The Boys & Girls Club by 8g7js2


									   The Boys & Girls Club
     of Saint John, Inc.
   After-school Program

Written Statements of Service
            2012– 2013

                         Revised Aug, 2012
                              THE BOYS & GIRLS CLUB OF SAINT JOHN, INC.

The Boys & Girls Club of Saint John is a voluntary, non-profit, youth serving, recreation
organization which has been in existence since 1900. The Club is the first recognized Boys &
Girls Club in Canada and is just one of over 100 Clubs across the country. The Saint John
Club has an annual membership of approximately 1800 youth between the ages of 2 – 17
years in a variety of programs and services.

                             BOYS AND GIRLS CLUBS - MISSION STATEMENT

         To provide a safe, supportive place where children and youth can experience new
opportunities, overcome barriers, build positive relationships and develop confidence and skills
                                             for life.

                                 BOYS AND GIRLS CLUBS - CORE VALUES

         - Inclusion & Opportunity
       We strive to offer children and youth from all economic, cultural and social backgrounds
access to the resources, supports and opportunities that will enable them to overcome barriers and achieve their
positive potential in life.

       - Respect & Belonging
       We provide a safe, supportive place, where every child is listened to, treated with respect and valued in an
environment of inclusion and acceptance. Our staff and volunteers model honesty, fair play, positive attitude,
cooperation and respect for self and others.

        - Empowerment
       We believe all young people can grow into responsible, contributing and self-reliant members of society.
Children and youth are at the center of everything we do. Through adventure, play and discovery, we encourage
and empower them to develop healthy lifestyles, a life-long passion for learning, leadership and a sense of social

        - Collaboration
        We work together with families and volunteers in each community, in partnership with government and
other organizations, to create healthy community solutions to providing children and youth with what they need for
optimal development.

       - Speaking Out
       We speak out on behalf of children, youth and their families to reduce disadvantage, enhance their lives
and enable their voices and ideas to be heard.


The Boys & Girls Club of Saint John, Inc.’s, after-school program is legislated by the Child Day
Care Facilities Operator Standards developed by the New Brunswick Department of Family
and Community Services (Social Development). Our philosophy is to provide an environment
that is guided by the Government of New Brunswick and by the Boys and Girls Clubs of
Canada Mission Statement, core values.


To provide the highest quality childcare services which are accessible to the citizens of Saint
John and surrounding areas.

   - To promote healthy lifestyles through daily activity and encouraging healthy eating.
   - To foster the learning, growth and development of program participants by allowing for the
     development of responsive, quality relationships with program staff.
   - To provide a safe and caring environment where participant’s well being is secured.
   - To provide an environment where participant’s emotional health, physical health, positive self
      identities and sense of belonging are nurtured and protected.
   - To stimulate the development of communication, social and cognitive skills of each participant.
   - To foster an environment which is socially inclusive and culturally sensitive in which
   consideration for others, inclusive, equitable and democratic practices are used and social
   responsibility is nurtured.
   - To promote the involvement of parents in the development of their children within the childcare

                                        PROGRAM CONTENT

The After-school program provides a wide variety of activities, keeping in mind each child’s
experiences, development, strengths and interests. Daily/weekly schedules will be posted on the
After-school bulletin board and copies will be sent home with the youth. The weekly program will be
provided in an open and flexible environment where playful exploration, problem solving and
creativity are encouraged and planned. The program will be offered in an intellectually, socially and
culturally engaging environment where communication, literacy and respect for diversity is valued and

Children will be grouped by ages/grade level (ie. K-2, 3-5) with a child to staff ratio that allows for
some individualized attention. Procedures are in place that allow for flexibility in groupings of children
due to personality conflicts, developmental stages or special needs.

Programming opportunities will provide for personal choices and allow for personal creativity through
active and quiet play, indoor and outdoor play, group and individual activities, structured and open
ended activities and snack time. Areas of programming will include playground, gym activities, out-
trips, science, drama, cooking, self-development activities, arts & crafts, board games, puzzles,
music, homework assistance, computers, video games, movies, community projects and special

                                       HOURS OF OPERATION

The After-school program operates throughout the school year, Monday to Friday from 1:30pm to
6:00pm. Additional 7:30am-8:30am service available (must sign up for this option). Service is also
provided from 8:00am to 6:00pm on school closure days (for example: professional development
days). Unfortunately, this only applies to schools in District 8. Every attempt will be made to offer the
After-school services on storm days when schools in District 8 are closed. In the event of severe
weather and the Club is forced to close, the cancellation announcement will be aired over the radio
stations no later than 6:45am.

The Club will be closed on the following statutory holidays:
- New Year’s Day                    - Canada Day               -   Remembrance Day
- Good Friday                       - New Brunswick Day        -   Christmas Eve (close at 1pm)
- Easter Monday                     - Labour Day               -   Christmas Day
- Victoria Day                      - Thanksgiving Day         -   Boxing Day
                               FEE STRUCTURE/PAYMENT SCHEDULE

Administration Fee: $25.00 per child
                    Due upon registration to confirm your spot!

