1. education
2. school

HEALTHY,
CONFIDENT,
SECURE
BEFORE & AFTER SCHOOL  2015-2016
NEENAH-MENASHA YMCA  Ages 5-12
Neenah Joint School District
Alliance Charter  Clayton  Coolidge  Hoover 
Lakeview  Roosevelt  Spring Road  Taft  Tullar
PROGRAM INFORMATION:
AGES 5-12
PROGRAM LOCATIONS
 Before School: Clayton, Coolidge, Hoover, Lakeview, Spring Road, Taft, Tullar
 After School: Alliance Charter, Clayton, Coolidge, Hoover, Lakeview, Roosevelt, Spring Road, Taft, Tullar
 MINIMUM ENROLLMENT: Each school‟s before and/or after school program needs a minimum enrollment
to operate (before school = 5 children/day; after school = 10 children/day). Families will be contacted in
early August in the event a program does not meet this minimum.
PROGRAM HOURS




Before School: 6:30 AM-start of school
After School: school dismissal-5:30 PM
Early Dismissal: 11:30 AM-5:30 PM (Noon on Friday for Alliance Charter students)
Vacation Days: 6:30 AM-5:30 PM (additional cost/registration-offered by the YMCA on select no school
days)
REGISTRATION BEGINS APRIL 6, 2015 – Space is limited
Registration packets can be picked up and returned to the Neenah-Menasha YMCA, 110 W. North Water St.,
Neenah, WI 54956. Registration packets must be 100% complete and received at least 7 days prior to the first
day of requested care. A child will not be enrolled in the program until all paperwork is completed and returned.
FEES AND BILLING
There is a non-refundable registration fee per child ($30/1 child or $50/family). The registration fee is required
when submitting the registration packet. Each child must register for a minimum of one day per week to remain
on the roster. Fees are automatically deducted the last Friday before the start of each month (August-April).
Monthly fees are only prorated in half-month increments. A child starting on days 1-15 will incur 100% of the
monthly fee; those starting on days 16-31 will incur 50% of the monthly fee.
MONTHLY FEES
BEFORE SCHOOL (Y Member/General Public)
1 day/week
 $35/$50
2 days/week  $60/$75
3 days/week  $75/$95
4 days/week  $90/$110
5 days/week  $105/$125
Additional Day  $12
AFTER SCHOOL (Y Member/General Public)
1 day/week
 $45/$60
2 days/week  $75/$90
3 days/week  $105/$130
4 days/week  $120/$150
5 days/week  $145/$175
Additional Day  $12
Early Dismissal Days  $7/$12 per day
Vacation Days (select No School days – separate registration form)  $30/$40 per day
FINANCIAL ASSISTANCE
The YMCA welcomes those who wish to participate and annually raises funds to help make that possible. The
YMCA scholarship program is supported in part by contributions from the Annual Campaign and other donors, and
provides scholarships and subsidies for qualifying applicants within our available resources.
If you receive assistance through the county or other agency, please note this on your School Age Contract. The
YMCA will also need the name and phone number of your case worker before enrollment is accepted.
QUESTIONS
Heather Landreman, Child Care Administrative Assistant/Registrar: [email protected] 920.729.9950
Julie Uhe, School Age Coordinator: [email protected] 920.886.2126
REGISTRATION STEPS:
1. All forms included in this packet must be 100% complete per state licensing
rules before we can accept your child into our program. Children will not be added
to attendance rosters until all paperwork is fully completed and returned.
2. Pending availability, all paperwork must be turned in at least 7 days prior to your
requested first day of attendance.
REQUIRED FORMS: (use the check boxes to ensure accuracy)
REGISTRATION FEE
 $30/1 child or $50/family
 This can be automatically deducted if you initial this on the Tuition Express payment
form.
BEFORE/AFTER SCHOOL CONTRACT
 Did you provide an e-mail? This is our main way of communicating to you.
 Did you list a specific start date? The first day of school is Tuesday, September 1, 2015.
 Did you list the correct rate in the rate boxes? Don‟t leave blank.
TUITION EXPRESS PAYMENT FORM
 Did you choose and complete one of the two options for payment?
 Only one Tuition Express payment form is needed per family; returning families only need
to complete a new payment form if the one on file has changed.
CHILD CARE ENROLLMENT FORM & Pick-up List
 Did you provide an emergency contact person & number?
