1. education
2. school

FOR YOUTH DEVELOPMENT
FOR HEALTHY LIVING
FOR SOCIAL RESPONSIBILITY
SCHOOL AGE CHILD CARE &
KINDERGARTEN ENRICHMENT
REGISTRATION PACKET
ST. FRANCIS DE SALES
SPENCER LOOMIS
SARAH ADAMS
SETH PAINE
MAY WHITNEY
ISAAC FOX
Foglia YMCA
1025 N. Old McHenry Road
Lake Zurich, IL 60047
847.438.5300
/FogliaYMCA
Dear Parents:
Attached is the Foglia YMCA’s School Age Child Care Program and the Kindergarten Enrichment Program
registration packet for the 2014-2015 school year. Please fill out all paperwork and submit a $50 non refundable
registration fee if you are a Foglia member and $100 if you are not per family. This is good for the entire school
year.
All of the paperwork in the packet is mandatory, including the physical, dental examination records and birth
certificate. This paperwork is required by the Department of Children and Family Services and must be completed.
If your child attended the program for the 2013-2014 school year we have retained their physical, dental
examination, and birth certificate.
Please be sure to write legibly when filling out the packet, as this information is vital to your child’s registration. If
we cannot read the e-mail address, we cannot communicate effectively.
The first day of Before and After School Care will be Monday, August 25, 2014.
There is a mandatory one week waiting period from when you hand in the FULLY COMPLETE registration
packet to when your child can start the program.
For the 2014-2015 school year Before Care will be held at Isaac Fox for Isaac Fox students only and at May
Whitney for all other students. Students who attend Before Care at May Whitney that do not attend May Whitney
will be bussed to their respective school by District 95 busses. Before Care is held from 6:45 a.m. – 8:15 a.m. After
School Care at every District 95 Elementary School is from 2:50-6:30 p.m. After School Care for St. Francis de
Sales students runs daily from 2:15-6:30 p.m.
If you have any questions regarding our School Age Child Care Programs, please contact me at 847-410-5373 or
[email protected] or our Program Coordinator Sarah Sidell at 847-410-5393 or
[email protected].
Thank you for your interest in our programs! We look forward to your family becoming part of ours!
Sincerely,
Jenna Stanonik
School Age Child Care Director
Foglia YMCA
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KINDERGARTEN ENRICHMENT
Welcome to the Foglia YMCA Kindergarten Enrichment Program. We are pleased to offer this program in
collaboration with District 95. The program is open to kindergarten students in any district. If your child does not
attend District 95 schools transportation must be provided on an individual basis as we do not have busses from
other districts.
*When you register for Kindergarten with District 95, let them know that your child will be attending this
program so that they can coordinate transportation.*
Our morning program will run from 8:00am until approximately 11:30 a.m. The students will be picked up from the
Foglia YMCA at 11:30 a.m. by District 95 busses and dropped off at their respective schools. If your child is
continuing on in the afternoon with the School Age Child Care After School Program, they will walk down to the
appropriate room within the school and join the rest of the grades at the school site.
Our afternoon program will run from 11:30 a.m. until 3 p.m. If your child is continuing on in the afternoon with the
School Age Child Care After School Program, they will be transported back to their respective school via YMCA
busses and join the rest of the grades back at the school site.
We do not provide Before Care for students attending our AM Enrichment Program. We do offer Before Care for
students attending AM Kindergarten. For the 2014-2015 school year Before Care will be held at Isaac Fox for
Isaac Fox students only and at May Whitney for all other students. Students who attend Before Care at May
Whitney that do not attend May Whitney will be bussed to their respective school by District 95 busses. Before
Care is held from 6:45 a.m. - 8:15 a.m.
Our Kindergarten Enrichment Program is a fully licensed DCFS program and will run under its parameters. All
paperwork must be completed before admittance into the program. We will provide a catered lunch and snack for
all students. Unless your child has specific dietary needs, which will be assessed on a case by case basis, students
are NOT allowed to bring their own lunch.