Full time fee: (those who attend 4 or 5 days per week)
               Please Note: Fees are based on registration, not attendance
               $70.00 per child per week
               $125.00 for two children per week
               $155.00 for three or more children per week

Part time Registration: (those who attend 3 days or less per week.)
                           Fees are based on attendance
             1 child        $14.00 per day
             2 children     $25.00 per day
             3 or more      $31.00 per day

Full Days (School closure days)                    Early Morning Drop off/Light Breakfast Service
Open 8:00am – 6:00pm                               Open 7:30am-8:30am (Transport children to school)
              1 child       $25.00                 1 child – Additional $30.00 per week
              2 children    $41.00                 2 children – Additional $45.00 per week
              3 or more     $52.00                 3 or more – Additional $60.00 per week


                                           LATE PICK UP FEE

The program finishes at 6:00pm. Parents who are late picking up their children will be charged a late
pick up fee of $5.00 for every 10 minutes after 6:00 PM, this fee will be added to your weekly
bill. Program staff do understand that delays are at times, unavoidable, if this happens, please call
the Club to let us know you are running late, otherwise, we would appreciate children being picked up
on time.

                             ENROLLMENT AND DISCHARGE PROCEDURES

The After-school program is open to all school aged children. Registration is based on the first come, first
served rule. Registration may be denied due to some restrictions including bus/van pick up capacity, number
of program participants (max. licensing is 120) and/or payment history. Participation in the program may begin
only upon proper completion of all required forms and payment of registration fee.

Two weeks paid notice is required should your child’s enrollment need to be cancelled. The Club
reserves the right to cancel a part time placement in lieu of a full time registration. The Club reserves
the right to cancel a child’s placement if deemed necessary. Two weeks notice will be given where


Our program is licensed by the Department of Social Development. With licensing we are given a
number of childcare spaces. The number of spaces is determined by floor/play space per child.
When you register your child in our Center, you are buying a space. That space is your child’s and
cannot be given to another, until your child is no longer attending. Therefore, you are financially

Parents of children attending the Afterschool Program will be required to pay the regular weekly
rates during Christmas Vacation and March Break (starting in 2012-2013) if your children are
here or not. Parents of children who do attend during Christmas Vacation and March Break will be
charged according to the full day rates. Refunds are not considered.

Payments – A TWO WEEK ADVANCE PAYMENT IS REQUIRED. Then payments are due every
Monday thereafter, paying for one week at a time. Accepted forms of payment are: cash, debit, pre-
authorized debit, visa, master card or pre-authorized visa or master card.
If payments are not received when due, this will result in an immediate suspension of services
until the fees have been paid. In this event, the parent will have to set up a convenient time to
make payment arrangements with the Director of Finance.
(Forms are attached for set up of pre-authorized bank and credit card debit).

Social Development Funding - Parents are solely responsible for child care fees until such time that
Notification is received from Social Development stating that the parent is to receive Day
Care Assistance. After Notification has been received, the parent’s account will be credited
in the amount of the assistance to be received. This policy also applies to renewals.
Services are suspended if payment is not received when due.

NSF Pre-authorized Debit - Should this happen, you will have five (5) business days to correct this
default of payment. There will be an additional charge of $20.00 for NSF Pre-authorized Debit.

Receipts - Receipts are issued annually for income tax purposes upon request. Annual
receipts are held back in the case of a delinquent account.

                                  NOTICE OF TERMINATION
At least two (2) weeks written notice must be given before the date the child is expected to be
withdrawn from our programs. If not, those two (2) weeks will have to be paid for, even if your

         THE BOYS & GIRLS CLUB OF SAINT JOHN, INC. EasyPay Program

Pre-Authorized Debit (PAD)

I authorize The Boys & Girls Club of Saint John, Inc. to debit my bank account (attach void cheque) for my payment of
$__________ on the Monday of each week for the following program:

Please circle the program entitled to payment:
General Operating / Daycare / Hot Lunch / Afterschool / Evening Youth / Summer Program / Capital Campaign

These services are for (check one)                                  ___ Personal                       ___ Business

You may revoke your authorization at any time in writing, at least 10 days prior to the next scheduled debit. To obtain a sample cancellation form,
or for more information on your right to cancel a PAD agreement, contact your financial institution or visit

Signature                            _________________________________

(Please print)
Name                                 _________________________________

Address                              _________________________________

Telephone                            _________________________________

Date                                 _________________________________

You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for

any debit that is not authorized or is not consistent with this PAD Agreement. For more information on your recourse rights, contact your financial

institution or visit

Please pass in completed form:                                                        or               by fax:          506-648-0804
The Boys & Girls Club of Saint John, Inc.
P.O. Box 2441
Saint John, NB E2L 3V9

                        PRE-AUTHORIZED PAYMENT FORM
                       PAYMENTS BY VISA OR MASTER CARD

                                 ***Please print clearly***

           Parent’s Name: ________________________________________________
     Child(rens) Name:______________________________________________

Program (please circle): After School / Daycare / Evening Program /
                         Summer Program

Credit Card #: _______________________________ VIN#_____

Expiry Date: _________ Name on Card: ___________________

Weekly pre-authorized payments: Monday of each week

Parents Signature: ________________________________

School pick up service is provided by the Club’s mini bus and vans. Pick up service depends on
school dismissal times, order of registrations, vehicle capacity and time restraints. Every attempt will
be made to accommodate those in need of this service; however, parents may be able to discuss
arrangements with the school board to have their child dropped off near the club on a school bus.
Please note: in case of severe weather or unforeseen circumstances, staff vehicles may be used as
a method of transportation. Any staff vehicles that will be used will have proper insurance coverage,
booster seats and seatbelts. Parents must notify the office no later than 1:00pm if their child is
not attending that day. Failing to notify the Club causes delays in pickups and inconveniences all
children and schools who are waiting. Those who fail to notify the Club run the risk of losing
transportation services or their spot in the program.

