C.A.R.E. Core Youth Enrichment Program (CCYEP)
Family Registration Form
Full Name of Child_____________________________________________________________________
Birth Date_________________ Age________ Grade_______ Gender: (Circle) Male/Female
Ethnicity: Hispanic or Latino
non-Hispanic or Latino
Race: Black/African American, White, Asian, Native Hawaiian or Pacific Islander, Other
Mother/ Guardian’s Name______________________________________________________________
Address_________________________________________________________ Zip________________
Home Phone:_________________________ Work Phone:___________________________________
Cell Phone :____________________________________( Text is used to communicate in emergencies)
Email: _____________________________________________________________________________
Father/ Guardian’s Name______________________________________________________________
Address_________________________________________________________ Zip________________
Home Phone:_________________________ Work Phone:___________________________________
Cell Phone :____________________________________( Text is used to communicate in emergencies)
Email: _____________________________________________________________________________
If Parents are divorced, who is the Custodial Parent? ________________________________________
If there are special circumstances with non- custodial parent visitation and/or pick up, you must provide
the Program Director with legal documentation.
School: ________________________________ School ID #__________________________________
Day School Teacher:______________________________ Email:________________________________
My Child will attend: (please indicate with aü). CCYEP works in conjunction with the Metro School
Calendar, however, all days will be scheduled by our Calendar of Open Dates)
After-school______ School Half days_______ School Full Days_______
Summer ________
Emergency Information: Please List the names responsible for authorized pickup in an emergency in case
the parent cannot be contacted. REQUIRED
Name_____________________________________ Relationship_______________________________
Phone :( W) ___________________________(H) _____________________ (C) __________________
Others: Please give the best phone number to be reached. REQUIRED
Name____________________________Relationship____________________Phone:_______________
Name____________________________Relationship____________________Phone:________________
Name____________________________Relationship____________________Phone:________________
Printed Parent Name: __________________________Parent Signature: __________________________
Medical Consent Child’s Name___________________________________________________________________ Doctor’s Name ____________________________________________ Phone# ______________ Address ______________________________________________________________________ Medical Problems/Allergies_______________________________________________________ I authorize the CARE Core Youth Enrichment Program to seek hospital emergency care and/or medical treatment as needed. Parent’s/Guardian’s Signature____________________________________ Date__________ Transportation Permission Slip Child’s Name __________________________________________________ My child has permission to ride on the Cathedral of Praise van or bus or transportation arranged by City of Life from school to the CARE Core Youth Enrichment Program and for field trips or other excursions. I understand that adequate transportation and supervision will be provided and agree not to hold City Of Life Corporation , Cathedral of Praise , their directors ,employees or volunteers responsible for any losses or damages whatsoever which I or my child may incur in connection with the program. Parent’s/ Guardian’s Signature ________________________________ Date _______________ Photo, Video and /Media Permission I give permission to the City of Life Corporation for photographs, videos, creative work, quotes, or other media which may include my child to be used in media releases and products to benefit City of life Corporation programs. Parent’s/Guardian’s Signature _________________________________________Date_________________ Printed Name of Parent/ Guardian ___________________________________________________ Child’s Insurance /Medical Information (Required): Child’s Name: ___________________________________________________________________________ Height: __________ Weight: _____________ Eye Color: ______________ Hair Color: ________________ Physician’s Name: _________________________________ Phone: ________________________________ Insurance Coverage: _______________________________ Phone: ________________________________ Name of Insured: __________________________________ Phone: _______________________________ Does your child have his/her immunization records on file at their Day School? _____________ Does your child have any ALLERGIES OR MEDICAL CONDITIONS that should be considered? ______ Yes ________ No If Yes, explain _______________________________________________________ Please answer yes or no and give an explanation if needed. DOES YOUR CHILD: 1. Have any allergies or reactions to medicine? ______ Yes ______ No 2. Have speech or hearing problems? ______ Yes ______ No ______ Yes ______ No 4. Wear Glasses, contacts, or protective eye wear? ______ Yes ______ No 5. Have tubes in his/her ears? ______ Yes ______ No 6. Have frequent ear infections? ______ Yes ______ No 7. Have any special problems not indicated above ______ Yes ______ No 3. Have trouble with his/her eyes or eyesight? If Yes, explain________________________________________________________________________ 8. Have a Chronic or recurring illness/condition? ______ Yes ______ No 9. Has your child ever been hospitalized? ______ Yes ______ No 10. Ever had surgery? ______ Yes ______ No ______ Yes ______ No 12. Has your child ever had a head injury? ______ Yes ______ No 13. Ever been knocked unconscious? ______ Yes ______ No 14. Has your child ever passed out during or after exercise? ______ Yes ______ No 15. Is your child dizzy during of after exercise? ______ Yes ______ No 16. Has your child ever had seizures? ______ Yes ______ No 17. Ever had chest pain during or after exercise? ______ Yes ______ No 18. Ever had high blood pressure? ______ Yes ______ No 19. Ever been diagnosed with a heart murmur? ______ Yes ______ No 20. Have skin problems (itching, rash, acne) ______ Yes ______ No 21. Have diabetes? ______ Yes ______ No 22. Have asthma? ______ Yes ______ No ______ Yes ______ No 24. Does your child get along with other children? ______ Yes ______ No 25. Are their other siblings in the house? ______ Yes ______ No 11. Have frequent headaches? 