Catholic Charities BeforeAfter S by benbenzhou


									                                                                                 Executive Director
                                                                         Marianne Majewski, LCSW

                                                                         Assistant Executive Director
                                                                                   Julio Coto, LCSW

                                                                         Assistant Executive Director
                                                                                  Joan Lorah, LCSW

February 1, 2010

Dear Parents,

Welcome to the Child Care Services Division’s 2010-2011 Partners School Age
Child Care Program. We are pleased to inform you that your child’s placement
into our program will be secured once a complete application is received.

Please note that any missing or incorrect information will delay the application
process. Please return the entire signed application, the $40.00 registration fee
and one month’s deposit(If paying by check please put on two separate checks
for accounting purposes), to our Phillipsburg administrative office at:

                   700 Sayre Avenue, Phillipsburg, NJ 08865
                    Or via email at

Families who submit their registration form and deposit on or before July
1st will have their registration fee waived (Enrollment for Drop-In services
excluded)! Refunds will not be considered for any reason after August 1, 2010.

**Please look for information about our new extended care option in this

Our child care staff is looking forward to working with you and your child. If you
have any questions or need assistance in completing your application, please
feel free to call our office at (908) 454-2074 or (908) 329-2009. Thank you.


Sandy Oswald, Program Director
BreEnna Balliro, Assistant Program Director
Child Care Services Division
                     700 Sayre Avenue ∙ Phillipsburg, New Jersey 08865
                     Telephone: (908) 454-2074 Fax: (908) 454-8151
                              2010-2011 MORRIS COUNTY
      Child(ren)’s Name(s)                                                                              Start Date

      Please indicate by checking program:                     AFTER SCHOOL                 DROP-IN           EXTENDED CARE

Sponsor’s Information                                                  Co-Sponsor’s Information
Sponsor’s Name:                                                        Co-Sponsor’s Name:
Home Address:                                                          Home Address:

Home Phone #:                                                          Home Phone #:
Employer:                                                              Employer:
Address:                                                               Address:

Work Phone #:                                                          Work Phone #:
Pager/Cell Phone:                                                      Pager/Cell Phone:
Work Days & Hours:                                                     Work Days & Hours:
Email Address:                                                         Email Address:

                                      Authorization Form/Emergency Contact
      I give Catholic Charities permission to contact the following persons in an emergency situation
      when a parent/guardian is not available. I give Catholic Charities my permission to release my
      child(ren) ONLY to the people listed below if I am not available. In my absence, the people listed
      are authorized to make decisions concerning my child(ren).
      *Please list one local person to be contacted in case of immediate emergency.
      Name(local only)                                    Relationship:
                                                          Work/Cell Phone #:
                                                                         Home Phone #:
      Name                                                               Relationship:
                                                                         Work/Cell Phone #:
                                                                         Home Phone #:
      Name                                                               Relationship:
                                                                         Work/Cell Phone #:
                                                                         Home Phone #:
      We will need identification from anyone on the list whom we have not met prior to the date on which they come to pick up
      your child. Catholic Charities requires a written note from you if a person other than those listed on this form is coming to
      pick up your child.
      *The following people are NOT permitted to pick up my child:
      Name                            Relationship
      Name                            Relationship
           *A court issued restraining order is required to enforce this policy if a parent is listed as one who may not pick up your
                                                                  child (ren).

                          The following information is requested for statistical purposes.
               Race:        American Indian or Alaskan       Asian      Black or African American
                         White       Hispanic         Other      Primary Language:

                            *How did you hear about our program? (Please check one)
                Newspaper         Website        Word-of-mouth         School publication         Other (please specify)

      Page 2 of 11                                                                                             Morris County
                              2010-2011 MORRIS COUNTY
         CHILD(REN)’S INFORMATION for 2010-2011 school year:
        Child’s Name                 Date of       Gender         Age          Grade           School/Sending District
                                      Birth         M/F                                              2010-2011

                                            Emergency Closing Procedure
         Please keep in mind that when school delays opening/closes early due to snow or another
         emergency, the before/after school program will not be in operation. Therefore, no one from
         Catholic Charities will contact you directly in the event of a delay or early closing. You and your
         child will need to follow your school’s emergency closing procedure. For information on your
         school’s emergency closing procedure, call the school office.

