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					NEWBURGH FAMILY YMCA Y-SCOOP PROGRAM REGISTRATION - 2009/2010 (revised 4/29/09)                                                 1

Child’s Name: ______________________________________ Date of Birth: ____/____/_____ Age:____
Address: ______________________________________City: ____________________, NY Zip: _________
Home Phone: _(_____)_________________________ Gender: _____________ Ethnicity: _____________

School Attending: _______________________________Program Attending: _______________________
Start Date: ______________________ Grade: ________ Teacher: ________________________________
Father’s Name: _____________________________ Mother’s Name: _____________________________
Cell Phone: ________________________________ Cell Phone: __________________________________
Employer: _________________________________ Employer: ___________________________________
Work Phone: _______________________________Work Phone: ________________________________
Email: ____________________________________ E-mail: ______________________________________
Child Resides with: __Father __Mother   __Both Parents __Other, please explain below:
________________________________________________________________________________
                        PLEASE SUBMIT ALL PAPERWORK, MEDICAL FORMS, IMMUNIZATIONS, ETC
                                    3 DAYS BEFORE YOUR CHILD STARTS Y-SCOOP
 TUITION and ATTENDANCE                       Please Circle Days Attending: Morning Program   M T               W TH        F
      10% discount for 2nd child, 15% for 3rd                               Afternoon Program M T               W TH        F
      MONTHLY RATE is as follows:
        #Days enrolled Per Week                             AM Only                   PM Only                 BOTH
          2 Days                                             $105                       $165                 $254
          3 Days                                             $117                       $176                 $265
          4 Days                                             $133                       $201                 $302
          5 Days                                             $149                       $227                 $339
 • MEMBERSHIP/REGISTRATION FEE: $55.00 non-refundable annual fee (if not currently enrolled through other Y
   program) Tuition covers a small snack and beverage drink, program activities, administrative costs, and cost of
   staffing. If your child gets extra hungry in the afternoons, please provide an additional snack besides the one
   provided during program time.
 • Children are scheduled to attend on days agreed to at the time of registration. ANY CHANGES IN THE CHILD’S
   ATTENDANCE SCHEDULE MUST BE MADE IN WRITING THROUGH THE YMCA OFFICE ONLY. No additional fee is
   required for this change but for liability reasons we must have requests from the parents directly.
 • Program will not be held on school half-days, snow days, or early dismissal.
PAYMENTS: (please circle)
            Cash or Money Order                             Check                           Credit Card
     Credit Card –Will be deducted on the 29    th monthly. Please provide the following information:

Mastercard            VISA           American Express                 Debit
Card #                                                             Exp. Date        /      /
 I authorize The YMCA to automatically deduct payment monthly
 Signature:_________________________________________Date___________________
A processing fee of $37 will be charged for a check returned due to “insufficient funds.”
     Monthly payments are based on the number of full school days in each school year set by the state. Cost for the
     year is divided equally among the 10 months of school, so payment is the same for each month.
     The Newburgh Family YMCA does not provide monthly billing.
     Tuition is due at the YMCA main office the first day of the month. Make payments payable to the NEWBURGH
     FAMILY YMCA with the child’s name and school site noted on it. Bring payment or mail to: Newburgh Family YMCA,
     10 Little Britain Road, Suite 204, Newburgh, NY 12550. Staff has been instructed not to accept payments.
     PAYMENTS RECEIVED AFTER THE 5TH OF THE MONTH ARE CONSIDERED LATE AND WILL BE ASSESSED A $20.00
     LATE FEE. Late payments may cause services for your child to be suspended until paid. If the child is withdrawn from
     the program for a month or more, a $15.00 fee will be charged for re-registration.
     LATE PICKUP FEE: A $10.00 fee will be charged for services rendered within the first 15 minutes after the
     6:00pm closing time. Thereafter a $5.00 fee will be charged for every five minutes that the child remains at the
     program site. Three late departures will result in the termination of the child from the program.
NEWBURGH FAMILY YMCA Y-SCOOP PROGRAM REGISTRATION - 2009/2010 (revised 4/29/09)                                               2

REFUNDS
     Please be aware that refunds will not be made for days paid for but not used at the parent’s discretion. The only
     exceptions are if the child misses five or more consecutive days due to serious, medically treated illness and the
     parent provides a doctor’s note, half credit will be applied for the days missed.
     No refund will be made for days when a child is suspended from the program due to behavior difficulties.

