YMCA of Western North Carolina Corpening Memorial Center AFTERSCHOOL 2013-2014 REGISTRATION CHECKLIST

The following information must be received before a child is able to start the program. Please note that many programs fill quickly, and early registration is recommended. There is a one week waiting period from the date the completed application is received until the date the child is able to start the program. Incomplete forms can delay a childs start date.
Forms Youth Information Form You are required to complete a new Youth Information Form annually. Please note that we cannot use the form from the previous school year. We CAN use your 2013 Summer Day Camp form for the upcoming school year per your request when you register for Afterschool. Discipline and Behavior Management Policy Afterschool Policy Signature Form Mobile Alerts Form Field Trip Permission Form

Bank Draft Authorization Form Payments are by bank draft only. Draft dates and information is listed below. Individualized Care Plan Needed only If your child will be taking a medication while at Afterschool programs Current Copy of Immunization Record We can use the immunization record on file if the information is the same and there are no updates. Current Photo of Child (please place on the Youth Information Form in the spot labeled photo.) *Child Care Subsidy Vouchers Attached (optional) *YMCA Financial Assistance Application Attached (optional) Registration Fee and Payment The Registration Fee is Due at Time of Registration and must be paid separately from bank draft.

Registration Fee: $35 per child Weekly Payment: $45 Members

or

$50 per family

$55 Non-Members

Payment Method: Bank Draft Only. Drafted on the 1st and 15th of each month at $90 per child for Members and $110 per child for Non-Members. Please attach voided check or copy of credit card to be used. Total Payment Amount Enclosed $ ______________

2013-2014 Corpening Memorial Center Youth Information Form

This youth information is effective for the 2013-2014 Afterschool Program.

Childs Information
Childs name________________________________________________________ Nickname _____________________________ Address _______________________________________________________ City ________________________ Zip ________________ _____ Male _____Female Birth date ________________ Age (as of Aug. 2013) ________ Ethnicity _________________

School child attends during school year _______________________Grade (as of Aug. 2013) ________________ If the Afterschool Program closes due to inclement weather, my child will: _____ Ride the school bus home _____ Picked up by a parent at school

Allergies (please be specific and note level of severity, etc.): __________________________________________________________________________________________ Current Medications (please note all medications AND complete the Individualized Care Plan if meds will need to be administered at the Y program): ______________________________________________________________________________________________________________________________________________________________________ Special Needs/Disabilities (please complete the attached Individualized Care Plan Form):______________________________________________________ What are activities that your child would enjoy while at Afterschool:_______________________________________________________________________________ What are your expectations for the Afterschool/Summer Camp program?_________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________ Names and Ages of Siblings: _________________________________________________________________________________________________________________________________ Swimming Ability (check one): _____ Non-Swimmer _____ Beginner _____ Intermediate _____Advanced

Family Information (List both parents/guardians AND check the one parent/guardian completing this form to contact for payments and questions.
___ Parent/guardians name _________________________________________________________ Employer ________________________________________________________ E-mail address ________________________________________________________(please provide the email address that we may use for contacting you) Home address _________________________________________________________ City _________________________ Zip _____________ Home # _______________________ Work # _______________________ ext. ___________ Mobile # __________________________ ___ Parent/guardians name _______________________________________________________ Employer ____________________________________________________________ E-mail address ________________________________________________________(please provide the email address that we may use for contacting you) Home address _________________________________________________________ City __________________________ Zip _____________ Home # ______________________ Work # ________________________ ext. __________ Mobile # __________________________

Emergency Information(If you do not have a doctor/dentist, please list Buncombe County Health Department or another provider of your choice. All
information is REQUIRED, including hospital name.) In case of emergency, please contact the following first: ____Mother/Guardian ___Father/Guardian

Childs doctor ________________________________________________________________________ Doctors phone # ___________________________ Childs dentist ________________________________________________________________________Dentists phone # ___________________________ Hospital preference ___________________________________________________________________________________________________________________ Insurance company ____________________________________________________________________ Policy # ____________________________________