         I have spoken to my child concerning any emergency, and he/she knows the manner in which to
         be dismissed. Initial                   Date

                      Child Information and Emergency Care Permission Form
Child’s Name                          Health Problems/Medical                   Allergies                  Medications
                                     Needs/Behavior Difficulties

                  Does your child have an IEP or has he/she had a child study team evaluation in the last
                  three years? Yes        No
                  List any special programs and its respective days your child is involved in. (ex. Brownies,

                  My child(ren),                                          , is/are in good physical health
                  and can fully participate in program activities.
                  CHILD’S PHYSICIAN:
                  PHYSICIAN TELEPHONE:
                  In extreme emergency, when I cannot be reached, I prefer that my child be transported to
                                             hospital for emergency care.
                  Health Plan                                 Group Id #
                  Subscriber’s Name
                  Subscriber Id#
         I understand that while my child/ren is/are in the care of Catholic Charities, if an emergency should occur,
         every effort will be made to reach me. If all efforts fail, I consent to any medical and surgical treatment,
         including hospital admission, examinations and diagnostic procedures, anesthetics, transfusions, and
         operations, which in the event of an emergency, are deemed necessary by competent medical clinicians to
         save the life or preserve the health of my child.
         I also approve the release from the case records of any medical history or other medical data that would be
         necessary for the physician and/or hospital to administer such treatment. If my child/ren need/s medical
         attention, my insurance provider will be billed first.
         I understand that the general consent is applicable specifically and exclusively to emergency situations that
         occur when I am not available to give consent. I understand that I am responsible for notifying Catholic
         Charities of any changes in my child/ren’s medical history.

         Print Name
         Parent/Guardian Signature                                                          Date

         Page 3 of 11                                                                              Morris County
                   2010-2011 MORRIS COUNTY
                     Morris County Fee Agreement 2010-2011

Child’s Name:
     AFTER SCHOOL                 M    T   W TH     F

    DROP-IN                       M    T   W TH     F

Child’s Name:
     AFTER SCHOOL                 M   T    W TH    F

    DROP-IN                       M    T   W TH     F

Child’s Name:
     AFTER SCHOOL                 M   T    W TH    F

    DROP-IN                       M    T   W TH     F

An annual, non-refundable registration fee of $40.00 per family is required to
reserve your slot.
            After School Fee              $
     Less Discount (10%-siblings only)    $
           Total Monthly Fee              $

                            After School Program Fees:
                5 days per week (Full Time)         $260.00 month
                4 days per week (Part Time)         $225.00 month
                3 days per week                     $185.00 month
                2 days per week                     $132.00 month
               Extended Care:                       $35.00 per month
  Extended care is from 6:00 pm-6:30 pm and will only be offered if 5 children or
                               more enroll at site.
                    Regular Dismissal:           $20 day per child
                    Half day/early dismissal:     $30 day per child
              *You must be pre-registered to utilize the drop-in service.*

  Full Time Enrollment Only: Sibling discount is 10% for any additional children.

            *No refunds will be given for any reason after August 1st.

***I have read the above and agree to pay the set monthly fee in advance to
Catholic Charities. Failure to comply is a breach of contract and will jeopardize my
child(ren)’s space(s) in the program.

Print Name

Signature                                          Date
Page 4 of 11                                                          Morris County
                    2010-2011 MORRIS COUNTY

              Partners Programs Revised Fee Schedule 2010-2011

                             SPECIAL OFFER!!
***Registration Fee waived if completed enrollment forms and one month’s
     deposit are received by July 1st (Drop-in services excluded)!!!***

               Month of Care                        Payment Due Date
       Last Month 2010-2011 school year        August 1st (or at initial registration)
               September 2010                            September 1st
                 October 2010                              October 1st
               November 2010                              November 1st
               December 2010                              December 1st
                 January 2011                              January 1st
                February 2011                             February 1st
                  March 2011                                March 1st
                  April 2011                                 April 1st
                   May 2011                                  May 1st

* A 10% discount is offered for additional siblings concurrently enrolled full-time in the
program, who are not receiving any other subsidy. Enrollment priority will be given to
full time families.