FINANCIAL ASSISTANCE
     Partial scholarships are made available through donations made to the Newburgh Family YMCA. Funding is limited
     and is available on a first come, first served basis based on total family income and the number of persons living
     in the household. Full scholarships are not available. Fill out a scholarship application to determine if you qualify.
     Failure to declare all sources of income and total income will disqualify your child from enrollment. If services have
     been rendered, legal action will be taken to recover funds received under fraudulent declaration.

IMPORTANT – PLEASE READ AND SIGN
   Registration and continued enrollment of your child in the Newburgh Family YMCA Y-SCOOP program is contingent
   upon available openings, the child’s ability to interact well within the group and setting that are provided, not
   requiring consistent one-on-one supervision, and the appropriate behavior of the child. If an opening is not available
   at the time of registration, your child’s name will be added to a waiting list of that site.

    I hereby enroll my son/daughter in the Newburgh Family YMCA Y-Scoop Program. In signing this agreement I certify
    that:
    a) I will make payments as agreed to;
    b) I will pickup my child(ren) no later than 6:00pm and if delayed I will pay the extended care fee;
    c) My child does not need one-on-one, specialized, or small group care;
    d) I have provided accurate medical information on my child and verify that no condition exists that would place
          his/her wellbeing at risk or that of other participants
    e) I grant the Newburgh Family YMCA and its agents full authority to choose, approve, and secure medical treatment
          for my child if I cannot be reached in case of an emergency, and release the Newburgh Family YMCA from any
          liability in connection therewith;
    f) I will go over the Y-Scoop program rules with my child and sign them. Should my child repeatedly not follow them I
          understand that the Newburgh Family YMCA may suspend and/or terminate my child’s enrollment and/or
          participation;
    g) I consent to the Newburgh Family YMCA using my child’s comments, photographic or video likeness in promotional
          materials for which there is no written or expressed compensation;
    h) I understand the program participants participate at their own risk, and any insurance claims must first be
          submitted to my insurance carrier as the primary coverage and then to the Newburgh Family YMCA;
    i) I will keep my child at home when ill.

    INSURANCE DISCLAIMER: The Newburgh Family YMCA specifically disclaims all responsibilities for medical costs and
    expenses which may arise as a result of injuries children may sustain while attending the program and makes no
    express nor implies representations or assurances as to the safety or security of the program, its facility or the
    equipment and materials utilized.


    Signature_______________________________________________ Date _____/_____/_____
NEWBURGH FAMILY YMCA Y-SCOOP PROGRAM REGISTRATION - 2009/2010 (revised 4/29/09)                                             3

                                Y-Scoop Participant Behavioral Agreement
We look forward to your child having a great time in the Newburgh Family YMCA Y-Scoop Program. Participants are
expected to follow the rules based on the YMCA Core Values: Caring, Honesty, Respect and Responsibility.
For the safety and well being of all children and staff, we need the cooperation of all children and parents in order to
encourage positive behaviors.

Child/Parent Rights
As a School Age Child Care participant, you have the right to:
  1.) Be treated with dignity and respect by everyone in our program.
  2.) Have a safe, calm, clean and orderly environment
  3.) Be free from fear of physical harm
  4.) Have a fair turn in any group activity
  5.) Make mistakes without being ridiculed by others
  6.) Seek help from adults who are here to help you

Child/Parent Responsibilities
As a School Age Child Care participant, you are expected to:
  1.) Be fair and accepting of others eager to join any activity
  2.) Use appropriate, acceptable language
  3.) Be kind, considerate, helpful and respectful towards others
  4.) Share equipment and materials fairly and use them properly
  5.) Cooperate with others and adults who are here to help you
  6.) Treat school property with respect
  7.) Be honest with everyone
  8.) Leave valuable property and money at home

Generally, we hope to resolve most problems through discussion and agreement with your child. If misbehavior continues,
the following consequences will occur:
           1.) “Conduct Report” and communication between parent and staff member. All “Conduct Reports” must be
               signed by parent.
           2.) “Conduct Report” and conference between parent, child and staff in charge
           3.) “Conduct Report”, conference between parent, child, staff in charge, Y-Scoop Director and 3 day suspension
               from the program
A child may be terminated from the program when behavior is continuously disruptive and/or threatens the well being of
themselves or others. This includes, hitting or hurting a staff member or participant unprovoked, stealing, behavior requiring
one-on-one or small group supervision, continuous use of offensive language or racial slurs, and inappropriate sexual
behavior or harassment.