Emergency Contact Information

When a parent/guardian is not available, I authorize these individuals to pick-up my child:
1. Name _________________________________________________________________________Relationship to child ________________________________________ Home # ____________________________ Work # ________________________________ ext. ____ Mobile # _______________________________ 2. Name _________________________________________________________________________Relationship to child _________________________________________ Home # ___________________________ Work # ________________________________ ext. ____ Mobile # ________________________________ 3. Name _________________________________________________________________________Relationship to child __________________________________________ Home # ___________________________ Work # ________________________________ ext. ____ Mobile # _______________________________ 4. Name _________________________________________________________________________Relationship to child ___________________________________________ Home # __________________________ Work # ________________________________ ext. ____ Mobile # ________________________________

Corpening Memorial YMCA Afterschool Program Discipline and Behavior Management Policy
To be completed and placed on file prior to enrollment

The YMCA staff will use positive behavior management techniques that are developmentally appropriate and adhere to the YMCAs Four Core Values of Caring, Honesty, Respect, and Responsibility. The use of corporal punishment is strictly prohibited.
Behavior Management Techniques YMCA Staff will 1. Involve the children in the development of the house rules. 2. Maintain consistent behavior expectations and reinforce the YMCAs Four Core Values. 3. Guide children by setting clear, consistent, fair limits for program behavior. 4. Use natural and logical consequences. 5. Redirect children to a more acceptable behavior or activity. 6. Use positive reinforcement, including a positive behavior recognition program. 7. Make eye contact and listen when children talk about their feelings and frustrations. 8. Guide children to resolve their own conflicts through the use of conflict resolution skills. 9. Use effective praise that is immediate, sincere and specific. 10. Modify and structure the environment to attempt to prevent problems before they occur. Discipline Action Steps YMCA staff will utilize the following forms of discipline 1. Personal Time removal of child from a situation for up to 5 minutes so they can regain control of their behavior. 2. Verbal or written communication to parent/guardian regarding a childs behavior. 3. Behavior Write-Up A childs behavior may result in the child being given a behavior write-up. Three behavior write-ups in any school year will result in the suspension of the child. The parent/guardian is responsible for contacting the site director to set-up an appointment to discuss the childs behavior. If the child is reinstated and then receives a fourth behavior write-up, the site director will suspend the child immediately and termination from the program may result. 4. Behavior Action Plan/Improvement Plan 5. Suspension Serious behavior problems will result in immediate suspension, and you will be responsible for picking up your child immediately. 6. Termination - The YMCA After School Program cannot serve children who display chronically disruptive behavior. Chronically disruptive behavior is defined as verbal or physical activity which may include, but is not limited to, the following: behavior that requires constant attention from the staff, behavior that inflicts physical or emotional harm on other children or self, behavior that abuses the staff and/or ignores or disobeys the rules. If a child cannot adjust to the program setting and behave appropriately, the child may not be able to return to the program. Reasonable efforts will be made to assist children in adjusting to the program setting. I, the undersigned parent or guardian of ___________________________________________ (childs full name), do hereby state that I have read and received a copy of the facilitys Discipline and Behavior Management Policy.

Signature of Parent or Guardian _______________________________________________________ Date _________________

2013-2014 Corpening Memorial YMCA Afterschool Policy Form

Parents/Guardians, please read each area below carefully. Your signature on this document indicates your acknowledgement,

