2010-11 After School Program

Laugh, Learn and Grow with the

YMCA School-Age Child Care Program!The YMCA of Greater Louisville, in partnership with area Private and Parochial Schools, offers the School-Age Child Care Program — where your child will learn, grow and have a great time!

kindergarten through

middle-schoolymcalouisville.orgFinancial assistance available.

Registration Registration will continue throughout the school year based on space availability. All sites have minimum and maximum enrollment numbers and registrations are processed on a first-come, first-served basis. Completed registrations must be received at least 2 business days prior to your child’s start date in order for your child to begin the program.

To register submit your registration form and non-refundable registration fee one of the following ways:

•Onlineatymcalouisville.org through August 9th

•BringregistrationformandfeetoyourSiteDirector

•Mailtheregistrationformandfeeto: YMCA School-Age Child Care Services 2411BowmanAvenue Louisville, KY 40217

Mail must be post-marked one week prior to start date.

Payment OptionsAll payments are to be made by bank or credit card draft. Automatic draft payments must be set up prior to the first day of attendance. All parents must pay registration fees. Drafts will occur each Wednesday for the current week, unless otherwise scheduled through our main office.

In-Service & Snow DaysFull day care available during in-service and snow days from 7 a.m. until 6 p.m. Site locations may vary due to site consolidation. In addition to completing the registration form, participants must be signed up to attend these days at the site of their choice. Details available at your site or at ymcalouisville.org. In-service and snow days are included in total number of days attended for the week.

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

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

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

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

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

School Sites Christian Academy of Louisville – Rock Creek 3110 Rock Creek Drive

Christian Academy of Louisville – English Station 711 S. English Station Road

St. Leonard Catholic School 440 Zorn Avenue

St. Margaret Mary Catholic School 7813 Shelbyville Road

St. Patrick Catholic School 1000 North Beckley Station Road

St. Raphael School 2131 Lancashire Avenue

YMCA School-Age Child Care Program ● (502) 637-1575

First Child Each Additional Child

YMCA Facility Member/Partnership Employee

Dependents

$53

$43

ProgramMembers

$48

$39

YMCA Facility Member/Partnership Employee

Dependents

$43

$35

4- or 5-day

1-, 2- or 3-day

Registration Fees Per Child

Weekly Rates

ProgramMembers

$58

$47

Through August 9, 2010$30 per child

August 10, 2010 throughout school year$45 per child

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

Please print legibly and include your registration fee.Register Online through August 9th at ymcalouisville.org.ProgramStartDate _____________________________________ E-mail Address to receive confirmation ______________________________________________________________

1st Child’s Name

First ____________________________ Middle ____________________________ Last ____________________________ 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

School Attending _______________________________________________________________________________________________________________________ Grade in School (2010-11) _____________

Attendance: 1-3 Days 4-5 Days

Participation: After-School Care In-Service Day Care Snow Day Care

2nd Child’s Name

First ____________________________ Middle ____________________________ Last ____________________________ 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

School Attending _______________________________________________________________________________________________________________________Grade in School (2009-10) _____________

Attendance: 1-3 Days 4-5 Days

Participation: After-School Care In-Service Day Care Snow Day Care

1st Parent/Guardian Name _____________________________________________________________ Relationship to Child ____________________________________ Date of Birth _____ / _____ / _____

Mailing Address _______________________________________________________________________ City ______________________________________ State ____________ Zip_______________________

Home Phone __________________________ Cell Phone _________________________ Work Phone _________________________ Employer ____________________________________________________

2nd Parent/Guardian Name ____________________________________________________________ Relationship to Child ____________________________________ Date of Birth _____ / _____ / _____

Mailing Address _______________________________________________________________________ City ______________________________________ State ____________ Zip_______________________

Home Phone __________________________ Cell Phone _________________________ Work Phone _________________________ Employer ____________________________________________________

Insurance Company ________________________________________________________________________________________ Policy Number __________________________________________________

Name of Physician _________________________________________________________________________________________ Physician Phone _________________________________________________

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

Emergency Contact and Authorized Pick-Up Information

Please give the names and phone numbers of people to contact in an emergency and/or names of persons authorized to pick up your child/children. Anyone picking up your child/children must be 18 years

of age or older. A Photo ID is required at pick-up.

Name ______________________________________________ Relation to child __________________________________ Phone 1 ____________________________Phone 2 ___________________________

Name ______________________________________________ Relation to child __________________________________ Phone 1 ____________________________Phone 2 ___________________________

TheYMCAhaspermissionformychild(ren)tobephotographedand/orinterviewedforpromotionalpurposes: Yes No

Mychild(ren)havepermissiontoparticipateinbasichealthandfitnessevaluations: Yes No Iamregisteringatuition-basedPre-Kstudent: Yes No

Yes,IwouldliketomakeacharitabledonationtoTheSpiritCampaign: $10 $25 $50 $100 Other/please contact me

Checkhereifeitherparentis: YMCA Employee School Partnership Employee YMCA Family Facility Member

Icurrentlyreceivea: Spirit Program discount 4-C Other 3rd party subsidy discount

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

I am currently on automatic draft. Please use the information on file to draft my account for my registration fee(s) and to set up my weekly payments. Account ending in ____ ____ ____ ____.

EFT Credit Card

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

IamauthorizingaNEWcreditcarddraftandIhaveprovidedalltheinformationbelow:

CreditCardType: Visa MasterCard Discover

Name as it appears on card ___________________________________________________________ Card Number _______________________________________ ExpirationDate _______________

BillingStreetAddress ____________________________________________________________________________ _____________________________________________BillingZip _______________

I have the legal authority to sign up my child/children named on this form. I understand that this is an application and the named child’s/children’s participation is contingent upon space being available in this program. I also understand that once my application is confirmed, I must complete payment by the deadline. I understand that the YMCA prohibits staff members from being alone with children they meet in YMCA programs outside of the YMCA. This includes but is not limited to baby sitting, tutoring, sleep-over’s, etc. This health history is correct as far as I know and the child/children herein described have my permission to engage in all activities and field trips except as noted by me. A photo of each child and a copy of each child’s current immunization certificate will be on file with the YMCA prior to my child/children attending the program. Failure to comply with the above could result in the loss of child care space. In the event I cannot be reached in an emergency, I hereby give permission to the director of the program or designee to secure emergency medical services, including transportation and a physician. I also give permission to the attending physician to order injection, anesthesia or surgery for my child/children as named above. Medical and accident insurance is the responsibility of the parent or guardian. To the best of my knowledge; the information on this form is complete and accurate. I have read and agree to these terms and conditions.

Signature ______________________________________________________________________________________ Date Signed _______________________

Please attach a recent wallet size photo and immunization

certificate for each child.

2010-11 School Year YMCA School-Age Child Care Program Registration Form