The Kindergarten Program will offer a broad range of curriculum and activities based on the YMCA’s Christian
principles of caring, honesty, respect and responsibility and encourage children to achieve a healthy spirit, mind
and body. Curriculum will include, but not be limited to the following:
Independent, group and one on one reading time
Weekly Swimming
Science Enrichment
Printing
Math Enrichment
Social Development
Team Building
Group Games
Arts and Crafts
Climbing Wall
Various Physical Education Units
Centers
Thank you for your interest in our programs!
If you have any further questions please contact Jenna Stanonik at 847.410.5373 or at [email protected].
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School Age Child Care & Kindergarten Enrichment
Attendance Policy and Procedures
When you turn in your completed registration packet with all required materials you will have been asked to
designate what your child’s attendance will be in our program. This is considered your confirmed schedule. Should
you need to make changes to said schedule please refer to the guidelines below.
CHANGE OF PERMANENT SCHEDULE
In order to make a change to your child’s confirmed schedule, such as decreasing or increasing the amount of days
they attend, we require a written notice by the 15th of the month, to be effective on the following month. This
allows us to make the necessary changes to your billing as well as our attendance rosters.
ADDING DAYS
If you would like to add a day for a particular week you may do so depending on space availability. There is an
additional cost of $25.00 per day. If there is an early release day that your child is not regularly scheduled for and
you would like them to attend the program an additional cost of $30.00 must be paid.
SWITCHING DAYS
Switching the days of the week your child attends is not permitted. For example, if your child’s confirmed schedule
states that they attend Monday, Wednesday, and Friday you may not “switch” Friday for Thursday one week even
though it is still the same amount of days. You would need to add Thursday for an additional cost even if your
child will not be attending Friday. Unfortunately, we cannot refund or issue credit for missed days.
WITHDRAWAL FROM PROGRAM
If you would like to withdraw your child from our program a two week notice must be given in order to make the
necessary changes to your billing as well as our attendance rosters. There is NO cancellation fee provided you give
us two weeks notice.
ABSENCES
If your child is absent from school, or not attending our program that day, you must notify us of the absence by
1:00pm. Please call the site cell phone for the school that your child attends and leave a message if the phone is
not turned on.
Kindergarten Enrichment
224.725.8840
Isaac Fox
224.725.8193
May Whitney
224.725.8192
St. Francis
224.725.8197
Sarah Adams
224.725.8196
Seth Paine
224.725.8194 | Land Line: 847.726.2327
Spencer Loomis
224.725.8195 | Land Line: 847.719.3618
** To make any of the above changes (besides reporting an absence) please contact Debbie Siedlecki, our business
secretary, at 847.410.5368 or [email protected]. Debbie is the only one who handles payments! **
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SCHOOL AGE CHILD CARE AND KINDERGARTEN ENRICHMENT
ORIENTATION FUN NIGHT
*MANDATORY FOR ALL NEW PARTICIPANTS*
Returning participants are welcome and encouraged to attend!
WHEN
Thursday, August 7th, 2014 from 6:30 p.m. - 8:30 p.m.
6:30 p.m. - 7:30 p.m.
- Informational Meeting in the Kindergarten Enrichment Room for the parents whose child(ren)
attends the following schools: Sarah Adams, Seth Paine and Spencer Loomis
- Meet and Greet with the Staff outside underneath the back pavilion for the parents whose child
(ren) attends the following schools: Isaac Fox, May Whitney, and St. Francis
7:30 p.m. - 8:30 p.m.
- Informational Meeting in the Kindergarten Enrichment Room for the parents whose child(ren)
attends the following schools: Isaac Fox, May Whitney, and St. Francis
- Meet and Greet with the Staff outside underneath the back pavilion for the parents whose child
(ren) attends the following schools: Sarah Adams, Seth Paine, and Spencer Loomis
WHERE
Foglia YMCA – Outside underneath the back pavilion
WHY
Because we want you to become part of our family!