The Club does not support the use of taxis or other transportation companies as a transportation
method for children to or home from the Club. The transportation waiver in this package must be
completed stating that the parent is assuming all responsibility for the use of this method of
transportation should parents decide to utilize this method of transportation.

The law now states that every child under the age of 9 or under 80 pounds or under 4ft 9inches tall
requires a booster seat for any transportation. The Club has a number of these in each vehicle. Any
parent who may have an extra booster seat and is willing to lend it or donate it to the Club, it would
be greatly appreciated.

                                       PARENTAL INVOLVEMENT
The Boys & Girls Club recognizes that families have the right and the responsibility to make child
care choices for their children. Parents are an essential source of expertise with respect to their own
children and are strongly encouraged to be actively involved in planning for the inclusion and
development of their children within the after-school program. Parents/Guardians and other
caregivers are invited to visit the program at any time during operating hours when their child is
present. Parents and children are also encouraged to visit the Club at least once prior to enrollment
in the program. To find out more, talk to the After-school supervisor. The Club maintains an “open
door policy” with regards to parental involvement, however, we do reserve the right to limit parental
involvement should the situation warrant. Should a situation arise where it is felt that a
parent/guardian is harassing a staff member, corrective action will be taken to sort out the situation.
Harassment, cursing at staff or other derogatory behaviors will not be tolerated.


Parents should feel free to discuss any situation with their child’s counsellor(s), staff are more than
willing to assist with any concerns that may arise. In the case of a disagreement or unresolved
concern, please discuss the matter with the After-school Program Supervisor. If an agreeable
solution cannot be reached, please talk to the Program Services Manager. Serious complaints or
grievances should be put in writing and addressed to the Program Services Manager.

                                   ADMINISTRATIVE STRUCTURE
Program Services Manager– Sandra Voutour                Executive Director – Debbie Cooper
After-school Program Co-ordinator – Nancy Robichaud

                                   OFF SITE ACTIVITIES/OUT-TRIPS

The after-school program provides a large number of out-trip opportunities for participants. A
schedule of out-trips will be posted on the information board and notices will be sent home. Parents
will be requested to sign an off-site consent form to allow children to participate in off-site activities.
Activities such as daily walks or neighborhood playgrounds are considered part of the regular

Transportation to and from out-trips may include walking, use of the Club bus or van, a rental vehicle
or staff vehicles. All vehicles will have proper insurance coverage and drivers will hold appropriate

                                       PERSONAL BELONGINGS

Please label any and all items brought to the after-school program with the child’s name. Sweaters
with drawstrings or very loose clothing are not recommended due to the risk of playground choking
hazards. Participants are not allowed to bring toys or valuables such as game boys, trading cards,
psp’s, games, etc. due to the risk of loss or theft. If these items are brought, they will be locked up
until the child is picked up. Money and other valuables should be given to the child’s counsellor upon
arrival for safe keeping. For younger children, a change of clothes can be left at the Club in case of

                                          OUTDOOR PLAY
All children should come prepared for daily outdoor play regardless of the weather in the
morning. Daily outdoor play will only be cancelled due to very wet or very cold conditions.

                               SNACKS/LUNCHES AND OTHER FOOD

The Boys & Girls Club’s After-school program is peanut free. Some participants have severe
allergies to peanut butter and other nut products. These items are not allowed to be brought to the
Club. A snack break will be scheduled daily for all age groups. Please send enough snacks for your
child each day as the Club does not provide snacks for after-school participants. The Club policy for
this program is that only healthy choices will be sold in the canteen and parents are strongly
encouraged to send healthy snacks. Also, although it is appreciated, we are not allowed to accept
homemade baked goods such as cakes or muffins, etc. Any such items must come from an
approved kitchen. Please talk to the After-school Director for more information.

For full days, when schools are closed, participants must bring a lunch and enough snacks for
the day. Kitchen services are not available and we do not provide lunch on these days. A microwave,
fridge and stove are available for lunches brought form home.

                                    CHILD PICK UP PROCEDURES

Children will only be released to parents/guardians or anyone who is listed as an alternate on the
child’s form. Parents are expected to notify the staff if any changes occur in this list. Identification
will be requested from anyone who is unfamiliar to the staff. Parents are asked to notify the child’s
counsellor if they are being picked up early or by someone other than those listed on the child’s form
(children will not be released without notification from a parent)! Every time a child is picked up,
the adult is expected to ensure that the child’s counsellor is notified before leaving the facility.


In the case of a child’s absenteeism, parents must notify the office by 1:00pm at 634-2011 with the
reason for not attending, whether or not the absence is illness related. Providing reasons for
absenteeism is a mandatory practice as stated in the New Brunswick Child Day Care Operator
Standards. This practice is to help ensure the effective management of illnesses within the
program. We may also need to ensure the completion of a “Return After Exclusion Form”. We do
not intend to invade your privacy, but the safety and well-being of all participants is important. Your
full co-operation is appreciated in this area.

                                   CHILD GUIDANCE PRACTICES

After-school program rules and regulations will be decided upon with input from the youth and will be
clearly explained to all participants. All rules will be logical and comprehensive and will be
administered in a consistent manner. Staff will follow positive discipline techniques and guidance at
all times and will do their best to eliminate potential problems. Positive reinforcement and
encouragement will be used as well as redirection of negative energy. Children will be provided with
the opportunity to discuss incidents with staff and parental involvement will be encouraged. Time
outs may be used as a means of calming a child to allow for an opportunity to discuss an incident.