*Note: Would you like a monthly reminder statement?
Yes    I would like to be mailed a monthly paper statement.

No     Please be aware payment is due the 1 st of the month. If paying by credit card,
please see page 6.

Would you like to receive a year end statement for tax or Flexible spending
Yes   I would like to be mailed a statement in January.

***I have read the above and agree to follow the payment schedule as stipulated
by Catholic Charities.

Print Name

Signature                                                     Date

Page 5 of 11                                                                Morris County
                     2010-2011 MORRIS COUNTY
                Catholic Charities Enrollment & Payment Agreement
                    (Please sign and remit with your check or money order.)

1. I am enrolling my child/children                                         . If I am carrying a
   balance from the previous school year, I will remit payment in full before my child is enrolled
   for the upcoming school year. Failure to do so will result in a loss of my child(ren)’s program
   space(s) for the 2010-2011 school year.
2.   If I choose to withdraw from the program, I will provide written notice by the 14 of the month
     prior to the month the withdrawal will take effect. My deposit will go towards my last month with
     proper notice. However, if for example, I notify the office after the 14 of March to be withdrawn
     for April (an untimely withdrawal), I understand my deposit will be applied to the last month
     billed- in this case, April.
3. I will submit my $40.00 non-refundable registration fee with my completed enrollment form. I
    will be billed monthly thereafter. One month’s deposit is due with your completed
    enrollment form (Separate check). **Registration fee will be waived for completed
    enrollment forms received no later than July 1st with one month’s payment (Drop-in
    services excluded)!
4. I am responsible for monthly payments to be made by the first of each month for services
    to be rendered (See Fee Agreement Schedule Page 5). I understand that if my payment is
    received late, a late fee of $10.00 will be charged to my account. Failure to make payment
    may jeopardize my child(ren)’s slot(s) and will result in temporary suspension or termination.
5. There is a $25.00 processing fee for a returned check. Families must then submit payment by
    credit card, cash or money order to the office.
6. I will notify Catholic Charities office of any work or home phone number changes for myself or
    emergency contacts. I will provide two phone numbers to be reached at in case of an
    emergency for the on site staff.
7. I understand that there will be no after school programs on days the school district closes
    and/or if the school closes early due to bad weather.
8. I am responsible for my child(ren)’s full tuition payment regardless of illness, vacation
    or differences in school calendars.
9. If I choose to have my child(ren) participate in after school activities, I will notify the
    staff in writing.
10. The staff will assume responsibility for my child from the time he/she arrives at the program
    until pick up. Upon arrival each child will be checked in by on-site staff. The child must be
    signed out by a parent/authorized person no later than 6:00/6:30 P.M.
11. If a medical emergency arises, the staff will first attempt to contact me. If I or the emergency
    contacts cannot be reached, the staff will contact the child’s doctor. If the emergency is such
    that immediate medical attention is necessary, my child may be treated as per the
    Emergency Care Permission form.
12. All our after school programs close at 6/6:30 P.M. Parents picking up their children after
    6/6:30 P.M. will be charged $1.00 for every minute they are late. These fines are billed
    directly to me and are payable upon receipt of the bill. Repeated lateness may result in
    dismissal from the program.
13. Parents who need to make changes in the number of days for which your child(ren) is/are
    enrolled should contact the billing office no later than the tenth of the month to be effective
    the following month. There will be a $10 charge for each change of contract fee.
14. There is a 10% sibling discount for additional children from the same family for before and
    after school programs (Full Time Enrollment Only).
15. I am aware that there will be NO REFUNDS for any reason after August 1st.