If you cannot make it or want more information please contact:
Kindergarten Enrichment. May Whitney Before Care, Sarah Adams, Seth Paine, & Spencer Loomis
Jenna Stanonik 847.410.5373 [email protected]
Isaac Fox, May Whitney, St. Francis:
Sarah Sidell 847.410.5393 [email protected]
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AFTER SCHOOL SWIM LESSONS AND INTRAMURAL
SPORTS
SWIM LESSONS
Added fun in the pool after school!
Swim lessons for your child with transportation to the Y. We will bus your child from their after school
site to the Y for a 4:15pm, 5:00pm, or 5:45pm lesson. Our school aged child care staff will stay with your
child until 6:30pm when out program typically ends. Due to the fact that the swim lesson schedule
changes from session to session please call member services to inquire.
Members: $80
Non-members: $160
INTRAMURAL SPORTS
This program allows your child to participate in intramurals during our after school program!
We will bus them from their school site to the Y for intramural sports which will take place on Tuesdays
and Thursdays from 4-5pm. Afterwards our program will continue to run and your child may be picked up
at the Y by 6:30pm. Our staff will supervise them while they participate in intramurals under the direction
of our Youth Sports Department and then stay with them afterwards to finish up homework, play games,
or go outside. Intramurals run according to session dates and will roughly follow the schedule below.
FALL I (August 31-October 25)
Registration begins August 5-12
WINTER
Basketball | TBD
Dodgeball | TBD
Soccer | September 2-25
Flag Football | September 30 - October 23
SPRING I
Tennis | TBD
Rock Wall/High Ropes | TBD
FALL II (October 26 - December 20)
Registration begins October 7-14
SPRING II
Soccer | TBD
T-Ball/Coach Pitch | TBD
Rock Wall/High Ropes | October 28 - November 20
Floor Hockey | November 25 - December 18
Half Session: $40 (one sport)
Full Session: $60
To sign up for either one of these great offerings please call member services at 847.438.5300 and
notify Sarah Sidell at 847.410.5393 or [email protected] or Jenna Stanonik at 847.410.5373 or
[email protected] so we know to add your child to the bus roster.
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Date Received: ____________________________________________
SCHOOL AGE CHILD CARE & KINDERGARTEN ENRICHMENT PROGRAM
2014-2015 SCHOOL YEAR
Participant’s Name: __________________________________________________________________________________________________________
School Name: ________________________________________________________________________ Grade: ______________________________
Circle One:
New Participant
Returning Participant
**Please turn in with completed packet, so School Age Child Care Staff can sign off on and place in child’s folder.
ALL PAPERWORK MUST BE COMPLETED BEFORE CHILD WILL BE ALLOWED TO ATTEND THE PROGRAM. **
REQUIRED INFORMATION
COMPLETED
Participant/Parent Information
_____________
Emergency Contacts/Authorized Pick-Up (at least 3)
_____________
Consents (2)
_____________
Days Needed
_____________
Insurance Information/Health History/Medical Release/Talent Release Form
_____________
YMCA Character Contract
_____________
Facility User/Field Trip Agreement
_____________
Developmental History
_____________
Transportation Consent (Kindergarten Enrichment Program Only)
_____________
Pick Up Agreement
_____________
Parent/Guardian Authorization and Consent for Student Records For the YMCA of Metro Chicago
_____________
Health Exam Form w/ Doctor Signature
_____________
TB Test Verification
_____________
Developmental History/Allergies (yes/no questions located on physical form)
_____________
Dental Exam Record w/ Doctor Signature
_____________
Birth Certificate
_____________
DCFS Standards (Receive and sign on first day of program for new participants)
_____________
SCHOOL AGE CHILD CARE STAFF ONLY
Initials _______________
Date ________________________
7
SCHOOL AGE CHILD CARE & KINDERGARTEN ENRICHMENT
2014-2015 PROGRAM REGISTRATION
Please complete for EACH CHILD. Return with your $50 member/$100 non-member NON-REFUNDABLE REGISTRATION FEE (per
family). Check, Money Order, and Major Credit Cards accepted.