If any unacceptable behaviour is ongoing, after several attempts at resolution, parents may be asked
to make alternate arrangements for their child. Every attempt will be made to resolve the situation
with parental involvement. As a last resort, parents may be asked to remove the child within an
acceptable time frame.

                           CHILD ABUSE AND NEGLECT PROTOCOLS

All after-school staff are educated as to the signs and symptoms of child abuse and neglect. Staff
are trained in dealing with disclosures and are knowledgeable in the mandatory reporting
requirements as set in the Child Victims of Abuse Protocols of the Province of New Brunswick.

It is the legal responsibility of all Club personnel to document and immediately report any suspected
case of abuse or neglect. Failure to report suspicion of abuse or neglect is a criminal offense under
the Family Services Act. Every attempt will be made, where appropriate, to gather information from
parents about suspicious marks on a child or suspicious circumstances.


    All staff are certified with Standard First Aid and CPR and trained in emergency procedures.
    Parents are required to sign a consent form for emergency medical attention and
    Fire drills are practiced once a month.
    In the case of building evacuation, children will be escorted to the nearest exit and gathered
     into their groups once outside the building.
    In the event of the need for an alternate location, children will be walked to Prince Charles
     School. In the case of a neighbourhood emergency, children will be taken by foot, Club bus or
     van or staff vehicles to the South End Community Centre, 210 Wentworth Street, 633-5115.

                                            HEALTH PRACTICES

Public Health research has proven that hand-washing significantly reduces the transmission of infections. It is
important for staff and children to wash their hands as often as necessary but always in these situations: upon
arrival at the Club, before snack, after using the washroom, after outside play, after cleaning up after a sick
child, after handling items soiled with blood or other body fluids and before and after giving or taking

Child Illness
In the case of child illness, parents will be contacted. The child will be placed in a supervised, designated area
separate from other children. The child must be picked up within one hour of notification of illness. A
POTENTIAL ILLNESS REPORT FORM will be completed and must be signed by the staff and parent each
time a child leaves early due to illness.

Parents will be contacted to pick up their child from the program if:
   (a) The illness prevents the child from participating comfortably in activities.
   (b) The illness results in a greater care need than the staff can provide without compromising the health
       and safety of the other children.
   (c) The child has a temperature of 38.5 Celsius (101 F) or greater, along with other signs of illness
       including diarrhea, vomiting or blood in the stool
   (d) The child has other signs and symptoms as outlined in the “Management of Illness in Chldren and Staff
       in New Brunswick Child Day Cares” (Flow Chart is posted on the bulletin board & See appendix)

See page 6.

Exclusion Criteria
Exclusion periods will be enforced as laid out in the “Management of Illness in Children and Staff in New
Brunswick Child Care Facilities”. Reports will be made to Public Health where required. Exclusion periods are
mandatory for diarrhea, hepatitis A, vomiting, pinkeye (until treated), scarlet fever and strept throat (until
treated), head lice (until treated and no evidence of live lice), drooling with herpes simplex (non genital),
impetigo (until treated for one day), scabies (until treated for 24 hours), measles (4 days), bacterial meningitis
(24-48 hours after starting antibiotics), mumps (9 days), German Measles (7 days), chickenpox (depends on
severity), other illnesses as warranted. In the case of diarrhea, if a child has 2 or more episodes or one
episode with fever, vomiting or blood in the stool, the child will not be allowed to remain in the program and
medical attention is required. A report to Public Health is also required in this case.

Parents must complete the form “Return After Exclusion” before a child can re-enter the program to
verify that all exclusion requirements have been met. A sample of this form is included in this
package (appendix 1). Please refer to appendix 2 for Parent’s role in managing illness and appendix 3
for the exclusion guide.

Communicable Disease
Parents will be notified of any communicable diseases, illnesses, infections or infestations in the after-school
program. Public Health will be notified as required.

Parents must provide an up to date immunization record for their children at the time of registration. Children
will not be allowed to attend the program until the immunization information is received. Parents are
responsible to provide notification of any changes in immunization as soon as possible. Should a
parent decide not to provide this information or decide not to immunize their child, the waiver on page
15 must be completed and followed as necessary.
FOLLOWING BOOKLETS ARE AVAILABLE UPON REQUEST*** “Management of Illness in Children and
Staff in New Brunswick Child Day Care Facilities” and “Guide for Managing Potential Illness in Child Day Care
Facilities in New Brunswick”. Also, please refer to the posted “potential illness” flow charts for information.


    AGE         Hepatitis   Diptheria   Pertussis   Tetanus   Polio    Hemophilus      Measles   Mumps   Rubella
                   B                                                  Influenza Type
    Birth          x
 2 Months          x           x           x          x        x            x
 4 Months                      x           x          x        x            x
 6 Months                      x           x          x        x            x
 12 Months         x                                                                     x        x        x
 18 Months                     x           x          x        x            x            x        x        x
4 to 6 Years                   x           x          x        x
14 to 16 Yrs                   x                      x
Every 10 yrs                   x                      x

DtaP-P/Hib – Diptheria, tetanus, pertussis, polio and Haemophilus Influenzae type b vaccine
DtaP-P – Diptheria, tetanus, pertussis, polio vaccine
Hep. B – Hepatitus B vaccine
MMR – Measles, mumps, rubella vaccine
Td – Tetanus, diptheria vaccine

****If a parent decides not to immunize their child or submit a copy of the child’s immunization
record, they must complete and sign the immunization waiver which includes agreeing to
exclude their child from the program when a communicable disease is in the facility.

