________________
First Name: ____________________________________
Relationship: ___________________________________
Address: _______________________________________
Home Phone: ___________________________________
Cell Phone: ____________________________________
Work Phone: ____________________________________
Employer: ______________________________________
Email: _________________________________________
Joint Custody Information Has there been a divorce or separation? Yes No
If Yes, who has custody? ___________________________________________ The joint/non-custodial parent can be contacted in the event of an emergency Yes No
Emergency Contacts (Other than Parent/Guardian) and Authorized Pick Ups Emergency Contact #1
Name: ____________________________________________ Relationship: _______________________________________ Cell Phone: ________________________________________ Work Phone: _______________________________________ Address: ___________________________________________
Emergency Contact #2
Name: ____________________________________________ Relationship: _______________________________________ Cell Phone: ________________________________________ Work Phone: _______________________________________ Address: ___________________________________________
Medical and Behavior Questions to help us provide the best care possible Has your child been diagnosed or treated for the following: Asthma Allergies Special Dietary Needs Allergies to Insect Stings Seizures Spectrum Disorder Allergy to Poison Ivy ADD/ADHD Other
Please provide details for any of the above checked boxes: Signs or symptoms to watch for: Please list current medications, prescribed or over the counter that your child is currently taking:
Parent/Guardian Signature: ___________________________________________
Parent/Guardian Information
Emergency Medical Information
Insurance Carrier: ___________________________
Policy Number: __________________________
Group Number: __________________________
Cumberland Cape Atlantic YMCA Emergency Contact & Health
Cumberland Cape Atlantic YMCA Rules & Authorizations
Cumberland Cape Atlantic YMCA
YMCA Policies
Before and After Rules In order for all participants to have the best possible experience, all participants and parents need to be aware of the rules and agree to follow them. If a participant or parent consistently or excessively breaks the rules and chooses not to take part in the program, they negatively impact other participants by jeopardizing their physical or emotional safety. When this happens, all other participants fail to receive the best possible experience. Rules: 1) Treat myself, and others, with Caring, Honesty, Respect, and Responsibility 2) Follow direction and instructions from staff 3) Keep hands, feet and all other body parts to myself 4) Respect all facilities, equipment, and property 5) Have FUN!
Consequences: 1) Redirection 2) Verbal warning or thinking time 3) Visit with director and/or call home. Child may speak to parents at that time 4) In the event that a second phone call is necessary, the child will be sent home 5) In the event of consistent/excessive failure to follow the rules, the child will be sent home and a suspension may be issued 6) If a child or parent endangers the physical, mental or emotional health of themselves or others, the child may be immediately
suspended or expelled Parent Signature: __________________________________ Child Signature: _____________________________
Authorizations My child is in good health and can participate in the normal activities of the program (including Healthy U & Boks) _________ Initial Here I agree to follow the Payment Policies; if not I will be subject to fees _________ Initial Here I have received and reviewed a copy of the YMCA Parent Handbook _________ Initial Here
I understand that my child must be physically signed in and out of the program by an authorized adult daily _________ Initial Here I understand that the YMCA is not responsible for lost, stolen or damaged personal articles _________ Initial Here My child and I have reviewed the Discipline/Behavior & Expulsion Policies and my child will participate in all daily _________ Initial Here activities I give permission for the Cumberland Cape Atlantic YMCA to: Seek medical treatment for my child, in my absence, in the event of an emergency ________ Initial Here Use any photo, voice recordings or videos taken of my child for any and all promotional purposes ________ Initial Here Allow my child to go on short walks under Y Staff supervision ________ Initial Here I hereby agree, and accept, responsibility in above initialed items. Parent Signature ______________________________________ Date _____________________________
Licensing Statement In keeping with New Jersey’s child care licensing requirements, we are obligated to provide you, as the parent/caregiver of a child enrolled in our program, with the attached informational statement. The statement highlights, among other things: Your right to observe our center at any time without having to secure permission The center’s obligation to be licensed and to comply with licensing standards and The obligation of all citizens to report suspected child abuse of all forms (physical, sexual, emotional, and neglect) to the DCP&P Name of child: ___________________________________ Name of Parent (s)/Guardian (s): __________________________
I have read and received a copy of the Information to Parents statement prepared by the Bureau of Licensing and the DCP&P Parent Signature _________________________________ Date _________________________________________________
Parent Statement of Understanding
The following information is important for the safety and protection of your child. Please read the information, sign this form, and return the original to the Cumberland Cape Atlantic YMCA (CCA YMCA). A copy will be filed with your child’s records.