Child’s Signature: ________________________________________________________

Parent/Guardian Signature: _______________________________________________

Date: ____/____/_____
NEWBURGH FAMILY YMCA Y-SCOOP PROGRAM REGISTRATION - 2009/2010 (revised 4/29/09)                              4

                                    Emergency Dismissal Procedure
Child’s Name: ___________________________________________ Teacher: _______________________

In the event of an early dismissal my child has permission to (please check one):
_____ I will pick my child up from school
_____ My child may ride home on their normal bus (bus # _______)
_____ My child may ride home on bus # ________ to:
       Name of persons home: __________________________________________
                House address: ___________________________________________
                                ___________________________________________
_____ My child may walk home
_____ My child may walk to:
       Name of persons home: __________________________________________
                House address: ___________________________________________
                                ___________________________________________

I have discussed this with my child ___________________________. This is a procedure to follow in case they
arrive home and no one is home. My child knows how to get into the house, where to go and who to contact. My
child knows if they are allowed to answer the phone or allow anyone into the house.

Parent/Guardian: _______________________________________
Parent/Guardian Signature: _____________________________________

                                              *** Please note***

This form will be kept confidential in your child’s file. We will use the information provided above in case of
emergency only, such as afternoon activities are cancelled. We will also call the parents in this event so we
know that you know there will be no program.
               In the event all after school activities are cancelled and child needs to be picked up:

Person(s) to be called:                               Phone number:
___________________________________                   ______________________________
___________________________________                   ______________________________
___________________________________                   ______________________________
___________________________________                   ______________________________


        *** In case after school activities are cancelled, who should the Y-Scoop staff contact first?***
         Name: ________________________________________ Phone:____________________________
NEWBURGH FAMILY YMCA Y-SCOOP PROGRAM REGISTRATION - 2009/2010 (revised 4/29/09)                        5



NEWBURGH FAMILY YMCA - CONFIDENTIAL STUDENT RECORD


Child’s Name: ______________________________________


PLEASE NOTE:

  You must submit your child’s immunization records to our main office before your child starts
  program. Updated records are needed every year in order to participate.


  Are there any allergies (ie. Food, medicine, insect bites, chemicals, etc)?           YES NO
  Specify


  Is your child on regular medication that we should be aware of?              YES NO
  Please explain:_____________________________________________________________
  __________________________________________________________________________

  Are there any special dietary needs? (Specify diet and condition)            YES NO
  Please explain:_____________________________________________________________
  __________________________________________________________________________

  Are there any hearing, visual, or dental conditions that require special attention?   YES NO
  Please explain:

  Are there any medical or developmental conditions requiring special attention?* YES NO
  Please explain._____________________________________________________________
  __________________________________________________________________________
*please note: the YMCA does not provide one-on-one care

Additional information: (Games/activities child enjoys, siblings, nickname, any recent adjustments, etc)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
NEWBURGH FAMILY YMCA Y-SCOOP PROGRAM REGISTRATION - 2009/2010 (revised 4/29/09)                                           6



                                              Emergency Information

Father’s Name: _____________________________ Mother’s Name: ______________________________
Cell Phone: ________________________________ Cell Phone: __________________________________
Work Phone: _______________________________Work Phone: _________________________________
Contacts/Approved pick-up
If parent is not available or cannot be reached, please name the person(s) designated to pick up your child.
Photo ID must be provided at pick-up.

Name                                               Relationship                              Phone Number
1)___________________________________         _______________________________ ________________________
2)___________________________________         _______________________________ ________________________
3)___________________________________         _______________________________ ________________________
4)___________________________________         _______________________________ ______________________________
5)___________________________________         _______________________________ ________________________

WARNING: Name person(s) NOT authorized to contact or pickup child (must submit legal documents and picture)
Person                                                          Reason
_______________________________________________            ________________________________________
_______________________________________________            ________________________________________

                 Please advise your child, school, and designated persons of this emergency information
         __________________________________________________________________________________________

Insurance Plan/Carrier: __________________________________________________ Policy #__________________________
Insured’s Name: ______________________________________________________ Insured’s Date of Birth ____/____/____
Child’s Physician:_______________________________________________________ Phone#: ___________________________
Preferred Hospital in case of an emergency: _________________________________________________________________


 AUTHORIZATION
     In the event that my child becomes seriously ill or injured, and I cannot be reached, I authorize
      the Newburgh Family YMCA personnel to: (a) initiate emergency treatment and transportation
      as indicated above, and (b) release stated insurance and medical information from this record
      to the medical service provider. I understand that medical service and medication costs are my
      responsibility and/or that of my medical insurance.

 Signature____________________________________________________Date___/_____/_____



                                How did you learn of our Y-Scoop Program?
       __ School     __ TV __ Radio __ Friend/word of mouth __ Print ad/newspaper                              __ Other