 Did you mark „yes‟ or „no‟ to all the authorization boxes above your signature?
 Did you provide your doctor‟s name, address and phone?
HEALTH HISTORY & EMERGENCY CARE PLAN
 Did you sign page 2 on the bottom?
 Sunscreen/Insect Repellant: If you don‟t plan to send this during the school year, mark
„No‟ to all four boxes. If you will send it, you must list the specific brand name & SPF.
Don‟t write “Any” or “Generic”.
 Please notify us of any medical issues or behavioral strategies that will help our staff.
DAY CARE IMMUNIZATION FORM
 Did you fill out Step 1 through 5? We need your signature on the Form.
 If you provide the immunization dates as an attachment you must complete steps 1 & 5
on the Immunization Form.
CHILD PICK UP AUTHORIZATION
SCHOOL AGE FAQ’s – keep this form for your records.
Drop off or mail registration packet to:
OR
Scan/e-mail to:
Neenah-Menasha YMCA
[email protected]
Attn: Heather Landreman
110 W. North Water St
PLEASE DO NOT FAX FORMS!
Neenah, WI 54956
BEFORE & AFTER SCHOOL CONTRACT
YMCA OF THE FOX CITIES
YMCA Location:
 Apple Creek
 Appleton
 Fox West
 Heart of the Valley
 Neenah-Menasha
School Year: 2015-2016
Child‟s Full Name:
Grade:
Child‟s School:
Program Site (if different):
School Age Program start date (xx/xx/xx):
Registration Fee:  $30 (1 child)
Before School Days of Attendance:  M  T  W  R  F
After School Days of Attendance:  M  T  W  R  F
Name, Parent/Guardian 1:
Telephone:
(h)
DOB:
Age (upon enrollment):
 $50 (2+ children)
Name, Parent/Guardian 2:
(w)
(c)
Telephone:
(h)
Address:
Address:
City, State, Zip:
City, State, Zip:
Parent 1 e-mail:
Parent 2 e-mail:
(w)
(c)
Is the child a YMCA Member?  Yes  No
Who does child reside with?  Both parents  Mother only  Father only  Other
Branch: ________________________________
 Shared placement (county assistance recipients must provide placement schedule!)
Who will be responsible for payment?  Both parents, joint account  Parent 1 only  Parent 2 only  Other:
 Both parents, separate accounts/split amount: Parent 1-____________% Parent 2-____________%
(Contract signature & separate Payment Form required for both parents if separate accounts/split amount)
 Parent is a NJSD Employee (employment verification needed) If checked, please indicate who:  Parent 1  Parent 2  Both
Does your family receive financial assistance?  Yes
__________
(initials)
__________
(initials)
 No
If yes, which program(s)*?
(*State Agency Funding recipients: please pay registration fee)
I acknowledge full responsibility for any YMCA Before/After School program fees not reimbursed to the YMCA by the Wisconsin Child
Care Subsidy program, including any unexcused absences causing my child/ren‟s weekly attendance to drop below 50%. Nonpayment
of fees incurred will result in the termination of care for my child/ren.
__________
(initials)
According to the above indicated schedule of attendance, my monthly payment will be $___________ for before school care and/or
$___________ for after school care for a total monthly payment of $____________ per child.
All fees will be deducted automatically out of a credit/debit card or checking/saving account. Additional days requested outside of
normal contract will be charged a fee of $12 per day per child based on availability. Early dismissal day usage will be billed $7 or $12
per day per child based on attendance. These fees will post to your account approximately one week after occurring.
There is an annual registration fee ($30 for 1 child and $50 for 2 or more children) that is due at the time of enrollment. This is a
non-refundable fee and does not apply towards any past or future program fees.
All contract changes must be submitted in writing by the 20 th of the month prior to care and will not take effect until the first day of
the following month. A $5 contract change fee will be assessed for each change. No contract changes will be accepted at the
school sites.
__________
(initials)
A two-week written notice (email is sufficient) is required when withdrawing a child from the program. Normal fees will continue to
accrue during the two-week period, which begins the day that written notice is received at the Y.
__________
(initials)
A late pick up charge is assessed of $10 per child for every 15 minutes starting one minute past the listed closing time.
__________
(initials)
No credit will be given for sick/absent/vacation days. You are expected to pay for days you contract.