I understand that CCA YMCA staff and volunteers are not allowed to baby-sit or transport children at any time outside the CCA YMCA program. If a violation is discovered, the Y will take immediate disciplinary action toward staff and/or volunteers.
I understand that staff and volunteers are not allowed to initiate contact with members and program participants outside the CCA YMCA, unless necessary in certain limited cases for the smooth operation of a CCA YMCA program. If deemed necessary, contact should be made with the program participant’s parent or guardian. Contact includes, but is not limited to, sharing of phone numbers, email addresses, personal websites and/or web logs. If a violation is discovered, the Y will take immediate disciplinary action toward staff and/or volunteers.
I understand that I am not to leave my child* at the CCA YMCA or program site unless a CCA YMCA staff or volunteer is
there to receive and supervise my child. I understand that my child must be escorted to and from the program area by me or another person on my authorized list. Children may not just be dropped off at the door. *Note: The CCA YMCA’s policy is that children under the age of 12 may not be alone in our facilities/program sites.
I understand children should not receive excessive gifts (e.g. toys, video games, jewelry) from CCA YMCA staff or volunteers, and I should report this to a supervisor if they do.
I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child, including relatives, must be listed with CCA YMCA and must be at least 18 years of age required by the CCA YMCA. Any other alternate pick-up arrangements must be made in writing by a parent/guardian. Phone notification of an alternate pick-up arrangement is only accepted in an emergency.
I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child’s safety, staff my have no recourse but to contact the police. Please do not put staff in a position where they have to make this judgment call.
I understand that I can help ensure my child’s safety by taking an active interest in his or her CCA YMCA experience. I too will monitor volunteer and staff interactions with my child and ask my child specific questions about program activities and volunteer or staff relationships with my child.
I understand that the CCA YMCA is mandated by state law to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.
I have received a copy of the CCA YMCA Youth Program Handbook and/or Program Policies and Procedures and will keep it for future reference.
Parent Signature ________________________________________ Date ___________________________
Parent Notification of Communications Policy
Families entrust their children to the Cumberland Cape Atlantic YMCA’s care for child care, camp, and other youth programs. Our promise to those we serve is to provide a safe environment in which all participants are treated in a caring, honest, respectful and responsible way.
CCA YMCA staff, volunteers, program participants and parents must work together to ensure adherence to this policy. CCA Staff and Volunteers: Will block any personal websites or blogs and mark them as private, denying access to any CCA YMCA program participants Will not disclose personal email, telephone, cell phone or website information to any program participants Will not attempt to contact any participant via phone, text message email, website or blogs for non-program related business Will not use any photos taken for CCA YMCA programs or marketing purposes for personal use Will not use cell phones for personal calls during business hours Will not use cell phone cameras to take photos of program participants for any reason Will notify his/her supervisor immediately if a youth attempts to communicate with an employee via e-mail, instant message, cell phone
or social network site
CCA YMCA Program Participants and Their Parents Agree: Not to contact any staff via staff’s personal telephone/cell phone, text message, email, websites or blogs Not to use cell phones during program hours (except for emergency situations) They will not use photos, logos or images of the CCA YMCA or its program participants Personal photos may only be taken with consent and may not be displayed in any derogatory fashion Will not take cell phone photos of staff or program participants while engaged in CCA YMCA programs
Of course, the CCA YMCA does not mean to interfere with anyone’s private life, but publicly observable communications, actions or words are not private, and personal expression can have legal consequences, including defamation, copyright infringement and trademark infringement.
Parent Signature ________________________________________ Date ____________________________
Cumberland Cape Atlantic YMCA
Statement of Understanding
Membership Fees
$30/Youth Program Member $55/Family Program Member Current Program Member Current Full Facility
Member All participants must be YMCA members. Membership fees are non-transferable and non-refundable
Financial Assistance
Third party Rutgers Southern Regional Child Care Resource & Referral (856-462-6800). If denied by Rutgers, Financial Assistance is available through the Y - applications are available at the Member Service Desk and on our website, www.ccaymca.org.