PARTICIPANT INFORMATION
Name: _______________________________________________________________ Birth Date: ______________________ Grade: _____________
Nickname: ________________________________ Male ________ Female ________
Address ___________________________________________________________________________________________________________________________
Street
City
State/Zip
PARENT/LEGAL GUARDIAN INFORMATION
Mother (Guardian) ____________________________________________________________ Home Phone: ______________________________
Address ___________________________________________________________________________________________________________________________
Employer _______________________________________________________________________ Work Phone _______________________________
Address ________________________________________________________________________ Cell Phone _________________________________
E-mail ______________________________________________________________________________________________________________________________
Father (Guardian) _____________________________________________________________ Home Phone ______________________________
Address ___________________________________________________________________________________________________________________________
Employer _______________________________________________________________________ Work Phone _______________________________
Address ________________________________________________________________________ Cell Phone _________________________________
E-mail ______________________________________________________________________________________________________________________________
Child Lives With:  Both Parents  Mother  Father  Other __________________________________________________
EMERGENCY CONTACTS/AUTHORIZED PICK-UP
Parents are always called first. If unavailable, AT LEAST THREE (3) LOCAL NAMES ARE REQUIRED BY DCFS.
NAME
RELATIONSHIP
CELL PHONE
HOME PHONE
1.
2.
3.
4.
5.
I, ________________________________ authorize the people listed above to pick up my child and be contacted in the event of an
emergency from the _____________ YMCA. In doing so, I relieve the YMCA of Metropolitan Chicago, its centers and employees of all
responsibilities for my child after he/she has been released from the program. Attempts will be made to reach the parent/legal
guardian first. Initials ___________
UNAUTHORIZED PICK-UP: People who CANNOT pick up your child from our program:
1. Name _______________________________________________________________________ Relationship ___________________________________
2. Name _______________________________________________________________________ Relationship ___________________________________
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SCHOOL AGE CHILD CARE RATES
Rates per Month
DISTRICT 95
BEFORE CARE
AFTER CARE
BOTH
ST. FRANCIS
1 Day per Week
$57
$80
$127
$95
3 Days per Week
$157
$215
$357
$259
4 Days per Week
$168
$247
$397
$298
5 Days per Week
$192
$297
$471
$358
School Enrolled: _________________________________________________________________________________
Days Enrolled – Please Circle
AM:
M
T
W
TH
F
PM:
M
T
W
TH
F
Start date: _____________________________
The first day of Before and After Care is Monday, August 25th
KINDERGARTEN ENRICHMENT
(with Before and After Care Options)
Rates per Month
NUMBER OF DAYS
1 Day per Week
BEFORE CARE
Add $50
KINDERGARTEN
$150
BOTH
$205
3 Days per Week
Add $150
$301
$488
4 Days per Week
Add $160
$340
$554
5 Days per Week
Add $180
$400
$658
(Kindergarten and after care)
School Enrolled: _________________________________________________________________________________
Days Enrolled – Please Circle
AM Enrichment:
M
T
W
TH
F
PM Enrichment:
M
T
W
TH
F
Start date: _________________________
The first day of Kindergarten Enrichment Program is Monday, August 25th.