__________
(initials)
The YMCA does not carry supplemental health insurance. I will be responsible for any medical expense related to an injury my child
may incur while participating in the program.
__________
(initials)
Children with special physical or emotional needs will be accepted if the program is determined to be in the child‟s best interests
and/or if the child does not require an inordinate amount of staff time that would take away from the other children‟s care.
I authorize the YMCA to use any photos taken of my child for promotional purposes, including web pages, cover issues, brochures or
flyers that promote information about the YMCA programs.
__________
(initials)
__________
(initials)
__________
(initials)
I understand that by signing this contract, I agree to all of the conditions listed above and within the YMCA policies.
Parent/Guardian Signature: _____________________________________________________________________ Date: ____________________
Parent/Guardian Signature: _____________________________________________________________________ Date: ____________________
YMCA USE:
Received ______
Med / Allergy / None
XLS ______
Confirm email ______
Sent to BO ______
Site Copies ______
-PAYMENT OPTION 1-
YMCA of the Fox Cities
Child Care RECURRING CREDIT CARD Authorization Form
You must choose either option 1 or option 2. No cash or checks are permitted.
No cash or checks are permitted. If you are using a debit card and funds are not available until Friday, do
not choose this option. Complete the Electronic Funds Transfer side to be debited from your checking or savings
account.
Complete and return this form to the YMCA of the Fox Cities Business Office at 229 E. College Avenue,
Appleton, WI 54911. If you have any questions, please contact Jackie at 920-954-7646 or
[email protected].
I (we) authorize the YMCA of the Fox Cities, to initiate recurring credit card charges to the below referenced
credit card account ending in the last four digits ___________ for the purpose of collecting child care related
fees. I (we) authorize the YMCA of the Fox Cities to withdraw sufficient funds to pay my (our) regular childcare
tuition and/or other childcare related fees that are due and payable. I (we) authorize the YMCA of the Fox
Cities to use the third party sender, Tuition Express* to capture, create, and transmit all credit card
information. I (we) indemnify and hold harmless, Tuition Express from any and all liability resulting from any
and all transactions. All disputes will be directed to and addressed by and between the YMCA of the Fox Cities
and the below signed cardholder. The YMCA accepts MasterCard, VISA and Discover.
___________________________________ ___________________________ ______________________________________
Cardholder Name
Phone #
__________________________________
Cardholder Billing Address
Email Address
________________________________________
City State Zip
Child(ren)’s Names_____________________________________________________________________
Child Care Accounts (Age: Infant to age 5) - fees will be deducted on the Friday prior to the week
care is provided.
School Age Accounts (School Year) – monthly fees will be deducted on the last Friday of the month
prior to the month of care. Any other fees will be charged as they come due.
Summer School Age and Day Camps – fees will be deducted on the Friday prior to the week care is
provided.
Declined Credit Card Fee - $10.00
This authorization will remain in full force and effect until I (we) notify the YMCA in writing of its
termination which must be received at a minimum of five business days in advance of the termination
date.
Registration Fees will be deducted from the credit card listed below unless a check or cash is included
with your Registration form.
_________________________________________ __________________________
Cardholder Signature
Date
----------------------------------------------------------------------------------------------------------------------
---
/
Credit Card Number
Expiration Date
(do not write down CVV number)
Record Retention Notice: The child care provider shall retain all parent (client) authorization forms in a secure location for a period of two years from
the date of client withdrawal from the Tuition Express™ program. *Tuition Express is an assumed business name of Blum Investment Group, Inc.
-PAYMENT OPTION 2-
YMCA of the Fox Cities
Child Care ELECTRONIC FUNDS TRANSFER Authorization Form
You must choose either option 2 or option 1. No cash or checks are permitted.
Complete and return this form to the YMCA of the Fox Cities Business Office at 229 E. College Avenue,
Appleton, WI 54911. If you have any questions, please contact Jackie at 920-954-7646 or
[email protected].
I (we) authorize the YMCA of the Fox Cities, to initiate debit entries to my (our) Checking or Savings
Account indicated below at the depository financial institution indicated below. I (we) authorize the YMCA
of the Fox Cities to withdraw sufficient funds to pay my (our) regular childcare tuition and/or other
childcare related fees that are due and payable. I (we) authorize the YMCA of the Fox Cities to use the
third party sender, Tuition Express* to process all payments. I (we) acknowledge that the origination of
Automated Clearing House (ACH) transactions to my (our) account must comply with the provisions of
United States Law.