Funds are limited – APPLY EARLY
Parent Checklist
Parent/Guardian please initial next to each item that you are handing in today.
_________ Completed Registration Form
_________ Photo Release (see page 3)
_________ Signed Medical Information – including insurance carrier, policy and group number
_________ Expulsion Policy
_________ Any notes or information to be filed on your child (optional)
_________ Correct payment and/or deposit amount
_________ Automatic bank draft form is completed (if using automatic monthly payment option)
Parent Signature
Parent is to sign off that all paperwork is filled out completely.
Parent Signature: ______________________________ Date: _____________________
Staff Signature
Staff member receiving the paperwork is to sign off that all papers are filled out completely and correct
money is remitted.
Staff Signature: _______________________________ Date: ______________________
Cumberland Cape Atlantic YMCA
Checklist
Cumberland Cape Atlantic YMCA
2019-2020 SCHOOL REGISTRATION
Additional Emergency Contacts
Child’s Name ____________________
School: ________________________
Emergency Contact #5 Name: _____________________________________
Relationship: ________________________________
Cell Phone: _________________________________
Work Phone: ________________________________
Address: ___________________________________
Emergency Contact #6
Name: _____________________________________
Relationship: ________________________________
Cell Phone: _________________________________
Work Phone: ________________________________
Address: ___________________________________
Emergency Contact #7
Name: _____________________________________
Relationship: ________________________________
Cell Phone: _________________________________
Work Phone: ________________________________
Address: ___________________________________
Emergency Contact #8
Name: _____________________________________
Relationship: ________________________________
Cell Phone: _________________________________
Work Phone: ________________________________
Address: ___________________________________
Please use this sheet only to add additional contacts and
pick-up people for your child. We will not accept it written on a separate piece
of paper.
Parent/Guardian Signature: _________________________ Date:___________
10:122-6.8 Expulsion Policy May be used to inform parents of the center’s policy on the expulsion of children from enrollment
EXPULSION POLICY Name of Center: Cumberland Cape Atlantic YMCA of Vineland
Name of Child: ________________________________
Signature of Parent: ________________________________ Unfortunately there are reasons we have to expel a child from our program either on a short term or a permanent basis. We want you to know we will do everything possible to work with the family of the child(ren) in order to prevent this policy from being enforced. The following are reasons we may have to expel or suspend a child from this center. IMMEDIATE CAUSE FOR EXPULSION - The child is at risk of causing serious injury to other children or himself/herself. - Parent threatens physical or intimidating actions toward staff members. - Parents exhibits verbal abuse to staff in front of enrolled children. PARENTAL ACTIONS FOR CHILD’S EXPULSION - Failure to pay/habitual lateness in payment. - Failure to complete required forms. - Habitual tardiness when picking up your child. - Physical or verbal abuse to staff. - Correcting, reprimanding, or yelling at a child CHILD’S ACTIONS FOR EXPULSION - Failure of a child to adjust after a reasonable amount of time. - Uncontrollable tantrums/angry outbursts. - Ongoing physical (fighting) or verbal abuse to staff or their children. - Excessive biting. - Dangerous activity, threats, theft, vandalism/mistreatment of property, possession of weapons, or
illegal substances SCHEDULE OF EXPULSION - If after the remedial actions above have not worked, the child’s parent/guardian will be advised
verbally and in writing about the child and or/parent’s behavior warranting an expulsion. An expulsion action is meant to be a period of time so that the parent/guardian may work on the child’s behavior or to come to an agreement with the center.