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INSURANCE INFORMATION
Is the participant covered by family medical/hospital insurance?  Yes  No
If yes, indicate carrier or plan name _______________________________________ Group # ______________________________________
Carrier Address ______________________________________________ City/State/Zip _________________________________________________
Name of insured ________________________________________ Relationship to Participant _____________________________________
HEALTH HISTORY
Describe any of your child’s current health conditions requiring medical attention, treatment or special
restrictions or considerations while at our program _____________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Does your child take any medications? _____________________________________________________________________________________
Does your child have any allergies, including food? _________ if so, please list _______________________________________
_______________________________________________________________________________________________________________________________________
Reaction to allergy/management of allergy ________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Are there any activities that your child should be exempted from for health reasons? ________ if yes, please
describe ____________________________________________________________________________________________________________________________
MEDICAL RELEASE
I do hereby give permission for the YMCA of Metropolitan Chicago staff to transfer child named above off
property for purpose of medical care as deemed appropriate by the Director and in the event that I
cannot be reached in an EMERGENCY, I hereby give my permission to the physician selected by the
Director, to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my
child named above. Initials ___________
TALENT RELEASE FORM
In consideration of my participation in activities to be conducted and/or sponsored by the YMCA, the receipt and sufficiency of
which is hereby acknowledged, I hereby freely and with our restraint consent to and grant the YMCA of Metropolitan Chicago and its agents,
successors, licensees, assigns, and affiliated entities (collectively, the “YMCA”) the right to publish, print, photograph, videotape, record or
otherwise reproduce my voice, appearance, opinions, statements, biographical information, name, place of residence (city and state) and
other personal information concerning me, to own all the results thereof as a work for hire for copyright purposes, and to exhibit, display,
distribute, transmit and/or otherwise exploit any and all such reproductions containing my voice, opinions, statements, appearance, and/or
other contributions, altered as the YMCA may see fit, in any and all media now or hereafter known, including without limitation by means of
internet, email, still photography, billboard, radio, television, video, soundtrack recordings, printing, merchandising, public displays,
exhibitions, and in advertising and/or publicity in connection therewith, and the right to use my name, city and state of residence in any
connection with any of the foregoing. The rights granted by my hereunder are granted for the entire universe and shall inure in perpetuity
and no further compensation shall be payable to me at any time in connection there with.
I hereby release the YMCA from any and all claims and demands arising out of or in connection with the uses stated above, including without
limitation any and all claims for libel, slander, invasion of privacy, infringement of my right of publicity, defamation, copyright or trademark
violation, and any other personal and/or proprietary rights, and I agree that I shall not now or in the future assert or maintain any such
claim against YMCA with respect to the subject matter herein. This release shall be governed by Illinois lay without regards to its conflict of
laws principles.
Signature of Parent/Legal Guardian: ___________________________________________________ Date: _____________________________
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YMCA CHARACTER CONTRACT
The goal of our Kindergarten Enrichment and Before & After Care Program is to provide an atmosphere for children
to develop a variety of satisfying skills and relationships while enjoying healthy activities. Throughout the year we
continue with our Character Development missions to develop Respect, Responsibility, Caring, and Honesty among
our participants. As a family, please read and discuss the Character Contract together.
•
•
•
•
•
•
•
Appropriate Conversation- Children will not be allowed to discuss inappropriate topics or contribute to
demeaning conversations about other children or staff.
Appropriate Language- Children must refrain from using obscene language or gestures for any reason.
Play- Children are asked not to engage in any horseplay with each other or with any staff member. No one
will be allowed to hit, push, or display any type of aggressive behavior. We will use words to settle our
differences. We keep our hands and feet to ourselves.
Respect- When asked to “do” or “not do” something, a child needs to follow directions first time given.
This is for the safety of all children. Please speak to staff & other children with courtesy and respect.
Responsibility- All children need to remain with their group and within eyesight of their counselor. This
applies here on the YMCA grounds and off-site fieldtrips. At all times we want campers to be safe.
Caring- It is important to use and care for equipment, toys, and games properly so that other children can
enjoy them. We will care for the property of the YMCA, other campers, and of YMCA staff.
Honesty- Children are asked to be truthful at all times during games, other activities, and when speaking
with their peers or counselors.
What will happen when this contract is violated: If an incident occurs where a child conducts him/herself in such a
manner which jeopardizes their safety, the safety of others, or is not in accordance with the mission of the YMCA,
the following steps will be taken.
1.) First Violation: a staff member will address and document the issue directly with the child. The child may be
removed from an activity for the day such as swimming, free time, etc. Parents will be contacted during the
day or at the end of the program depending on the time and severity of the incident.