Failure to comply is a breach of contract and will jeopardize my child(ren)’s space(s) in the

Print Name

Signature                                           Date

Page 6 of 11                                                                       Morris County
                   2010-2011 MORRIS COUNTY
                        RELEASE OF PERSONAL IMAGE

       I hereby irrevocably grant to Catholic Charities, Diocese of Metuchen,
Metuchen Community Services Corporation, its licensees, successors and
assigns, permission to: (1) photograph, record or otherwise reproduce my child’s
likeness, name and other visual and audio effects (hereinafter “Image”); (2)
include or otherwise use the Image in connection with any Public Service
Announcement (PSA); and (3) exhibit, distribute, exploit, advertise and publicize
in any manner, in any media now known or hereafter devised, throughout the
world and in perpetuity, the Image or any portion thereof.

       Catholic Charities, Diocese of Metuchen, Metuchen Community Services
Corporation, its licensees, successors, and assigns, shall own, and I shall have
no claim of any kind, in or to the Image, or PSA. Catholic Charities, Diocese of
Metuchen, Metuchen Community Services Corporation, its licensees, successors
and assigns, may edit, modify, add to, and/or delete any elements or
components of the Image.

        I hereby agree that I will not assert or maintain against Catholic Charities,
Diocese of Metuchen, Metuchen Community Services Corporation, its licensees,
successors and assigns, any claim, action, suit or demand of any kind or nature
whatsoever, including, but not limited to, those grounded upon invasion of the
right of privacy or of publicity or resulting from my child’s real name becoming
known or any other civil rights, defamation, emotional distress, libel or slander or
for any other reason in connection with the exercise of the consent or the rights
granted pursuant to this Release.

Check One:

     I give you the consent to photograph, advertise, or use my child(ren)’s
   image as stated above.

      I do not give consent to use my child(ren)’s image in any manner above.

Child(ren)’s Name(s):

Parent Name (Print):

Parent Signature:


Page 7 of 11                                                          Morris County
                    2010-2011 MORRIS COUNTY

                          Child Care Catholic Charities
                               Confirmation Form

INFORMATION: (please fill in) and return ONLY if using your credit card
each month.
Statements will be sent each month if requested showing your payment and charges. If
your card expires or the number changes, it is YOUR responsibility to notify our office at
(908) 454-2074.





3- Digit Security PIN: #

Expiration Date:

Cardholder’s Name (please print):

Cardholder’s Address:

Cardholder’s Signature:

Child(ren)’s Name(s):

School Attending:

Cardholder above gives Catholic Charities authorization to process monthly child care fee
on or about the first of each month.

NOTE: Monthly reminder statement will NOT be sent unless requested.
Please check if you would like to receive a statement:                    Request Statement

                              700 Sayre Avenue, Phillipsburg, NJ 08865
                          Telephone: (908) 454-2074 Fax: (908) 454-8151

Page 8 of 11                                                                    Morris County
                    2010-2011 MORRIS COUNTY

                           Partners Child Care Program 2010-2011

                          By Catholic Charities, Diocese of Metuchen

PARTNERS MISSION: Believing that all children deserve the opportunity to develop to their
fullest potential, our division is dedicated to providing the highest quality of child care services to
children and their families.


We recognize the dignity and value of the work we do with our families, staff, stakeholders, and
the community.
We provide the highest quality of services to our families and the community.
We recognize the need to be flexible to the changing needs of families, staff, and the
communities we serve.
We will work creatively and cooperatively with families, staff, community, and stakeholders to
ensure that the whole is stronger than the parts.
Culturally Sensitive:
We are responsive to the individuality of our families, staff, and the community.

ENROLLMENT: Any child residing in one of our districts is eligible to attend the before and/or
after school program in his/her district. We accept children ages 5-13 years. Morning kindergarten
children can be accommodated by the before school program (if available), while afternoon
kindergarten children can be accommodated by the after school program.

HOURS: The programs operate from the first day of school in September until the last day of
school in June. After school programs operate from dismissal until 6:00/6:30 PM. Each program
follows the school’s calendar. Programs operate on planned early dismissal days from dismissal
time until 6:00/6:30 PM.