- The parent/guardian will be informed regarding the length of the expulsion period. - The parent/guardian will be informed about the expected behavioral changes required in order for
the child or parent to return to the center. - The parent/guardian will be given a specific expulsion date that allows the parent sufficient time to
time to seek alternative child care - Failure of the child/parent to satisfy the terms of the plan may result in permanent expulsion from
the center
A CHILD WILL NOT BE EXPELLED - If a child’s parent/guardian:
- Made a complaint to the Office of Licensing regarding a center’s alleged violation of the licensing requirements
- Reported neglect or abuse occurring at the center - Questioned the center regarding policies and procedures - Without giving the parent/guardian an adequate amount of time to make other child care
arrangements PROACTIVE ACTIONS THAT WILL BE TAKEN IN ORDER TO PREVENT EXPULSION - Staff will try to redirect child from negative behavior - Staff will reassess classroom environment appropriateness of activities and supervision - Staff will always use positive methods and language while disciplining children - Staff will praise behaviors - Staff will consistently apply consequences for rules - Child will be given verbal warnings - A brief time out may be given so child can regain control - Child may lose certain privileges - Child’s disruptive behavior will be documented and maintained in confidentiality - Parent/guardian will be not notified verbally - Parent/guardian will be given copies of the disruptive behaviors that might lead to expulsion - Director, parent/guardian and classroom staff will have a conference to discuss how to promote
positive behaviors - Parent/guardian will be given literature or other resources regarding methods of improving behavior - Recommendation of evaluation by professional consultation on premises - Recommendation of evaluation by local school district child study team
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YMCA AFTERSCHOOL PROGRAM REGISTRATION/DATA FORM
Please complete the following information for each child enrolled in the program
Child’s Name ____________________________________________________________ (Please Print) Last First Middle
Child’s Home Phone _________________________ Emergency Phone __________________
Child’s Home/Mailing Address:______________________________________________________
No. & Street or P.O. Box City State Zip code
Sex: (circle one) M F
Date of Birth: _____________ (Month/Day/Year)
Grade:
☐ Kindergarten ☐ First Grade ☐ Second Grade
☐ Third Grade ☐ Fourth Grade ☐ Fifth Grade
☐ Sixth Grade ☐ Seventh Grade ☐ Eighth Grade
Does your child qualify for free or reduced lunch? ☐ Yes ☐ No
Ethnicity Information
Please check the ethnic group the child most identifies with:
☐ Caucasian/White ☐ African American/Black
☐ Hispanic/Latino ☐ Native Hawaiian or other Pacific Islander
☐ American Indian or Alaska Native ☐ Asian
☐Two or More
Primary Language Spoken at Home:
☐ English ☐ Polish ☐ French ☐ Japanese ☐ Chinese
☐ Spanish ☐ Unknown ☐ Other, please specify ____________________
Secondary Language Spoken at Home:
☐ English ☐ Polish ☐ French ☐ Japanese ☐ Chinese
☐ Spanish ☐ Unknown ☐ Other, please specify ___________________
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-FOR YMCA USE ONLY-
Primary Priority Factor for Referral (Answer by checking yes or no for each applicable
primary factor listed below). IMPORTANT – this information will be needed when entering
data in the Program Data Management (PDM) system
☐ Yes ☐ No 5+ School Days Absent
☐ Yes ☐ No 5+ School Days Tardy
☐ Yes ☐ No 5+ Behavioral Referrals
☐ Yes ☐ No State Assessment Reading Score (Non-Proficient)
☐ Yes ☐ No State Assessment Mathematics Score (Non-Proficient)
☐ Yes ☐ No Other factor, please describe (required):
APPROVED BY INTEGREVIEW IRB
MAY 3, 2018
Dear Parent,
We are inviting your child/children to participate in a research study called YMCA Afterschool
Achievement Gap (AG) Program: Determining the Impact of Y-USA’s Out-of-School Time Approach
(“you” refers to you or your child/children throughout this consent form). The Achievement Gap (AG)
research study is designed to determine if the program is increasing your child’s academic achievement
and social competence. Your child/children was/were selected to participate in this study because s/he
is participating in the YMCA’s AG afterschool program.
This research is being conducted by Y-USA and is funded by Y-USA’s Strategic Initiatives Fund (SIF).
For the 2018-19 program year, there will be approximately 51 YMCA associations implementing the AG
ASP program at 130 sites with up to 10,000 participants/students.
Consent to Participate in Program Evaluation
Your local YMCA and YMCA of the USA evaluate our programs to see what we are doing well, to identify
areas of the program that we can improve, and to make sure that the children we serve are benefitting
from this program. Participant demographics and attendance will be collected as part of participation in
this program. The evaluation, for which we are seeking consent, involves collecting additional
information from program participants and their parents/caregivers.