2.) Second Violation: a staff member will address and document the issue directly with the child. The parent or
guardian will receive a phone call and may be asked to pick up their child within the hour. The child may or may
not be allowed to participate in the program the next day.
3.) Third Violation: a staff member will address and document the issue directly with the child. Parents may be
contacted immediately to pick up their child from the program. The child will be suspended for the day or week
depending on the severity of the incident.
4.) Fourth Violation: Child will be dismissed from the program for the remainder of the week.
We reserve the right at any time to dismiss your child from the program immediately if we deem unsafe placement
due to environment, physical, emotional or other harm to themselves, other children, staff and members.
The following Character Contract guidelines have been read and discussed.
______________________________________________________ ______________________________________________________
Child’s Signature
Parent/Legal Guardian Signature
11
____________________
Date
FACILITY USER/FIELD TRIP AGREEMENT
I agree to follow all rules and regulations of the YMCA of Metropolitan Chicago (“YMCA”) while in, upon or about
the premises or while using or observing the premises or any facilities or equipment, or participating in any
program affiliated with the YMCA without respect as to location, and understand to agree hat I may be expelled at
any time, with no refund of any monies paid, for failure to abide by such rules and regulations.
IN CONSIDERATION OF BEING PERMITTED TO UTILIZE THE FACILITIES, SERVICES AND PROGRAMS OF THE YMCA FOR ANY PURPOSE,
INCUDING BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT OR PARTICIPATION IN ANY PROGRAM AFFILIATED
WITH THE YMCA WITHOUT RESPECT AS TO LOCATION, I HEREBY AGREE TO THE FOLLOWING:
1. I UNDERSTAND THAT ACTIVITIES AT THE FACILITY OR ELSEWHERE, INCLUDING USE OF EQUIPMENT AND PARTICIPATION IN PROGRAMS,
CAN INVOLVE MOVEMENT, STRAIN AND OTHER ELEMENTS THAT CREATE RISK OF SERIOUS INJURY OR DEATH. I ALSO UNDERSTAND THAT
PROGRAM ACTIVITIES INCLUDE FIELDTRIPS TO LOCATIONS OUTSIDE THE YMCA PREMISES, AS DESCRIBED IN DETAIL IN THE PROGRAM
MATERIALS, AND THAT PUBLIC OR PRIVATE TRANSPORTATION MAY BE UTILIZED TO TRANSPORT PARTICIPANTS TO AND FROM THESE FIELD
TRIP LOCATIONS. I HEREBY, ASSUME FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE OR LOSS,
regardless of severity, that I or my minor child/ward may sustain from my or my minor child/ ward’s presence in, upon or about the premises
or while using or observing the premises or any facilities or equipment, or participating in any programs affiliated with he YMCA without
respect to location, or while being transported to and from field trip locations outside the YMCA premises, except for any injury, damage or
loss that is caused solely by the YMCA’s gross negligence.
2. I, FOR MYSELF, ANY PERSONAL REPRESENTATIVES, ASSIGNS, HEIRS AND NEXT OF KIN, HEREBY FULLY RELEASE, WAIVE, DISCHARGE AND
COVENANT NOT TO SUE the YMCA of Metropolitan Chicago, its operating centers, their respective officers, directors, Board of managers,
Trustees, members, volunteers, employees or agents (the “Releasees”) and each of them from any and all claims for injuries, damage or loss
that I or my minor child/ward may have or which may accrue to me or my minor child/ward from my and/or my minor child/ward’s presence
in, upon or about the premises or while using or observing the premises or any facilities or equipment, or participating in any program
affiliated with the YMCA without respect as to locations, or while being transported to and from field trip locations outside the YMCA
premises, except for any injury, damage or loss that is caused solely by the YMCA’s gross negligence.
3. I HEREBYAGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Releasees and each of them from any loss, liability, damage or cost
they my incur from my or my minor child/ward’s presence in, upon or about the premises or while using or observing the premises or any
facilities or equipment, or participating in any program affiliated with the YMCA without respect as to location, or while being transported to
and from field trip locations outside the YMCA premises, except for any loss, liability, damage or cost that is caused by the YMCA’s gross
negligence.