Only medication brought to the facility by the parent, whether over the counter or prescribed, will be
given to the child. A consent form for administration of medication when required must be completed
at the time of registration. Any time that a child is in need of medication, the administration of
medication record must be completed by the parent and signed by the staff member who administers
the medication. All medication that is brought to the after-school program must be in the original
container with the original label, have child protective caps and be identified with the dosage and the
name of the child. Prescribed medications must have the name of the physician, dosage instructions
and the time period of use.

At the time of registration, a consent form must be completed for the possible administration of
acetaminophen when required. Under conditions, where it may be necessary to administer
acetaminophen (provided by the parent), the following procedures will be followed:

1. Staff recognize symptoms that the parent has previously identified
2. Take the child’s temperature and record
3. Contact the parent to discuss and receive verbal consent
4. Administer the medication
5. Parents must sign the consent form upon arrival at the Club

Special Medical Conditions
For those children who register in the After-school program and require special medical care or
precautions, written instructions are required from the parent to assist us in caring for your child.
Examples of these conditions or care include asthma puffers or chambers, diabetic blood level
testing/ insulin pumps, severe migraine headaches, allergies and the use of epipens, etc. Written
instructions should include preventative measures, signs and symptoms to be aware of, what to do in
case of certain scenarios and emergency contact numbers.

Reportable/Non-reportable Incidents

Reportable Incidents in the After-school program include:
    (a) unexpected illness or injury where the child requires immediate transfer to the hospital
    (b) motor vehicles accidents or injuries caused while being transported
    (c) missing child
In the case of any of the above, the parent will be notified immediately. An incident report form will
be completed and forwarded to the Regional Co-ordinator, Department of Family & Community
Services. A copy will be given to the parent if requested.

Non reportable incidents are those that do not require emergency medical attention ie. Cuts, bruises
and bumps. The child may need some minor first aid by a staff member.

Daily logs are kept by after-school staff for the children in their care. Any notable incidents of injury,
behaviour, health or other situations will be noted in the log and the parents will be requested to
sign the log upon notification of the incident.

Pets and other animals are not allowed in areas occupied by the children during the after-school

All of the attached forms must be completed to register for the program.

Records of immunization are required at the time of registration. These are
available from your child’s school, Public Health, or your family doctor.
                                                      APPENDIX 2

Managing Illness in Child Day Care Facilities Parent’s Role

Your involvement as a parent is important! You can take the following steps to help make sure that child day care facilities
are safe and healthy places for all children:

Step 1: Make sure you provide up-to-date information about your child’s immunization to the child day care operator. If you
choose not to immunize your child, you must sign a waiver from the child day care facility.

Step 2: In general, if your child is too sick to participate comfortably in activities and has symptoms or a condition that may
affect the health of other children, it is necessary that your child not attend day care. You must keep your child at home or
make alternative child care arrangements if your child has any one or more of the following symptoms or conditions:

h. Fever (oral temperature 38.5º C or greater; rectal temperature 39º C or greater, armpit temperature 38º C or greater
accompanied by behaviour changes or other signs of illness)
i. Diarrhea as defined by an increase in frequency of stools and/or change to unformed loose, watery stool. Fever, loss of
appetite, nausea, vomiting, abdominal, mucus or blood in stool may also occur
j. Vomiting illness with two or more episodes of vomiting in the previous 24 hours (in excess of typical infant spit-ups)
k. Mouth sores associated with an inability of the child to control his/her saliva
l. Rash with fever or behaviour changes
m. Infections (e.g. infected eyes with discharge) until 24 hours after treatment started by physician
n. Infestations (e.g. scabies, head lice, pinworm) until after first treatment with a medicated product.

Step 3: If your child does not attend day care due to illness, you must let the day care know your child’s illness symptoms.

Step 4: If your child gets ill at the child day care facility, you will be notified and you will be asked to make arrangements to
pick up your child within one hour of being notified by the day care staff. This is important to make sure your child gets the
treatment he/she needs as well as to prevent the spread of illnesses to other children.

Step 5: You are encouraged to take your child to a physician if your child’s symptoms do not improve within 24 hours after
leaving the child day care facility.

Step 6: For some illnesses, there is a required time period where your child cannot attend a child day care facility. These
rules have been developed by health care professionals across Canada to make sure that your child is fully recovered and
to prevent the spread of infectious diseases in day cares. These illnesses are listed in a document called the “Exclusion
Reference Guide” which is available from your day care operator. If your child has been diagnosed with any of the illnesses
in this Guide, you must follow the requirements in order for the day care operator to allow your child to be re-admitted into
the child day care facility.

Step 7: When you take your child back to the day care after having been sick with an infectious illness, you must complete
a form to certify that you have followed necessary rules for re-entry to the child day care.