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What you will be asked to do
For evaluation purposes, we ask your permission to use your child’s social-emotional learning (SEL)
assessment results, which is completed by the YMCA group leader at the beginning and end of the
program year. We also ask you to complete a short anonymous survey about your satisfaction with the
afterschool program at the end of the program year. Finally, we also ask your permission to use your
child’s standardized reading and math test scores, along with school attendance records, for program
evaluation purposes. Y-USA will comply with all state and federal laws in collecting, storing, analyzing
and presenting data. Your expected participation in this research study will be one hour or less.
Benefits
A benefit means that something good happens to you or your child. By participating in the afterschool
program, your child will receive academic and SEL programming and exposure to enrichment activities,
field trips, and other school-related activities. For the evaluation component, you or your child will not
receive any direct benefit. However, future afterschool participants may benefit from changes to the
program that were implemented a result of the evaluation. That is, the evaluation may make the
program better for future afterschool participants.
KEEPING YOUR INFORMATION CONFIDENTIAL
Y-USA will follow all applicable federal and state laws that protect your child’s personal and school
related information (e.g., FERPA), including maintaining appropriate physical, electronic, and
procedural safeguards. Student information is confidential and will not be shared or discussed with
anyone outside of the approved study researchers, their partners, and data collectors. All collected data
for this project will be securely stored in lockable locations, secure computer files, or on computer
servers accessible only to the approved and trained researchers and authorized staff. Y-USA plans on
keeping this data indefinitely, in order to identify trends in program participation, fidelity, quality, and
outcomes over time.
We will not use your child’s name in any report or publication; rather, your child’s data will be
aggregated with other students enrolled in the program. This data may be included in Y-USA site and
national program reports, as well as in peer-reviewed education and evaluation journal articles.
There is a very small risk that confidential data will be compromised. We will minimize this risk by
ensuring that only approved local-Y and Y-USA evaluation staff involved in the program have access to
student information. As required for evaluation purposes, we may share your child’s information with
our evaluation partners, who we also require to protect your child’s privacy and confidentiality to the
maximum extent allowable by law.
The Institutional Review Board (IRB), IntegReview, and accrediting agencies may inspect and copy your
records, which may have your name on them. Therefore, absolute confidentiality cannot be
guaranteed.
PAYMENT FOR BEING IN THE STUDY
You will not be paid for being in this study.
LEGAL RIGHTS
You will not lose any of your legal rights by signing this consent form.
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ALTERNATIVES TO PARTICIPATING IN THE STUDY
Since this study is for research only, the only other choice would be not to be in the study.
Your right to withdraw from the project
Participation in the evaluation is voluntary and you can withdraw your consent to participate at any
time. Your child’s participation in the program will not be affected. You have the right to refuse your
child’s participation in program evaluation. You will not lose any of your legal rights by signing this
consent form.
CONTACT INFORMATION
If you have questions about the research at any time, or if you have a visual or other impairment and
require this material in another format, please contact Y-USA at 800-872-9622.
If you do not want to talk to the investigator or study staff, if you have concerns or complaints about
the research, or to ask questions about your rights as a study subject you may contact IntegReview.
IntegReview’s policy indicates that all concerns/complaints are to be submitted in writing for review at a
convened IRB meeting to:
Mailing Address: OR Email Address:
Chairperson IntegReview IRB
3815 S. Capital of Texas Highway
Suite 320 Austin, Texas 78704
If you are unable to provide your concerns/complaints in writing or if this is an emergency situation
regarding subject safety, contact our office at:
512-326-3001 or
toll free at 1-877-562-1589
between 8 a.m. and 5 p.m. Central Time
IntegReview has approved the information in this consent form and has given approval for the
investigator to do the study. This does not mean IntegReview has approved your being in the study.
You must consider the information in this consent form for yourself and decide if you want to be in this
study. If your child is aged 10 or older, s/he will also have the opportunity to decide if they want to
participate themselves. This process is called assent.