I further expressly agree that the forgoing ASSUMPTION OF RISK, RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as
broad and inclusive as is permitted by the law of the State of Illinois and if any portion thereof is held invalid, it is agreed that the balance
shall, notwithstanding, continue in full legal force and effect.
THIS AGREEMENT APPLIES TO ALL PAST, PRESENT AND FUTURE VISITS AND USES BY ME TO ANY YMCA FACILITY OR PROPERTY.
I HAVE READ AND VOLUNTARILY SIGNED THIS ASSUMPTION OF RISK, RELEASE WAIVER AND INDEMNITY AGREEMENT, and further agree
that no oral representation, statements or inducements apart from the foregoing written agreement have been made.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE AGREEMENT. THIS AGREEMENT CONTAINS A WAIVER AND RELEASE.
Signature of Parent/Legal Guardian ____________________________________________________________ Date ______________________
Printed Name of Parent/Legal Guardian _____________________________________________________________________________________
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DEVELOPMENTAL HISTORY OF CHILD
Please describe your child’s interaction with children of the same age: _____________________________________________
_______________________________________________________________________________________________________________________________________
How would you describe your child’s personality? ________________________________________________________________________
Does your child have and special fears that we should be aware of? ________________________________________________
_______________________________________________________________________________________________________________________________________
Does your child have any special needs that we should be aware of to better understand your child and
be able to work with your child? (Please be specific) ____________________________________________________________________
_______________________________________________________________________________________________________________________________________
KINDERGARTEN ENRICHMENT PROGRAM
TRANSPORTATION CONSENT
My child, ___________________________________________________, age ________, will be (check all that apply):
____ dropped off at Foglia YMCA for Enrichment Program by parent
____ dropped off at Foglia YMCA for Enrichment Program by bus
____ picked up at Foglia YMCA by parent by 11:30 am
____ picked up at Foglia YMCA by parent by 3:00 pm
____ transported back to ________________________________ Elementary School by District 95 Bus for Afternoon
Kindergarten
____ transported back to _________________________________ Elementary School by YMCA Bus for After Care
The school has been informed of this arrangement. I have been informed that the Foglia YMCA’s
responsibility does not begin until my child is on the YMCA’s premises or on their bus. If there is a
change in this schedule, I will inform the Foglia YMCA.
____________________________________
___________________________
_________________________
Parent’s Printed Name
Parent’s Signature
Date
13
Pick Up Agreement
The following agreement is made between __________________________________ and The Foglia YMCA After Care Staff
Parents/Guardians
Provider
for the pick-up of their child/children
care home/day care center.
_______________________ from the day care home/group day
Name
I/We agree to pick up the above named child/children before 6:30 o’clock p.m.
every day he/she/they are in child care except for early release days when the
program ends at 6:00 o’clock p.m.
If I/We fail to pick up our child/children by the appointed time, I/we understand that a late fee of $15.00 per
quarter hour (or portion thereof) will begin to accrue after the above stated pick up time.
If I/We fail, without notice, to pick up my/our child/children at the above stated time, or arrange for someone else
to pick them up, the provider will make 3 attempts to contact me/us. If the provider is unable to contact me/us, the
provider should contact the emergency person listed on the Application/Record of Child Information sheet, or
persons on the contingency list, to advise them my/our child/children are still in their care without notice from me/
us. If, for any reason, there is no telephone service the provider will contact police to request assistance in
contacting me/us or my/our emergency persons.
Provider agrees to keep my/our child/children for 1 hour after the above stated pick-up time, with late fees
accruing, before contacting the local police and/or the Child Abuse Hotline if contact cannot be made with parents/
guardians or emergency persons.
Provider will continue normal responsibilities for the child’s protection and well being and agrees not to discuss
your tardiness in arriving with your child/children beyond reassuring them you, or someone known to them will be
there soon to pick them up.