understanding, and agreement with all policies of the YMCA of Western North Carolina.
Policies/Procedures, Childcare Laws I have received a copy of the policies/procedures in the Afterschool Parent Handbook and agree to all policies. I have also received a copy of the North Carolina Child Care Law and Rules in my Registration Packet from the YMCA. Attendance, Payment Deadlines, Refunds, and Late Payments I understand that I am to notify my childs Site Director when he/she will be absent on scheduled days so that the YMCA staff know my child is safe. I understand payments are due in full by the deadlines outlined in the Parent Handbook regardless of absenteeism and weather related closings. Any deposits and other fees paid are non-transferable and will not be refunded due to cancellation. If drafts or checks are not honored you are still responsible for the payment plus a $30 service charge applied by Federal Automated Recovery System. If there is an outstanding balance on your childs account, your child(ren) will be unable to attend any YMCA program. Weekly Deposit and Registration Fees A one-time nonrefundable and non-transferable registration fee of $35 per child, $50 per family is due at the time of Summer Camp AND Afterschool Registration. Payment of a separate registration fee is required for both programs. YMCA Financial Assistance I understand that I am responsible for the full program fee, until a YMCA representative has contacted me regarding the amount of financial assistance I am eligible for. Subsidy Voucher Participation I agree to notify the YMCA of any changes in my subsidy voucher status and to abide by the rules set forth by the issuing agency. All subsidy voucher participants are responsible for paying the rate discrepancy between what the YMCA charges and what the voucher will reimburse. The parent/guardian is responsible for any payment for child care not covered by the voucher. Emergency Treatment/Emergency Transportation I agree that the operator, YMCA of Western North Carolina, may authorize the physician of their choice to provide emergency care in the event that I cannot be contacted immediately. I authorize for my child to be transported in the case of an emergency when medical attention by a physician is necessary. I understand that the YMCA will not transport children in their personal vehicles at any time and a hospital or fire/emergency department will always be contacted. I, as the operator YMCA of Western North Carolina, do agree to secure transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the ph ysician or the childs parent, guardian, or full-time custodian. Provisions will be made for adequate and appropriate rest and outdoor play. Field Trips/Transportation I permit my child to leave the YMCA on authorized trips under the supervision of the YMCA staff. A written schedule of all activities to be conducted off the YMCA Camp premises will be posted for parents to review. By signing this form, you give your child permission to be transported in YMCA vehicles. Activities Outside the Fenced Playground Area I hereby give permission to the YMCA of WNC for my child to participate in developmentallyappropriate supervised activities outside the fenced playground at the Corpening Memorial YMCA location. I understand this statement is required to be signed for licensing and that this space is still on the YMCA property. Sunscreen: (initial the appropriate statement) ______ I allow YMCA staff to provide sunscreen for my child (sunscreen product information available by request). ______ I will provide sunscreen for my child in an individual bottle labeled with their name and grade (given to a YMCA staff) School Success I understand that the YMCA works with the McDowell County schools to develop and deliver activities that engage and impact children. I give permission for YMCA staff to talk with school staff in regards to my childs grades, behavior and other information. Behavior Management Policy: I have read and signed the Behavior Management and Discipline Policy in the Registration Packet and agree with all policies as outlined. Registration Paperwork Signature on this document indicates responsibility for payments and is the only one who can alter the forms. I understand that if I do not fill out the Registration Packet completely, or fail to attach any of the required documents, my child will not be able to attend the program until complete. YMCA Statement I hereby, for myself, my family, heirs, executors, and administrators, waive and release any and all claims and damages I may have against the YMCA of Western North Carolina and their respective agents, representatives, successors, and assigns, for any and all injuries which may be suffered by me or my family in connection with participation in YMCA activities and programs. I agree to adhere to all policies as outlined on this policy/signature page. I also grant full permission to the YMCA to use any photographs or video recording taken of me or my family. I agree to comply with YMCA policies and procedures and understand that my participation can be terminated without refund for exhibiting inappropriate behavior or abuse toward the YMCA staff and/or facilities. Parent/Guardian Name:__________________________________________________________ Parent/Guardian Signature:____________________________________________________

(please print)
Childs Name:________________________________________________________________________ Date:________________________ Signature YMCA Representative:

Hali Colligan, Angela Strickland, Tim Blenco and Paul Vest

Date: August 2013-June 2014

CORPENING MEMORIAL YMCA AFTERSCHOOL ~ MOBILE ALERTS

As part of the registration process, we now require you to complete this form with updated information to ensure proper receipt of texts.

First Name: _________________________________________ Childs Name:_______________________________________

Last Name: _________________________________________

Address: _______________________________________________________ City: _____________________________________________ State: __________ Zip Code: ____________________ Email: __________________________________________________________ Mobile Phone #: ( ) _________ - ___________________ Mobile Phone Carrier: ______________________________

Parents DOB (Month, Day, Year): __________________________ Member of YMCA?: (Please circle) YES NO

_______________________________________________________________________________________________________________________

By signing below, I certify that I am over the age of 13 (Children s Online Protection Act) and that I understand that by signing up for these alerts, standard message rates may apply depending on my wireless plan.