AGREEMENT TO BE IN THE STUDY
This consent form contains important information to help you decide if you want to be in the study. If
you have any questions that are not answered in this consent form, ask one of the study staff.
_____ I have read and understand this consent information, and I agree to participate in the
Achievement Gap research study
OR
_____ I have read this and understand this consent information, but I do not agree to participate in
the Achievement Gap research study
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Printed name of Parent(s)/Caregiver(s):
Signature:
Print student name:
School:
Date: __________________________________________________
There are two copies of the consent form and both need your signature. The first copy needs to be
returned to the afterschool program staff. Since there is important information in this consent form,
including contact information if you have questions or concerns, we want you to keep the second copy
for your records.
We appreciate you taking the time to consider being a part of the YMCA Afterschool Achievement Gap
(AG) Program: Determining the Impact of Y-USA’s Out-of-School Time (OST) Approach project.
Dear YMCA Afterschool Member, You are being asked to be in the Achievement Gap (AG) research study. It is designed to determine whether afterschool programs can improve how you learn things and help your achievement in school. This involves things like personal responsibility, goal setting, and getting along with others, while achievement is measured through your math and reading test scores. Your afterschool program is designed to improve these two things and we want to see if this is true. What You Will Be Asked to Do and What Will Happen in the Study We ask that you give your okay (permission) for your group leader to conduct social-emotional learning (SEL) assessments at both the beginning and end of the afterschool program year. SEL measures things like goal setting and getting along with others. We also ask your okay (permission) to use your test scores for reading and math. Finally, we ask if it is okay to survey your parents/caregivers about their satisfaction with this program. This survey should take your parents less than 10 minutes to complete. You will not be asked to do anything else for this research study. Keeping Your Information Private We will reduce the risk of other people seeing your responses by being sure that only YMCA research staff and our evaluation partners will have access to data. We will keep it safe in a locked office. Before we look at the data, your name and any other information that can identify you will be removed. In other words, researchers will not know who the data belongs to. Finally, to protect your privacy, we will follow all the rules that have been created regarding your privacy and personal information.
Benefits
A benefit means that something good happens to you. By participating in the afterschool program, you
will receive lots of benefits like academic help and support, fun activities, field trips, and other school-
related activities. For the evaluation part, you will not receive any direct benefit. While you may not
directly benefit, you may make the program better for future afterschool participants.
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Your Right to Withdraw from the Project You do not have to be in this study if you do not want to be. You can say no and no one will be mad at you. If you decide to stop after we begin, that's okay too. No one will be mad at you if you decide not to participate or to stop participating in the study after you start. Being in the study or not will not affect your program participation. Your parents and guardians also have the right to refuse your participation in the study.
I have read (or someone has read to me) this assent form. Additionally, the YMCA group leader (teacher) has explained the study to me and has answered all of my questions.
______ I agree to be in this study. OR ______ I do not agree to be in the study. Printed name of Child/Afterschool member: Signature: School: _____
Date: __________________________________________________ There are two copies of the consent form and both need signature. The first copy needs to be returned to your afterschool program staff. Since there is important information in this consent form, including contact information, if you have questions or concerns, we want you to keep the second copy for yourself.
YMCA PHOTO/AUDIO VISUAL/NARRATIVE RELEASE
I am 18 years of age or older and, if not, my parent or legal guardian has also provided their consent by
signing below.
Consent & License. For my participation in activities to be conducted by the National Council of Young
Men’s Christian Associations of the United States of America (“YMCA of the USA”) or any of its chartered
member associations in the United States (collectively “the Y”), and collaborating third parties, I consent,
now and for all time, to the making, reproduction, editing, broadcasting or rebroadcasting of:
video film or footage of me,
sound track recordings of me
photo reproductions of me
any narrative account of my experience
My consent includes a perpetual license to the Y and collaborating third-parties for the use of the above
materials for publication, display, sale or exhibition in promotions, advertising, education and commercial
uses. Use includes reproductions in any form and media currently existing or later conceived, adaptations
and/or revisions, throughout the world in perpetuity.
I understand and agree there may be no additional compensation for this license, and I will not make any
claim for payment of any kind from the Y or collaborating third-parties. I may, or may not be, identified in
such licensed uses; however, my name will not be used to endorse any particular products or services.