Parents/Guardians agree to advise provider immediately of any changes regarding their personal contact
information, including addresses and phone numbers for home and work and cell phone numbers. Parents/
Guardians also agree to provide immediate notice to the provider of any changes for their emergency contact or
contingency persons.
________________________________
Parent/guardian
________________________________
Provider A
________________________________
Parent/guardian
________________________________
Provider B
____________________
Date signed
____________________
Date signed
This form meets the requirements of Rule 406.12 (h) and Rule 408.60 (j)
14
Foglia YMCA
2014-15 Draft Agreement
FOR YOUTH DEVELOPMENT
FOR HEALTHY LIVING
FOR SOCIAL RESPONSIBILITY
Dear Parents,
In years past we have sent out billing coupons that you received at the beginning of the school year
and you would make your monthly payments using those. This year we are moving away from that and
ask that you participate in our payment drafting program. If you are unable to participate in automatic
draft you will receive monthly invoices which will represent one-ninth of the total fees due, plus any
additions or any past due balances (the entire school year is divided into nine equal payments). Your
monthly payment is due by the 1st of each month. Your last payment for the school year will be due
May 1, 2015.
If you are interested in participating in our payment drafting program please complete the bottom
portion of this letter and return it to the attention of Debbie Siedlecki no later than August 15th.
You will be authorizing a monthly charge to your Visa, Mastercard, Discover, American Express, or
checking account. If electing a draft from a checking account, please attach a voided check. Your
first auto draft will be on 9/1/14.
Membership #
Credit Card Payment Drafting Agreement
I,
, (parent) agree to participate in the payment drafting
program for the 2014-2015 school year for fees due for my child/children named below:
Name of Child
Name of Child
Name of Child
$
Monthly amount to be drafted the first of each month, September 2014 - May 2015
Credit Card #
Exp Date
Signature
Date
15
3 Digit Code
Foglia YMCA
2014-15 Payment Agreement
FOR YOUTH DEVELOPMENT
FOR HEALTHY LIVING
FOR SOCIAL RESPONSIBILITY
We are thrilled that you have chosen to enroll your child in our child care program at the YMCA!
To ensure proper communication, we have outlined our policy related to child care payments. If
you have questions, please feel free to contact Jenna Stanonik at 847.438.5307.
PLEASE READ CAREFULLY, SIGN AND RETURN WITH YOUR FIRST PAYMENT
1. A registration fee is due at the time of registration to reserve your spot if you wish to enroll
your child. The amount of the fee is dependent upon the program and YMCA membership status.
2. Registration fees are non-refundable or transferable.
3. We ask that you sign up for automatic draft payments. You will be provided a draft letter with your
first billing. Fees are drafted the 1st of each month of service. There will be 9 monthly drafts with
the first being September 1 and the last draft being May 1.
4. If for some reason you cannot do automatic draft, you will be billed on approximately the 15th of
each month for the following month and your payment is due on or before the 1st of that month.
For example, you will receive on approximately October 15 your bill for the month of November, with
payment due on or before November 1. There is a $10 late payment fee if the payment is not paid on
or before the 1st. If fees are not paid by the end of the month before the new month begins, your child
will not be allowed to attend until fees for that month are paid in full.
5. Kids Day Off school programming is not included in the price but we do offer Kids Days Off on most
days school is not open. Those days need to be registered and paid for at the front desk.
6. If you wish to cancel your child’s enrollment you must give two weeks paid notice.
7. There is a $25.00 fee due for all NSF checks. The missed payment and the NSF fee must be made with
cash, credit or a money order. After two NSF checks, personal checks will no longer be accepted for
payments.
8. There are no credits or refunds for missed days except for medical absences of one week or more and
must be accompanied by a doctor’s note.
I have read and understand the above statements. I fully understand my responsibility for payment of
my child’s fees. I also understand that my child may be released from the program if I have not met my
financial obligations.
Child’s Name
Parent’s Signature
Date
16
1
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