Current Resident or MAKING LEARNINGFUN Childcare Enrichment Program YMCA OF GREATER LOUISVILLE

We serve all JCPS students in grades K-8. Transportation is available by JCPS school bus between your child’s school and CEP if needed.

The YMCA of Greater Louisville, in partnership with Jefferson County Public Schools, offers the Childcare Enrichment Program–where your child will laugh, learn and grow.

2011-12 SCHOOL YEAR REGISTRATION

ymcalouisville.org

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

HELPING BUILD CONFIDENCEWith values of caring, honesty, respect and responsibility as our guide, we work with you every day to ensure your children have fun while helping them realize their potential. You can feel confident knowing your child is safe and well cared for by our qualified staff. Every staff member receives extensive hours of training and professional development and is CPR and First Aid certified. We are licensed child care and meet or exceed state licensing requirements.

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

ALWAYS HERE FOR YOUOur before school program is from 7 am until the start of your child’s school day. Our after school program is from the close of the school day until 6 pm. Continuous care is also available 7 am - 6 pm during school breaks, including in-service days and snow days. Spring Break, Winter Break, and Summer Camps require separate registrations.

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

CHILDCARE ENRICHMENT PROGRAM2011-2012 School Year

SIGN UP TODAY!

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

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

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

REGISTER TODAYRegistration for the before and after school programs will continue throughout the school year based on availability. All sites have minimum and maximum enrollment numbers and registrations are processed on a first-come, first-served basis. Completed registrations must be received at least two business days prior to your child’s start date. The 2011-12 school year program begins on Monday, August 15th.

You can register one of the following ways:

• Online at ymcalouisville.org through August 4th

• 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. Please do not fax registration forms. If you have additional questions, call 502 637 1575, or visit ymcalouisville.org.

First Child Each Additional

Program Members

$47 $59 $73

$39 $48 $60

Program Members

$37 $49 $63

$31 $40 $52

Y Facility Member/

Partnership Employee

Dependents

$42 $54 $68

$35 $44 $56

Y Facility Member/

Partnership Employee

Dependents

$32 $44 $58

$27 $36 $48

4- or 5-day Before School Only

After School Only

Before & After School

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

After School Only

Before & After School

Registration Fees Per Child

WEEKLY RATES 2011-12 Childcare Enrichment Program

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

snow day only rate is $22 per day, per child.

$30 per child through August 4

$45 per child starting August 5

CEP SITES & LOCATIONS

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

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

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.

CEP is open to all JCPS students in grades K - 8. If your child’s school is not a CEP site listed below, transportation is available between your child’s school and their CEP site. Visit our website or call 502 637 1575 for detailed transportation information.

1st CHILD

2nd CHILD

1st PARENT/GUARDIAN

2nd PARENT/GUARDIAN

INSURANCE INFORMATION

PLEASE LIST ANY ADULT OTHER THAN THE ABOVE THAT MAY BE PICKING UP THIS CHILD OR THAT MAY BE CONTACTED IN AN EMERGENCY. Anyone picking up your child must be at least 18 years of age or older. A picture ID is required at pick-up.

CHILDCARE ENRICHMENT PROGRAM 2011-12 SCHOOL YEAR REGISTRATION FORMPLEASE PRINT LEGIBLY and include your registration fee. Register Online through August 4th at ymcalouisville.org.

Program start date Email address (To receive important program updates and registration information)

First name Middle initial Last name Date of birth / / Gender M F Age

Race African American/Black Alaskan Native Asian/Pacific Islander Caucasian/White Hispanic Native American 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 Bleeding/Clotting Disorders Autism Aspergers Fragile X Cerebral Palsy Bipolar Disorder Tourettes Rhett Syndrome Down Syndrome Chronic Health Problems Asthma/Severe Allergies Diabetes Heart defect/disease Other

Does this child have an IEP? Yes No

Childcare Enrichment Program Site School Attending

Attendance 1-3 Days 4-5 Days Grade in School (2011-12)

Participation Before-School Care After-School Care Before- & After-School Care In-Service Day Care Snow Day Care

First name Middle initial Last name Date of birth / / Gender M F Age

Race African American/Black Alaskan Native Asian/Pacific Islander Caucasian/White Hispanic Native American 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 Bleeding/Clotting Disorders Autism Aspergers Fragile X Cerebral Palsy Bipolar Disorder Tourettes Rhett Syndrome Down Syndrome Chronic Health Problems Asthma/Severe Allergies Diabetes Heart defect/disease Other

Does this child have an IEP? Yes No

Childcare Enrichment Program Site School Attending

Attendance 1-3 Days 4-5 Days Grade in School (2011-12)

Participation Before-School Care After-School Care Before- & After-School Care In-Service Day Care Snow Day Care

Name Relationship to child Date of birth / /

Address City State Zip

Home phone Cell phone Work phone Employer

Name Relationship to child Date of birth / /

Address City State Zip

Home phone Cell phone Work phone Employer

Health insurance company Policy number

Name of physician Physician phone

.

Name Relationship to child Phone 1 Phone 2

Name Relationship to child Phone 1 Phone 2

The YMCA has permission for my children to be photographed and/or interviewed for promotional purposes Yes No My child(ren) have permission to participate in basic health and fitness evaluations Yes No

Yes, I would like to make a charitable donation to The Spirit Campaign $10 $25 $50 $100 Other/please contact me

Check here if either parent is School partnership employee YMCA employee YMCA family facility member Spirit recipient 4-C recipient

YES! I would like to learn more about FREE or LOW-COST health insurance for my children and teens.

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

I am currently on draft. Please use the account on file ending in ___ ___ ___ ___. Authorized account holder signature _________________________________________________________________________

I am authorizing a NEW bank draft from my checking account and I have attached a voided check.

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

Credit Card Type: Visa MasterCard Discover

Name on card Authorized cc signature

Card number Expiration date

Billing street address Billing zip code

I have the legal authority to sign up the child/children named on this form and to the best of my knowledge the information on this application form is complete and accurate. I understand that my application will not be processed unless it includes the full fee or automatic draft authorization. I understand that the YMCA prohibits staff members from being alone with children they meet in YMCA programs outside of the YMCA. This includes but is not limited to baby-sitting, tutoring, sleep-overs, etc. In the event I cannot be reached in an emergency, I hereby give permission to the director of the program or designee to secure emergency medical services, including transportation and medical care. I also give permission for the attending physician to order injections, anesthesia or surgery for this child as named above. I understand that medical and accident insurance is the responsibility of the parent or guardian. If my child(ren) attend Jefferson County Public Schools, by signing this form I am giving the YMCA permission to communicate and exchange information with JCPS for the purpose of providing and enhancing services to my child(ren). There may also be times when JCPS or the YMCA may take photographs (or other digital images) of students participating in activities. Those images may appear in the YMCA’s or JCPS’s publications, including electronic publications. By signing this form, I am giving permission to JCPS and the YMCA to use my child(s) image for the purposes listed above. I understand that this release may be revoked by me at any time by written request.

Signature Date Signed

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