We thank you in advance for taking these steps to make child day cares a safe and healthy place for all children
in New Brunswick.
                                                       APPENDIX 3

New Brunswick Child Day                  EXCLUSION CRITERIA                            RETURN AFTER EXCLUSION FORM
Care Facility Exclusion
Reference Guide

Campylobacter                            Exclude until diarrhea is gone                          YES
Cryptosporidium                          Exclude until diarrhea is gone; No                      YES
                                         swimming for 2 weeks
Eschericheria coli * (E. coli 0157 H7)   Exclude until diarrhea is gone and two        YES Public Health signature required
                                         stool cultures taken 24 hours apart are
                                         negative. Proof of negative cultures
                                         must be provided to Public Health.
                                         Public Health will then notify daycare
                                         of re-admittance permission
Giardia                                  Exclude until diarrhea is gone                           YES
Head Lice                                Exclude until first treatment is complete                YES
                                         and there is no evidence of live lice.
Hepatitis A                              Exclude for 1 week after onset of                        YES
Impetigo                                 Exclude until antibiotic treatment has                   YES
                                         been taken for 1 full day.
Measles                                  Exclude all cases until at least 4 days                  YES
                                         after onset of rash. Exclude all children
                                         who lack proof of immunization until
                                         vaccinated or until 2 weeks after last
                                         case in the daycare.
Meningitis (Bacterial)                   Exclude until well enough to return and                  YES
                                         at least 24-48 hours after starting
                                         appropriate antibiotics
Mumps                                    Exclude child with mumps for 9 days                      YES
                                         after onset of swelling Exclude
                                         susceptible contacts from days 12-25
                                         following exposure if other susceptible
                                         people are present (consult Public
Norwalk virus                            Exclude until diarrhea and/or vomiting                   YES
                                         are gone
Pinkeye (Conjunctivitis)                 Exclude until 24 hours after treatment                   YES
                                         has begun.
Rotavirus                                Exclude until diarrhea is gone.                          YES
Rubella (German Measles)                 Exclude for 7 days after onset of rash. If               YES
                                         child has congenital rubella and is less
                                         than 1 year old, consult Public Health.
                                         Risk of severe damage to fetus if
                                         pregnant woman gets rubella in first
                                         trimester, therefore all staff should prove
                                         immunity (vaccination or blood test, prior
                                         to employment, if possible)
Salmonella                               Exclude until diarrhea is gone                           YES
Scabies                                  Exclude until 24 hours after treatment.                  YES
                                         Treatment of household contacts usually
Scarlet Fever                            Exclude until 24 hours after treatment                   YES
                                         has begun
Shigella*                                Exclude until diarrhea is gone and two        YES Public Health signature required
                                         stool cultures taken 24 hours apart are
                                         negative. If antibiotics administered,
                                         stool specimens to be taken at least 48
                                         hours after completion of antibiotics.
                                         Proof of negative cultures must be
                                         provided to Public Health. Public
                                         Health will then notify daycare of re-
                                         admittance permission.
CONDITION                                EXCLUSION CRITERIA                           RETURN AFTER EXCLUSION FORM
Whooping Cough (Pertussis)               If infants under age 1 year or pregnant              YES
                                         women are present, exclude child with
                                         whooping cough for 5 days after start of
                                         antibiotics or 3 weeks after start of
                                         cough and culture negative if no
                                         antibiotic treatment given (consult with
                                         Public Health)

Chickenpox (Varicella Zoster)            If mild and the child is able to take part            NO
                                         in activities, no exclusion is required.
Common cold                              Do not exclude unless too ill to take part            NO
                                         in activities
Ear infections (Otitis media)            Do not exclude unless too ill to take part            NO
                                         in the activities
Fifth Disease (Parovirus B19 (Erythema   No exclusion required                                 NO
Hand, Foot, and Mouth Disease            No exclusion required                                 NO
Hepatitis B                              No exclusion required. Open wounds                    NO
                                         should be covered.
Herpes Simplex (non-genital)             Exclude children who do not have                      NO
                                         control of oral secretions (droolers) and
                                         have infection for the first time.
                                         Exclusion not indicated for recurrent cold
Influenza                                Do not exclude unless too ill to take part            NO
                                         in activities
Meningitis (Viral)                       No exclusion required                                 NO
Mononucleosis (Infectious)               No exclusion required                                 NO
Pinworms                                 No exclusion required                                 NO
Ringworm                                 No exclusion required                                 NO
Roseola                                  No exclusion required                                 NO
Shingles                                 If mild and the child is able to take part            NO
                                         in activities, no exclusion is required.
                                         Lesions should be covered if possible.

DIARRHEA                                 Exclude until diarrhea is gone or physician
                                         determines child is not infectious. A child with
                                         2 or more episodes of diarrhea or one episode
                                         of diarrhea with fever, vomiting or blood in the
                                         stool should not remain in daycare and the parents
                                         should be advised to seek medical attention for the child
                                             THE BOYS AND GIRLS CLUB OF SAINT JOHN                       13
Registration Date: _____________ Registration Fee Paid:___________ Start Date: ____________


Name of child: ____________________________________________ Male Female

Date of Birth ______________________Medicare #: ___________ Expiry date: ___________

Home Address: _______________________________________________ Apt #__________

City________________________________ Postal Code _______________________________

Telephone#: _________________Cell#:____________ E-mail:_________________________

Mother/Guardian Name: __________________ Father/Guardian Name: _____

Place of work: (mother) Work telephone #: ________________

Place of work: (father) Work telephone #: _________________

Marital Status: Single Married Widowed Separated Divorced

Name of Family Physician: ___________________________

Telephone: ______________ Address: _______________________

ALLERGY ALERT: Please list your child’s allergies
______________________ ____________________                                       ____________________
______________________ ____________________                                       ____________________

With whom has the child lived Mother Father Both Guardian for most of the past year?
Other (specify) ________________________

Who has permission to pick your child up from the center? _________________________________
 If changing pick up arrangements parents(s) must call the center prior to the child being picked up.

Is there anyone who does not have permission to pick your child up from the center?