__________________________________________________
___________________________________________
________________________________________
Address
________________________________________
City State Zip
__________________________________
Bank or Credit Union Address
__________________________________
City State Zip
Your Name
DEPOSITORY - Bank or Credit Union
Phone Number __________________________ Email Address ________________________________
Type (circle): Checking or Savings
[attach copy of voided check!]
______________________________________________________
Routing Transit Number
____________________________________________
Account Number
Child(ren)’s Names ____________________________________________________________________
Child Care Accounts (Age: Infant to age 5) - fees will be deducted on the Friday prior to the week
care is provided.
School Age Accounts (School Year) – monthly fees will be deducted on the last Friday of the month
prior to the month of care. Any other fees will be charged as they come due.
Summer School Age and Day Camps – fees will be deducted on the Friday prior to the week care is
provided.
Bank Return Fee: $10.00
This authorization will remain in full force and effect until I (we) notify the YMCA in writing of its
termination which must be received at a minimum of five business days in advance of the termination
date.
Registration Fees will be deducted from the account listed above unless a check or cash is included with
your Registration Form.
_____________________________________________ _______________________
Signature Date
*****Please attach a copy of a voided check. Deposit slips are not accepted*****
Record Retention Notice: The child care provider shall retain all parent (client) authorization forms in a secure location for a period of two years from
the date of client withdrawal from the Tuition Express™ program. *Tuition Express is an assumed business name of Blum Investment Group, Inc .
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Early Care and Education
STATE OF WISCONSIN
CHILD CARE ENROLLMENT
Use of form: Use of form is mandatory for Family Child Care Centers to comply with DCF 250.04(6)(a)1. Failure to comply may result in issuance of a noncompliance statement.
This form may also be used by Group Child Care Centers and Day Camps to comply with DCF 250.04(6)(a)1. And DCF 252.41(4)(a)1.respectively. Personal information you provide may
be used for secondary purposes [Privacy Law, s.1504(1)(m), Wisconsin Statutes].
Instructions: The parent / guardian shall fill out the form completely, sign it and submit it to the center prior to the child’s first day of attendance. Information on this form shall be kept
current. When enrolling a child under two years of age, a completed Intake for Child Under 2 Years form must also be on file prior to the child’s first day of attendance.
CHILD INFORMATION
Name (Last, First MI)
Birthdate (mm/dd/yyyy)
First Day of Attendance
PARENT OR GUARDIAN – All parents / guardians are permitted to visit during center hours and are allowed to pick up the child unless access is prohibited or restricted by a court order.
Attach court order, if any. If child resides at multiple locations, the department recommends the provider obtain and attach a schedule.
a. Name and Relationship to Child
Home / Cell Phone No.
Email Address Where Reachable While Child is in Care
Home Address (Street, City, State, Zip)
b. Name and Relationship to Child
Does the child reside at this location?
 Yes  No
Home / Cell Phone No.
Home Address (Street, City, State, Zip)
Does the child reside at this location?
 Yes  No
Place of Employment and Work Phone No.
Email Address Where Reachable While Child is in Care
Place of Employment and Work Phone No.
AUTHORIZED PERSONS – Persons other than parents / guardians who are authorized to pick up the child or accept the child if dropped off. If none one, write “None.”
a. Name and Relationship to Child
Home / Cell Phone No. Email Address Where Reachable While Child is in Care Place of Employment and Work Phone No.
b. Name and Relationship to Child
Email Address Where Reachable While Child is in Care
Place of Employment and Work Phone No.
EMERGENCY CONTACT – The person to be notified in an emergency when parents / guardians cannot be reached.
 Yes  No This person is authorized to pick up the child.
Name and Relationship to Child
Home / Cell Phone No. Email Address Where Reachable While Child is in Care
Place of Employment and Work Phone No.
PHYSICIAN / MEDICAL FACILITY INFORMATION
Name – Physician
Home / Cell Phone No.
Address (Street, City, State, Zip Code)
Telephone Number
AUTHORIZATION
 Yes  No I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.
 Yes  No I have had an opportunity to review the policies of this child care center and summary of the Wisconsin Rules for Licensing Child Care Centers.