23. Have or ever had an eating disorder? PLEASE NOTE CARE CORE WILL NOT ADMINISTER ANY MEDICATIONS General Permissions/Agreements I give my permission to the City of Life C.A.R.E. Core Youth Enrichment Program (CCYEP) and its providers, unless otherwise noted in the space below, to have my child participate in activities at the program location, 4300 Clarksville Pike, as well as other off-‐site locations, knowing that this might include special activities, such as swimming, skating, or other off-‐site events, field trips, picnics or celebrations. 1. With the medical information on the previous page in mind, I give my permission to have my child engage in all activities, except as noted. 2. I give permission to secure proper medical treatment for my child in the event of an emergency. If I or my emergency contact cannot be reached, I give permission for a physician to order routine tests and treatment for the health of my child. I give permission to a physician to secure treatment and/or hospitalize my child; after all emergency contact attempts have been made. I, the undersigned; understand, acknowledge, and agree: §
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That I have read and understand the information above and in the Parent Policy Booklet & The Summary of School Age/ Adolescent Approval Requirements. That I will update changes in my enrollment information in a timely fashion. That the City of Life CCYEP will always make itself available to children, parents, and day school staff regarding any concerns they might have. That I, or my child, may be asked to complete surveys for program evaluation purposes. That City of Life CCYEP may request my child’s records that may contain personal information (such as grades, ID#’s, attendance, behavior, IEPs, health records, etc.) for the sole purpose of helping my child succeed in school. I therefore waive, with respect to these disclosures, any duty of confidentiality arising from Federal or State requirements. That I will not seek to hold City of Life Corporation or Cathedral of Praise responsible for any losses or damages whatsoever which I or my child may incur in connection with the program. That fees are due the Friday before the week of service; that returned/stop payment checks will incur a service fee of $30; and that only cash or a money order will be accepted if a check is returned. That program hours, starting times and ending times must be honored. Children cannot come to the program before the starting time or stay later than the closing time. That the City of Life CCYEP will always protect the safety, interests, and rights of all individuals in the program. Therefore each program will provide a Parent Policy Booklet, The Summary of School Age/ Adolescent Approval Requirements or other program-‐specific information, including behavior policies and grievance procedures. __________________________________________________ Student Name (Please Print) _____________________________________________/____________________________________ Parent’s Name (Printed) Parent’s Signature ENROLLMENT POLICIES/FEES Admissions: The C.A.R.E. Core Youth Enrichment Program (CCYEP) does not discriminate based on race, sex, color, nationality, religion, or disability. To file a complaint, call: USDA Director, Office of Civil Rights, (202)720-‐5964. Applications are processed on a first-‐come, first-‐served basis. Students are admitted to the program until all available spots are filled. Each parent/guardian must complete the enrollment forms. Children 5 years of age through 13 years of age may participate in the CARE Core After School Program and Summer Enrichment Program. To Enroll a Child: An initial non-‐refundable enrollment fee of $25 must be paid upon registration. The enrollment fee secures your child’s space in the program. Each child must have signed, complete enrollment forms on file. A copy of any legal custody documents must also be on file. Before/After Care Program Fees: Registration……………………………………………………………………………………………………………$25.00/Child Weekly Fee – After Care………………………………………………………………………………………….$40.00/Child School Half Days (additional to weekly fees)...…………………………………………………. $5.00 day/Child School Full Days (additional to weekly fees)…………………………………………………….$10.00 day/Child Late Child Pickup Fee (after 6:02PM)…………………………………………………….…………$1.00/per minute Reduced Fee with F/R Lunch documentation……………………………………………………….$30.00/Child Summer Enrichment Program Fees: Registration…………………………………………………………………………………………………………….$25.00/Child Weekly Fee………………………………………………………………………………………………………………..$95/Child Activity fee………………………………………………………………………………………………………………….$40/child *** $5.00 discount on weekly fee for sibling(s) (CARE Core Youth Enrichment Program reserves the right to amend Fees as needed) Fees are charged on a weekly basis no matter how many days your child attends for the week (no prorated fees). Paying the weekly fee holds your child’s spot in the program. Fees are due on Friday before the week of service. Fees may be placed in the “Fee Box “in the Program Director’s Office at any time prior to the due date. The returned/stop payment check’s fee is $30. Cash or a money order, for payment, will be required if there are two returned checks. Payments: Make all Checks or Money Orders payable to: City of Life Corporation. Hours: C.A.R.E. Core after care services are Monday –Friday, from 3 p.m.