Ownership, Confidentiality, and Shared Use. With respect to any of the above uses, I further agree:
All works shall belong to YMCA of the USA;
The Y has no duty of confidentiality regarding any licensed uses;
YMCA of the USA shall exclusively own all known or later existing rights to the uses throughout the
world;
The Y and collaborating third-parties may use any video film, footage, sound track recordings and
photo reproductions of me and/or my narrative account for any purpose without additional
compensation to me.
Release from Liability. I agree that my consent is irrevocable. I hereby release and discharge The Y and
collaborating third-parties, from any and all claims, actions, lawsuits or demands of any kind arising out of
my consent, license grants, uses, or the shared uses of any works or materials referenced herein.
Signature: ____________________________________ Date: __________________
Printed Name: ________________________________ Age: ________
Address: ________________________________________________________________________
________________________________________________________________________________
I am the parent or legal guardian of (child’s name). I hereby consent and grant the licenses detailed in
the foregoing on behalf of my minor child.
Signature of parent or legal guardian: _____________________________________________
Printed name: _____________________________________________________________________
071808 6/18
2019-2020 Cumberland Cape Atlantic YMCA
Before & After School Payment Authorization
Form (OPTIONAL PAYMENT METHOD)
IMPORTANT
Please fill out this section Child’s Name: ____________________________________ Additional Child Name: ____________________________ School Name: ___________________________________ Before After Both
Semi-Monthly - Split Payment Drafted on the 5th and 20th of each month
Monthly - Payment Drafted in Full on the 20th of each month
Automatic Payment Plan: The Cumberland Cape Atlantic YMCA (CCA YMCA) or YMCA of Vineland offers an automatic payment plan via our accounting software company called DAXKO. Monthly fees are automatically charged to a Bank, Credit Union, or Credit Card Company. There’s no additional cost for this program.
Bank/Credit/Debit Draft Agreement:
1. I understand that Daxko has been authorized as an agent on behalf of the CCA YMCA to initiate debit entries against my Checking/Savings Account or Credit/Debit Card. Also, I acknowledge that the origination of ACH (Automatic Clearing House) transactions to my account must comply with the provisions of United States Law.
2. I understand that Daxko, a U.S. corporation, will be processing electronic funds transfers. Debit to your account will be presented in your bank statements as “Cumberland Cape,” and these funds will be electronically transferred to CCA YMCA and posted to your child-care account monthly.
3. The CCA YMCA, Board of Directors and/or management may, at their discretion, adjust the rate plan applicable to childcare programs at any time. I understand that I will receive at least a 30 day notification prior to any such change.
4. All Before and After Care payments will be debited on the 20th of each month (October-June)
Option 1: Credit/Debit Card: Print Name of Account Holder: __________________________________________
When using the credit/debit card payment method: Should any debit not be honored by my credit card company for any reason, I understand that I am still responsible for the payment plus a $20.00 service charge applied by the YMCA. This is in addition to any service fee my credit card company may require.
Expiration Date: ______________ Security Code: _____________ Card: AMEX Discover Mastercard Visa Credit Card Billing Address: __________________________________________________________________________
Is this the primary contact for all billing concerns/questions? Circle: YES NO
Option 2: Bank Draft/EFT: *Please include a voided check with this form*
When using the bank draft/EFT method: Should any debit not honored by my bank/EFT account for any reason, I understand that I am still responsible for the payment, plus a $30.00 service charge applied by the YMCA. This is in addition to may service fee my bank com-pany may require.
Print Name of Account Holder: _______________________________________ Name of Bank: _______________________
Bank Routing/Transit Number: Bank Account Number:
Authorization: I hereby authorize the CCA YMCA to debit the above credit card/ bank draft/ EFT on the dates
indicated for my 2019-2020 Before & After Care monthly payments. I understand that I am being enrolled in the
automatic payment plan as described above and agree to any and all fees that may incur use of this service.
X _________________________________________________ X _______________________________ Cardholder Signature Date
Staff Use Only Member ID #: ________________ Date Received: ________________ Staff Signature: _____________________________
Program Membership Expiration Date: ___________________________ Discount (if applicable): _______________________