 Yes  No I give permission for my child to participate in.  Transported  Walking field trips and other activities during operating hours
 Yes  No I have been informed of the number of pets in the center and their degree of contact with enrolled children. Note: If pets are added after a child is enrolled, parents
shall be notified in writing prior to the pet’s addition to the center.
SIGNATURE – Parent or Guardian
Date Signed
DCF-F-CFS0062 (R. 12/2014)
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Early Care and Education
DCF-F (CFS-2343) (R. 03/2009)
STATE OF WISCONSIN
Page 2 of 2
HEALTH HISTORY AND EMERGENCY CARE PLAN
Use of form: This form is required for family and group child care centers and day camps to comply with DCF 250.04(6)(a)1. And 250.07(6)(L)5., DCF 251.04(6)(a)6. And 251.07(6)(k)5.,
and DCF252.44(6)(g) of the Wisconsin Administrative Codes. Failure to comply may result in issuance of a noncompliance statement. Personal information you provide may be used for
secondary purposes [Privacy Law, s.1504(1)(m), Wisconsin Statutes].
Instructions: The parent / guardian should complete this form for placement in the child’s file prior to the child’s first day of attendance. Information contained on the form shall be shared
with any person caring for the child. The department recommends that parents / guardians and center staff periodically review and update the information provided on this form.
CHILD INFORMATION
Name (Last, First MI)
Address – Home (Street, City, State, Zip Code)
Telephone Number
Birthdate (mm/dd/yyyy)
PARENT / GUARDIAN INFORMATION
Name
Date – First Day of Attendance (mm/dd/yyyy)
Provide information where the parent(s) / guardian(s) may be reached while child is in care.
Telephone Number – Home
Telephone Number – Work
Name
Telephone Number – Home
PHYSICIAN / MEDICAL FACILITY INFORMATION
Name – Physician
Address – Medical Facility
Telephone Number – Work
Telephone Number - Cellular
Telephone Number - Cellular
Telephone Number
SUNSCREEN / INSECT REPELLENT AUTHORIZATION If provided by the parent, the sunscreen or insect repellent shall be labeled with the child’s name. Per DCF 251.07(6)(f)2.,
authorizations shall be reviewed every 6 months and updated as necessary. Per DCF 250.07(6)(f)2.a., Authorizations shall be reviewed periodically and updated as necessary.
Brand Name – be specific, don’t write “any”
Ingredient Strength
 Yes  No I authorize the center to apply sunscreen to my child.
 Yes  No
I authorize the center to allow my child to self-apply sunscreen.
 Yes  No
 Yes  No
I authorize the center to apply repellent to my child.
I authorize the center to allow my child to self-apply repellent.
Brand Name – be specific, don’t write “any”
Ingredient Strength
HEALTH HISTORY AND EMERGENCY CARE PLAN If available, attach any health care plan information from the child’s physician, therapist, etc.
1. Check any special medical condition that your child may have.
 No specific medical condition
 Asthma
 Diabetes
 Cerebral palsy / motor disorder
 Epilepsy / seizure disorder
 Other condition(s) requiring special care – Specify.
 Gastrointestinal or feeding concerns including special diet and supplements
 Any disorder including Cognitively Disabled, LD, ADD, ADHD, or Autism
 Milk allergy. If a child is allergic to milk, attach a statement from the medical professional indicating the acceptable alternative.
 Food allergies – Specify food(s).
 Non-food allergies – Specify.
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Early Care and Education
DCF-F (CFS-2343) (R. 03/2009)
STATE OF WISCONSIN
Page 2 of 2
2.
Triggers that may cause problems – Specify.
3.
Signs or symptoms to watch for – Specify.
4.
Steps the child care provider should follow. If prescription or non-prescription medications are necessary, a copy of the form Authorization to Administer Medication should be
attached to this form. Note: group child care centers and day camps may use their own form.
5.
Identify any child care staff to whom you have given specialized training / instruction to help treat symptoms.
a.
b.
c.
6.
When to call parents regarding symptoms or failure to respond to treatment.
7.
When to consider that the condition requires emergency medical care or reassessment.
8.
Additional information that may be helpful to the child care provider.
SIGNATURE – Parent or Guardian
Review Dates: ____________________
Date Signed (mm/dd/yyyy)
____________________
____________________
____________________
____________________
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-44192 (Rev. 09/08)
STATE OF WISCONSIN
ss. 252.04, Wis. Stats.