-‐6p.m. Children cannot come to the program before the beginning time or stay later than the closing time. Sign In/Out: Please sign your Child In/Out every day. You must enter the building to sign your child in/ out. Only Adults who are on the Pickup List with proper Identification will be allowed to pick up your child. No siblings under the age of 18 will be allowed to pick up a child. All persons on your pick up list must have a current state driver’s license with a photo ID to pick up your child. Please inform those who pick up your child that their ID will be copied and placed in a file for future reference. Anyone who is suspected of being under the influence of alcohol or other drugs will not be permitted to leave with a child. Every effort to ensure the safety and protection of the child will be made up to and including notifying the appropriate authorities. Late Pick-‐up Fees: After 6:02, late fees are $1 for every minute thereafter. After 3 occurrences, a Mandatory Parent Meeting will be held to determine future enrollment opportunities. Continued late pick up (after 6:00 PM) will result in a child being released from the program. If children have not been picked up, and there isn’t any notification after 45 minutes, the Department of Children’s Services will be called, as required by law. Meals: Breakfast (8:00 – 8:30 am), Lunch (12-‐1), and an Afternoon snack (3:30 – 4:00 pm) will be served each day. We will plan nutritious and tasteful meals and snacks with known allergies of the children enrolled in mind; however, we cannot prepare special foods to meet the needs of individual children. Parents may be required to provide their child’s meal if a special diet is needed. Accidents: The CCYEP maintains first-‐aid supplies in the event of simple accidents. Our Staff are certified in CPR and First-‐Aid. If a child has an accident that might need a doctor’s attention, parents are notified immediately. Simple accidents such as small scrapes or cuts are treated, accidents are documented and a copy of the written documentation is given to the parent. Each child must have emergency medical information on file, including an emergency contact person and medical transportation plan. Medication: The CCYEP does not administer medication of any kind, prescribed or over the counter. Children are checked upon arrival for signs of communicable diseases and abuse. If children are ill with fever or vomiting, parents are called to pick them up immediately. Children who are ill, with fever or a communicable disease (flu, cold, strep throat, etc.) cannot attend until released by a physician along with appropriate documentation. Discipline: The CCYEP uses positive techniques of guidance including; redirection, anticipation, elimination of potential problems, positive reinforcement, and encouragement rather than competition, comparison or criticism. When a child exhibits unacceptable behavior, the child is removed from the group and allowed to regain self-‐control. He/she may lose a privilege (such as not being allowed to go on a special outing) if unacceptable behavior persists. A last resort is to terminate the child from the program. The Following procedures are followed: 1. Child will be given a warning. 2. Quiet time away from the rest of the group(see attachment for Behavior Modification Notice) 3. Have a Meeting with Child’s Parent 4. Call Parents if child is unable to behave after above consequences have been tried, or if your child’s behavior is extremely dangerous or disruptive, you will be notified by the Director to pick up your child immediately. 5. Have a Meeting with Executive Director 6. Suspension or dismissal from the CCYEP. The CCYEP holds the right to dismiss a child immediately if she/he does bodily harm to himself or herself or another student. THERE IS ZERO TOLERANCE FOR BULLYING, PHYSICAL ALTERCATIONS, AND/OR VERBAL ABUSE TOWARDS ADULTS OR OTHER CHILDREN IN THE PROGRAM. Safety: The CCYEP will conduct safety drills (fire, tornado and transportation etc.). Children must follow all safety guidelines as indicated by policy and procedure on site as well as transport. If a child is unable to follow these safety policies he/she may be suspended or released from the program. Transportation Transportation is a service and we follow all C.A.R.E. Core Youth Enrichment Program safety guidelines, which include specific behaviors of children on the vehicle. Consequences of such behavior, that we cannot control, may lead to suspension or dismissal from the program. Things from Home: Parents are asked to cooperate with the CCYEP “No toys, games (board or electronic) or money Rule”. It is better for teachers and children if personal toys and games remain at home. Please do not allow your child to bring money to the program. Withdrawal Procedures – Parents, if for any reason you have to withdraw your child from your planned participation, we request prior written notice. GRIEVANCE POLICY/PROCEDURES Policy: City of Life Corporation aims to resolve problems and grievances promptly and as close to the source as possible with graduated steps for further discussions and resolution at higher levels of authority as necessary. Procedures: 1. The Parent attempts to resolve the complaint as close to the source as possible. This level is informal and verbal. If not resolved…. 2. The Parent notifies the Supervisor in writing as to the substance of the grievance and state the remedy sought. Either party may request written statements and agreements. This level should not exceed one week. If not resolved…. 3. The Supervisor must refer the matter to the Executive Director or Board of Directors, if applicable. The grievance must be in writing. This level should not exceed one week. If not resolved…. 4. The Parent will be advised of his/her rights to pursue the matter with external authorities if they so wish. Contact Information: Brittany Moore, Associate Executive Director Phone: 615.299.0508 Email: [email protected] Brenda Ramsey, Executive Director Phone: 615.299.0520 Email: [email protected] City of Life Fax: 615.299.5535 Location: Cathedral of Praise Church 4300 Clarksville Pike Nashville, TN 37218 The City of Life does not discriminate on the basis of age, race, sex, color, national origin, or disability in admission, access to, or operations of its programs, services, or activities.