Signature: ___________________________________________________

Date: ______________________________________

PERMISSION SLIP FOR FIELD TRIP

Childs Name________________________________________________________________

I give permission for my child to attend all field trips

(August 26-June 13)

during the Corpening YMCA Afterschool Program.

Parent/ Guardians name: __________________________________________________ I can be reached at (______) ________________________, during the hours of your scheduled field trips.

Signature of parent/guardian

________________________________________

______________

date

---------------------------------------------(Cut along this line and KEEP THIS HALF)

PERMISSION SLIP FOR FIELD TRIP

Corpening YMCA Afterschool Program 2013-2014

Afterschool has special field trips planned for special schools out anf half days during the school year. We would like to have your permission to take your child off site in a YMCA bus for these trips. Contact numbers in case of Emergency:
Angela Strickland: 828-659-9622 or Hali Colligan: 828-775-1852

Method of Travel: YMCA BUSES Driver(s): Our Trained Staff (All staff attends Driver Training before camp begins.)

To give permission, please sign the top half of the permission slip and take the bottom half for your records.

YMCA OF WESTERN NORTH CAROLINA Corpening Memorial YMCA - Afterschool Program 2013-2014
DRAFT PAYMENT FORM Childs Name__________________________________________ Please Note: MEMBER: $45 per week NON-MEMBER: $55 per week
This form is for Bank Draft participants that plan to use a savings, checking, or credit card draft for their payment option. Drafts occur on the 1st and 15th of each month at $90 (members) and $110 (nonmembers). Please note that drafts will not begin until September 1 st and an alternative payment option is required for the first payment.

CREDIT CARD/BANK DRAFT INFORMATION Credit Card Draft Information Type of Credit Card: Visa MasterCard Discover AMEX Expiration Date ____________________ Name on Card__________________________________________ Credit Card Number ____________________________________________________ (please include 3 digit code on back of card) ____________

Bank Draft Information Please attach a voided check. Name of Bank ___________________________________________________ Name of Account Holder ________________________________ Routing Number _________________________________________ Account Number ________________________________________

I authorize the YMCA of Western North Carolina to draft twice a month from my account. I understand a different payment method is required for the first payment and registration fee. Should my draft not be honored for ANY REASON, I realize that I am still responsible for that payment plus a $25 service charge applied by E-Cash Flow. This is in addition to any service fee I may be charged by my financial institution. E-Cash Flow will automatically electronically debit the account when funds become available. I understand that my child(ren) will be unable to attend the program until my past due balance is paid.

________________________________________ (PRINT NAME)

____________________________________________ (SIGNATURE)

_________________ __ (DATE)

YMCA of Western North Carolina Corpening Memorial Center Individualized Care Plan Form
This form will be utilized when a parent/guardian has indicated on the Youth Information Form that their child will be taking a prescription medication, has a special need and or disability while participating in the YMCA program. CHILDS NAME: ______________________________________________ CHILDS DATE OF BIRTH _______________________

Name of Prescription Medication to be taken at the YMCA:____________________________________________ Expiration Date: _____________ Time to Be Taken and Frequency: ____________________________________ Dosage Amount ________________Beginning Date: ____________________ Ending Date: ________________ Special Instructions: ____________________________________________________________________________

Possible Reactions: _____________________________________________________________________________ Prescribing Provider: _______________________________________ Phone: ____________________________ Pharmacy: ________________________________________________ Phone: ____________________________ I give the YMCA staff authorization to give medicine noted above and to call the health care provider if needed. Parent/Guardian Signature: __________________________________________ Date: _____________________

Parents/Guardians - Please note special needs, concerns and/or disabilities that are important for our staff to be familiar with prior to your childs admittance into the program Please be specific. _______________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ If the YMCA staff and/or the parents/guardians feel it is necessary, a meeting will be scheduled in advance to discuss specific information. The YMCA program welcomes all children to the extent that it is reasonably able to do so. A child who requires measures that constitute a fundamental alteration to the program or other undue hardship, or a child that poses a direct threat to the health and safety of others, will not be able to participate in the program. All children, regardless of their circumstances, are subject to YMCA disciplinary procedures. ____________________________________________________________________________________