DAY CARE IMMUNIZATION RECORD
COMPLETE AND RETURN TO DAY CARE CENTER. State law requires all children in day care centers to present evidence of immunization against certain diseases within 30
school days (6 calendar weeks) of admission to the day care center. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver
is filed with the day care center. See “Waivers” below. If you have any questions on immunizations or how to complete this form, please contact your child’s day care provider or
your local health department.
PERSONAL DATA
STEP 1
PLEASE PRINT
Child’s Name (Last, First, Middle Initial)
Date of Birth (Month/Day/Year)
Name of Parent/Guardian/Legal Custodian (Last, First, Middle Initial)
Address (Street, Apartment number, City, State, Zip)
Area Code/Telephone Number
IMMUNIZATION HISTORY
STEP 2
List the MONTH, DAY AND YEAR the child received each of the following immunizations. DO NOT USE A (4) or (X) except to indicate whether the child has
had chickenpox. If you do not have an immunization record for this child, contact your doctor or local public health department to obtain the records.
TYPE OF VACCINE
First Dose
Second Dose
Third Dose
Fourth Dose
Fifth Dose
Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
Diphtheria-Tetanus-Pertussis
(Specify DTP, DTaP, or DT)
Polio
Hib (Haemophilus Influenzae
Type B)
Pneumococcal Conjugate
Vaccine (PCV)
Hepatitis B
Measles-Mumps-Rubella
(MMR)
Varicella (chickenpox) vaccine
Vaccine is required only if the
child has had not had
chickenpox disease.
Has the child had Varicella (chickenpox) disease? Check the appropriate box and provide the year if known.
 Yes year ____________________ (Vaccine is not required)
 No or Unsure (Vaccine is required)
REQUIREMENTS
STEP 3
The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these requirements at day
care entrance. Children who reach a new age/grade level while attending this day care must have their records updated with dates of additional required
doses.
AGE LEVELS
NUMBER OF DOSES
5 months through 15 months
2 DTP/DTaP/DT
2 polio
2 Hib
2 PCV
2 Hep B
16 months through 23 months
3 DTP/DTaP/DT
2 polio
3 Hib 1
3 PCV2
2 Hep B
1 MMR3
1
2
2 years through 4 years
4 DTP/DTaP/DT
4 polio
3 Hib
3 PCV
3 Hep B
1 MMR3
1 Varicella
At Kindergarten entrance
4 DTP/DTaP/DT4
4 polio
3 Hep B
2 MMR3
2 Varicella
1
If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or after, no
additional doses are required. Minimum of one dose must be received after 12 months of age (Note: a dose 4 days or less before the first birthday is also
acceptable).
2
If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months of age or after, no
additional doses are required.
3
MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1st birthday is also acceptable).
4
Children entering kindergarten must have received one dose after the 4th birthday (either the 3rd, 4th, or 5th ) to be compliant (Note: a dose 4 days or less
before the 4th birthday is also acceptable).
COMPLIANCE DATA AND WAIVERS
STEP 4
IF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the day care center), OR
IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to day care center).

Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been received. I
understand that it is my responsibility to obtain the remaining required doses of vaccines for this child WITHIN ONE YEAR and to notify the day care center
in writing as each dose is received.
NOTE: Failure to stay on schedule or report immunization to the day care center may result in court action against the parents and a fine of up to
$25.00 per day of violation.



For health reasons this child should not receive the following immunizations __________________ (List in STEP 2 any immunizations already received)
_______________________________________________________________________________________
Physician’s Signature Required
For religious reasons this child should not be immunized. (List in STEP 2 any immunizations already received)
For personal conviction reasons this child should not be immunized. (List in STEP 2 any immunizations already received):
SIGNATURE
STEP 5
To the best of my knowledge this form is complete and accurate.
______________________________________________________________________
SIGNATURE – Parent, Guardian or Legal Custodian
_________________________________________________
Date Signed
Neenah-Menasha YMCA
CHILD PICK-UP AUTHORIZATION
Child’s Name
DOB
Name, Parent 1:
Name, Parent 2:
Home Address
Daytime #:
Cell/Alternate #:
Daytime #:
Cell/Alternate #:
Please list the full name and relationship (to child) of each person authorized to pick up your child. They must present valid
photo identification before Y staff can release the child to them.