What language(s) are spoken at home? English French Other (specify) _________


Name ________________________________________ Age _______

Name________________________________________ Age _______

Name ________________________________________ Age _______

Other people living in the home:




EMERGENCY CONTACTS (not including parents/guardians)

1. Name Address: ___________________________

Telephone #: ______________ Relationship: __________________________

2. Name Address: __________________________

Telephone #: ______________ Relationship: _________________________


Has your child attended preschool/child care before? Yes No

If yes, for how long?   6 months 1 year 2 years more than 2 years

Name of child’s present or most recent preschool/child care center:


1. Immunizations: Please provide a copy of your child’s immunization record. If for any reason your child
has not received any or all of the immunizations appropriate to his/her age, please inform us.

Parent(s) are responsible to update their child’s immunization record and provide this to the facility as changes

2. Medical History: Please indicate if your child has had any of the following:
            Yes    No
Measles     ___    ___
Rubella     ___    ___
Mumps       ___    ___
Chicken Pox ___   ___
Meningitis ___     ___
Pertussis   ___    ___
(Whooping Cough)

3a. Health Status: Please indicate if your child has any of the following:
           Yes     No
Asthma     ___     ___
Diabetes   ___     ___
Eczema    ___     ___
Psoriasis  ___     ___
Epilepsy   ___     ___
Seizures   ___     ___
Other      ___    _________________________________________________

3b) Medical Treatment Please indicate medical treatment your child may require.
Name of Medication_________________________ Dosage_________________


3c) Emergency Treatment Please indicate any situations where emergency treatment
and/or medication(s) may be required by your child (ie. epipen, benadryl)


4. Allergies a) Please list any medication allergies

b) Please list any food allergies _________________________________________

c) Any other allergies? _______________________________________________________

5. Additional information Please provide any information you feel is important to help
ensure that your child’s after-school participation is a positive experience. Please include
information about likes, dislikes, hobbies, interests, concerns, personality, any activities in
which your child cannot participate, how your child makes friends, how your child gets along
with adults and any other information that you feel we should know.


I understand that it is my responsibility as a parent to immediately notify the staff of any
changes to the information provided in the child profile form and the waiver of liability form
with regards to pick-up authorization and immunization records.

Parent/Guardian Signature: ___________________ Date: ________________

                         THE BOYS AND GIRLS CLUB OF SAINT JOHN, INC.
        In consideration of acceptance of this application in the Boys and Girls Club of Saint John, Inc.
After-school Program Sept. 2012- June 2013,I __________________________________________
the parent/legal guardian of ____________________________(name of child), our heirs, executors,
administrators, successors and assigns waive and release any and all rights and claims for damages
we have or may have against the Boys and Girls Club of Saint John, Inc., volunteers, directors,
agents or their representatives, successors and assigns for any and all injuries, accidents, mishaps
or illnesses which may directly or indirectly result from any participation in the After-school Program
offered by the said Club, and the activities associated with those programs as determined in the sole
discretion of the Club.

SHALL NOT BE RESPONSIBLE FOR ____________________________(name of child)

       I, the undersigned, the parent/legal guardian, have read this waiver and understand the terms
and I acknowledge and agree to the terms stated therein.

Date: _________ SIGNATURE OF PARENT/LEGAL GUARDIAN: ___________________________
CHILD’S SCHOOL: ______________________ GRADE: _____ DISMISSAL TIME: _________
Please be advised: Pickups at schools in outlying areas such as Lakewood Heights and Loch
Lomond Schools will depend on a minimum registration number.
Note: Some children may have to wait a few minutes at their school depending on other school
pickup times.
Please make arrangements for your son/daughter to be picked up by 6:00pm. If YOU are unable to
pick up your child, please contact the staff to let them know who will be doing so. Please list three (3)
alternate names authorized to pick up your child. Identification will be requested the first time that an
unknown person picks up your child. If this information changes, please notify the staff.
1.     Name _________________________________      Phone (h) ________________
                                                        (w) ________________
       Address: ________________________________________________________

       Relationship to Child: ______________________________________________

2.     Name _________________________________      Phone (h) ________________
                                                        (w) ________________
       Address: ________________________________________________________

       Relationship to Child: ______________________________________________

3.     Name _________________________________      Phone (h) ________________
                                                        (w) ________________
       Address: ________________________________________________________

       Relationship to Child: ______________________________________________
I understand that my child will only be released to those listed above. Photo ID will be requested from anyone
who is unknown to the child’s counsellor. Please refer to the section on “Child Pick-up Procedures”.
SIGNATURE OF PARENT/LEGAL GUARDIAN_______________________________


I (we) the parent(s) of _______________________(child’s name), have made the decision not to

immunize my (our) child OR to provide our child’s record of immunization. I (we) understand that the

After-school program requires an up to date immunization record. I (we) understand and agree to the

fact that as a result of my (our) decision, my (our) child will be excluded from participation in the

After-school program at any and all times when a communicable disease is present in the

facility. Examples of these include measles, mumps, hepatitis A, etc.

I (we) understand that we will be notified of such cases.               Date: _____________

Parent’s Signatures:_________________________               __________________________

                      Emergency Medical Attention and Transportation Consent Form

Name of Child: _______________________            Date: ________________

If at any time, due to circumstances such as an injury or sudden illness, medical treatment is necessary, I (we)
authorize the operator, administrator or staff of The Boys and Girls Club of Saint John, Inc. to take whatever
emergency measures are necessary for the protection of my (our) child while in their care.
I understand this may involve applying first aid, calling a physician or nurse, carrying out the instructions given,
and/or transporting my (our) child to a hospital, including the possible use of an emergency vehicle.
I understand that this may be done prior to contacting me (us) and any expenses incurred for such treatment,
is my (our) responsibility.