TELEPHONE: Each program has a telephone with a voice mail message system. Staff will
distribute the phone number during the first week of school. This phone is for emergency use only
and will only be answered during program hours. To leave a message for the after school staff,
please leave a message on the site’s voice mail system or with the school office.

      *Your one month’s deposit payment. (Separate check)
      *Your $40 per family non-refundable registration fee.
      *Your completed enrollment packet.

Page 9 of 11                                                                         Morris County
                    2010-2011 MORRIS COUNTY
BILLING: Catholic Charities will bill you monthly, and all payments are due one month in
advance. Payments can be made by check, money order or credit card. Any unpaid balances will
be due prior to enrollment for the 2010-2011 school year. Please be aware If you request to
receive a monthly billing statement as a reminder of your balance due, and that statement
fails to be sent or is not received due to unforeseen circumstances, your obligation for
payment is in no way reduced or eliminated. Please send and make checks payable to:

Catholic Charities SACC
700 Sayre Avenue
Phillipsburg, NJ 08865
Phone: (908) 454-2074
Fax: (908) 454-8151/9871

For any questions about your account, please contact the following:

Warren/Morris Counties
Billing Department
Phone: (908) 454-2074 or (908) 329-2029

**You may now also send your application in to our new child care email address at

DROP-IN ONLY: **Drop-ins are required to send in a $40.00 deposit towards the last month
of drop in fees with their registration fee for a total of $80.00.As the service is used, the drop-
in fee will be billed and payable upon receipt. Any unused payments will either be credited to the
next school year’s account or refunded.

**NEW**EXTENDED CARE: Extended care will be offered to enrolled families at a rate of $35 a
month for one child and $30 for each sibling. Extended care will ONLY be offered if we have 5 or
more children whose parents need to extend their care hours to 6:30 pm are enrolled. Extended
care will be cancelled if we do not reach 5 children.

FINANCIAL ASSISTANCE: There are various New Jersey programs that provide assistance to
working parents. For information about these programs contact the following in your area:

        Child and Family Resources, Morris County: (973) 398-1730

AFTER SCHOOL ROUTINE: All after school programs follow a curriculum called “Links to
Learning” from the National Institute on Out of School Time through weekly activity calendars.
Daily interest areas children can choose from may include: arts and crafts, literacy, health and
fitness, and indoor/outdoor physical activities. Weekly enrichment activities are offered in science,
math, social competence, and cultural diversity. Monthly community service projects are
encouraged. A time for snack is also provided.

HOMEWORK POLICY: A scheduled time is offered in the program for children to work on
homework during the program hours. At this time, program staff will be available to assist children
one-on-one. Quiet activities are provided during this time for the other children. Children are able
to work on homework outside of the scheduled time; however, program staff are not able to sit
with the children individually. We believe that completing homework is the child’s responsibility.
Parents should discuss this expectation with their child in advance of starting the program.

                  Thank you for choosing Partners School Age Programs

Page 10 of 11                                                                     Morris County
                   2010-2011 MORRIS COUNTY


       , the parent/guardian(s) of                               ,
   acknowledge that I/We have received a copy of Catholic Charities Partners
   Programs Parent/Guardian Handbook and have been given the opportunity to
   read the manual and ask questions about and understands the policies
   contained therein. Furthermore, I/We agree to abide by the policies set forth
   in the manual.

   I/We understand that the policies described in the Parent/Guardian Handbook
   are not conditions of enrollment, and the language does not create a contract
   between Catholic Charities Partners Programs and the Parent/Guardians.
   Catholic Charities Partners Programs reserves the right to alter, amend, or
   otherwise modify these guidelines, in its sole discretion, without prior notice.

   I/We acknowledge that this Parent/Guardian Handbook is the property of
   Catholic Charities Partners Programs and must be returned to Catholic
   Charities Partners Programs when the aforementioned child is no longer
   enrolled at Catholic Charities Partners Programs.

   Signature:                                                 Date:

   Print Name:

   Signature:                                                 Date:

   Print Name:

  Program Attending:

Page 11 of 11                                                      Morris County

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