Pick-up Person’s Full Name
Relationship to Child
Telephone #
1.
2.
3.
4.
5.
Parent
Signature_________________________________________________________________________Date_____________
Please Note: A valid Driver’s License or photo ID must be presented at the time of pick-up. Child will only be released to an authorized individual listed
above.
POST THIS IN A
VISIBLE AREA!
YMCA BEFORE/AFTER SCHOOL FAQ
Who do I contact for…?
Registration/Contract Changes/Billing/Payment Questions: Heather Landreman, [email protected]; 920.729.9950
Automatic Billing/Payment Questions: Jackie VanDeVoort, [email protected]; 920.954.7646
Program Questions/Concerns: Julie Uhe, [email protected]; 920.886.2126
Child Absence from Program: School site cell phone (see below)
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What is the cell phone number for my child’s school site?
Alliance Charter
Clayton
Coolidge
Hoover
Lakeview
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920.209.1492
920.209.1491
920.209.5974
920.209.5923
920.209.9392
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Roosevelt
Spring Road
Taft
Tullar (School)
Tullar (Church)
920.209.1492
920.209.1530
920.209.9197
920.209.0163
920.209.1448
What if my child is not coming on a contracted day?
This is very important! If your child will not attend on a day that they are contracted for you are required call the site cell phone (not the school
office or the YMCA) and leave the Y staff a voice mail. This is the only way to guarantee they will know not to expect your child. Repeated
failure to call in cancellations could result in suspension from the program. You will be billed for all days you are contracted for, whether or not
your child attends.
How do I change the days my child attends the program?
All monthly contract changes are due in writing by the 20th of the month prior to the month of the change to Heather Landreman at
[email protected]. Contract changes are NOT accepted at the school site or verbally to any staff member. It must be in writing to
Heather Landreman.
What are the program hours for before and after school care?
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Before School: 6:30 AM-start of school
After School: school dismissal–5:30 PM
Early Dismissal: 11:30 AM or Noon-5:30 PM
Vacation Days: 6:30 AM-5:30 PM
How do I sign up for Early Dismissal Days & Vacation Days?
EARLY DISMISSALS: Your child must be contracted for the specific day an early dismissal occurs in order to attend. You will incur the early
dismissal fee about one week after attendance occurs.
VACATION DAYS: Separate registration and fees required to have your child attend Vacation Days with the YMCA on select no school days
outside of before & after school care. Space is limited. All Vacation Days registrations are due to the YMCA by date given on registration form
and are subject to availability. The school sites will not accept the registration forms or payments.
What are the monthly fees?
BEFORE SCHOOL
1 day/week:
2 days/week:
3 days/week:
4 days/week:
5 days/week:
Additional Day:
Y member
$35/month
$60/month
$75/month
$90/month
$105/month
$12/day
General Public
$50/month
$75/month
$95/month
$110/month
$125/month
$12/day
AFTER SCHOOL
1 day/week:
2 days/week:
3 days/week:
4 days/week:
5 days/week:
Additional Day:
Y member
$45/month
$75/month
$105/month
$120/month
$145/month
$12/day
General Public
$60/month
$90/month
$130/month
$150/month
$175/month
$12/day
Early Dismissal:
$7/day Y member
$12/day General Public
*Vacation Day:
$30/day Y member $40/day General Public
*A separate registration form will be needed to sign up
IF YOU RECEIVE COUNTY
ASSISTANCE...
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Proof of county authorization is required before your child attends OR you must provide your own
payment information. We will credit your account once the county assistance is provided.
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Any payment that county does not cover, you are required to pay.
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Any changes to your home address, number of authorized care hours or your work hours must be
reported to the county within 10 days.
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Payment is required for all the hours you are approved for through county
o Example: If you are approved for 30 hours of child care per week, but your child only attends
25 hours that week, county will pay for the 25 hours and YOU must pay for the remaining
balance. Remember this is still in effect even if your child does not attend due to vacation,
early pick up, etc.
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IF YOU HAVE SHARED PLACEMENT THE SCHEDULE MUST BE PROVIDED TO THE Y SO WE CAN BILL THE
COUNTY CORRECTLY.
The Y is here to help you with payments. Resources for payment assistance are available and we offer
payment plans.
Questions about county assistance should go directly to Jackie VanDeVoort at 920.954.7646 or
[email protected]