Signature of Parent(s) or Guardian(s) _________________                ______________________

                                          Transportation Authorization

I, ___________________________________, give permission for the After-school staff
       (name of parent/guardian)
to take my child on outings away from the premises, either by foot or Club vehicle. I (we) understand

that the vehicles and drivers will be properly licensed and insured. In the case that my (our) child is

being transported to the Club from their school, I give permission for Club staff to transport by Club

vehicle or staff vehicle (in case of bad weather). Also, if I choose to utilize other means of transportation

services, including taxi or private transportation companies, I do so at my own risk and will not hold the Club

responsible for this transportation.

Date: ____________ Signature of Parent(s) or Guardian(s)__________________ ________________

Child’s Name: _______________________
Date: _____________

I (we) understand that at times, it may be necessary for the staff of the After-school program to
administer medication to my (our) child. I (we) understand that only medication brought to the facility
by ourselves, whether over the counter or otherwise, will be given to my (our) child. I (we) realize that
this consent form must be signed at the time of registration and a separate administration of
medication record must be completed each time my (our) child is in need of medication administered
by the staff. I (we) will only provide medication that is in the original container and that is properly

Parent’s Signature(s): _______________________             ________________________

                                Consent for Release of Information
I (we)____________________, the parents/guardians of __________________________ authorize
the operator, administrator, or staff of the Boys and Girls Club of Saint John After-school Program to
release information about my child to schools or other agencies only when deemed necessary.
I (we) understand that I (we) will be contacted prior to this information being passed on and I
(we) reserve the right to say no. I (we) also understand that the After-school Program staff will
do everything possible to protect the privacy and confidentiality of my child’s information.

In addition, I (we) understand that non-payment of fees is not private information and may be
released without consent to other After-school Program Operators or other applicable agencies.
______________________________                           _________________________
        (Parent’s Signature)                                            (Date)
______________________________                           _________________________
        (Parent’s Signature)                                            (Date)

                             Consent for Participation in testing or photos
I (we) ______________________, the parents/guardians of _____________________,
authorize the participation of my child in testing for various educational institutions and participation in
photos for various promotional projects.
I (we) understand that I (we) will be contacted prior to these events and I (we) reserve the right to say
_____________________________                              ________________________
                (Parent’s Signature)                                  (Date)
_____________________________                              ________________________
                (Parent’s Signature)                                  (Date)

                                      CONSENT FORM
        For Outings, Excursions, Activities off the Premises of the Boys and Girls Club

I(we)____________________________________,the parents/guardians of ____________________

authorize the operator, administrator, or staff of the Boys and Girls Club of Saint John, Inc. to take

my (our) child on outings, excursions and activities away from the facility, either on foot, in the Club’s

minibus or van or in a rental vehicle. I (we) understand that I (we) will receive advance notice of any

planned outings, excursions, or activities away from the facility.

Parent/Guardian’s Signature:________________________________ Date: _______________

                          Understanding of Health/Illness Policies

I (we) understand that the health and well-being of children attending the After-school program is top
priority. I (we) understand that when my (our) child becomes ill while at the Club, the following will
take place (as noted in the handbook).
                        1. I (we) will be contacted if the circumstances warrant (see handbook)
                        2. I (we) must and will pick our child up from the program within one hour of
                            notification and I may have to complete a “Potential Illness Report Form”.
                        3. I (we) will exclude my (our) child from the program for as long as is
                            necessary (see handbook).
                        4. I (we) will complete the “Return After Exclusion” form as required to verify
                            that all exclusion requirements have been met. (Sample included)
                        5. I (we) will notify the staff if my child will be absent and will provide the
                            reason why.
                        6. I (we) understand all of the program’s health policies as written in the
                        7. I (we) have read and understand the “New Brunswick Child Day Care
                            Facility Exclusion Reference Guide” and the “Managing Illness In Child
                            Day Care Facilities Parent’s Role” pages included in this handbook
                            (please post for handy reference).
                        8. I (we) agree to call the Club with information regarding the reasons why
                            my child is absent.

Parent’s Signature(s): _______________________________               Date: __________________

                            WRITTEN STATEMENTS OF SERVICE
I (we)_______________________, the parents/legal guardians of ______________________
          (Parents/Guardians)                                       (Child’s Name)

have read, understood and agree to comply with all of the Club’s written statements of service in

this Parent/Guardian Handbook.

Signature of Parent/Legal Guardian: _____________________________Date: ______________


Early Morning Drop off/Light Breakfast Service
Open 7:30am-8:30am (Transport children to school)
1 child – Additional $30.00 per week
2 children – Additional $45.00 per week
3 or more – Additional $60.00 per week

Transportation Authorization And Breakfast Authorization

I, ___________________________________, give permission for the Early Morning staff
       (Name of parent/guardian)
to take my child to school, either by foot or Club vehicle. I (we) understand that the vehicles and drivers will be

properly licensed and insured. In the case that my (our) child is being transported to their school from the

Club, I give permission for Club staff to transport by Club vehicle or staff vehicle (in case of bad weather).

Also, if I choose to utilize other means of transportation services, including taxi or private transportation

companies, I do so at my own risk and will not hold the Club responsible for this transportation.

Required time for child to be at school _______________.

I, ___________________________________, give permission for the Early Morning staff to provide a light
       (name of parent/guardian)
breakfast for my child. Please do not send breakfast with your child due to peanut-free policy.

Date: ____________ Signature of Parent(s) or Guardian(s)__________________ ________________

To top