Manchester Family YMCA 7540 Hull Street Road Richmond VA 23235 P 804.276.9622 F 804.745.4866, www.manchesterfamilyymca.org Welcome to the 2015 Manchester Family YMCA Summer Camp! We are happy that you have chosen the YMCA for your child’s summer experience. Before your child can attend our program you must complete the following steps: 1. Fill out an enclosed information packet for each child attending camp. Please be sure to fill in all blanks and return it to the YMCA Child Care Office no later than two weeks prior to the session your child is attending. 2. Two local emergency contacts in addition to the parents must be provided; two phone numbers and complete mailing addresses must be provided. The two emergency contacts must live at separate addresses. 3. A copy of your child’s latest physical and immunization record must be turned in with your packet, a copy from the school or doctor’s office is acceptable. You must also provide us with a copy of your child’s proof of identity; a public school report card or birth certificate. 4. Sunscreen and bug spray should be applied to each camper before arrival at camp. Please complete a MAT medication form (one per item) if you would like for your child to re-apply sunscreen and/or bug spray during the day (after swimming and after rest time). Parents must supply bug spray and sunscreen. Counselors will assist children but may not apply lotions. Spray sunscreen and bug spray are suggested. 5. If your child will need prescription medication while at camp, please request a MAT medication form. This form will need to be completed and signed by your child’s physician. A completed form is required before medication may be accepted or administered. 6. Please read the Parent Handbook and other materials enclosed. **Your child’s registration will not be considered complete until the above have been completed and turned in! ** REMINDER: Registration fee and weekly deposits are due at time of registration. All remaining session fees will be drafted the Monday prior to the start of each session. If you have any questions, please do not hesitate to contact Youth and Family Director, Ashley Spiller at [email protected] or Business Services Director, Kim Domingo at [email protected]. We look forward to serving your family this summer!
Transcript
Manchester Family YMCA 7540 Hull Street Road Richmond VA 23235
P 804.276.9622 F 804.745.4866, www.manchesterfamilyymca.org
Welcome to the 2015 Manchester Family YMCA Summer Camp!
We are happy that you have chosen the YMCA for your child’s summer experience.
Before your child can attend our program you must complete the following steps:
1. Fill out an enclosed information packet for each child attending camp. Please be sure
to fill in all blanks and return it to the YMCA Child Care Office no later than two weeks
prior to the session your child is attending.
2. Two local emergency contacts in addition to the parents must be provided; two phone
numbers and complete mailing addresses must be provided. The two emergency
contacts must live at separate addresses.
3. A copy of your child’s latest physical and immunization record must be turned in with
your packet, a copy from the school or doctor’s office is acceptable. You must also
provide us with a copy of your child’s proof of identity; a public school report card or
birth certificate.
4. Sunscreen and bug spray should be applied to each camper before arrival at camp.
Please complete a MAT medication form (one per item) if you would like for your child
to re-apply sunscreen and/or bug spray during the day (after swimming and after rest
time). Parents must supply bug spray and sunscreen. Counselors will assist children
but may not apply lotions. Spray sunscreen and bug spray are suggested.
5. If your child will need prescription medication while at camp, please request a MAT
medication form. This form will need to be completed and signed by your child’s
physician. A completed form is required before medication may be accepted or
administered.
6. Please read the Parent Handbook and other materials enclosed.
**Your child’s registration will not be considered complete until the above have been
completed and turned in! **
REMINDER: Registration fee and weekly deposits are due at time of registration. All
remaining session fees will be drafted the Monday prior to the start of each session.
If you have any questions, please do not hesitate to contact Youth and Family Director,
Ashley Spiller at [email protected] or Business Services Director, Kim Domingo at
[email protected]. We look forward to serving your family this summer!
MANCHESTER FAMILY YMCA SUMMER CAMP
Manchester Family YMCA
(804) 276-9622
www.manchesterfamilyymca.org
Youth and Teen Summer Day Camp
2015
Camper’s First Name: _____Camper’s Last Name: ____________
Sex: Birth Date: ______ School: __ Next Grade: ___
Street Address: _______City: ______Zip:___________
Home Phone: ___________________ Email Address: _____________________
I wish to enroll my child in a Manchester Family YMCA summer program as indicated by the registration
form. I understand checks will be processed as a one-time EFT from my bank account and the session
balance will be drafted on the Monday prior to the start of the session.
Parent Signature: Date:
VIRGINIA CHILD CARE LICENSING AGREEMENT
School Year:
Please print information on form.
Child’s Information:Last Name: First Name: MI
Nickname: Gender: Female Male Birth Date Age
Address: City: State: Zip:
Start Date: End Date: YMCA Facility Member Yes No
List Previous Child Care Centers/Schools: Member #:
School Attending: School Phone #: ( ) Grade:
Parent(s)/Guardian(s) Information:
Parent/Guardian: Relationship:
Address:
Home Phone: ( ) Work Phone: ( ) Company Name:
Cell Phone:
Primary E-Mail:(To Receive Program Updates)
Parent/Guardian: Relationship:
Address:
Home Phone: ( ) Work Phone: ( ) Company Name:
Cell Phone:
Primary E-Mail:(To Receive Program Updates)
Person or agency having legal custody:
Address if different from above:
Emergency Contact Information: (Other than Parent(s)/Guardian(s) listed above)
First Emergency Contact: Relationship:
Home Phone: ( ) Work Phone: ( ) Company Name:
Cell Phone: ( ) Alternate Phone #: ( )
Address: City: State: Zip:
Second Emergency Contact: Relationship:
Home Phone: ( ) Work Phone: ( ) Company Name:
Cell Phone: ( ) Alternate Phone #: ( )
Address: City: State: Zip:
Person(s) authorized to PICK-UP your child: Relationship:
Person(s) authorized to PICK-UP your child: Relationship:
Person(s) NOT authorized to PICK-UP your child: Relationship:
Person(s) NOT authorized to PICK-UP your child: Relationship:
Parent/Guardian Signature: Date:
Administrator of Center: Date:
EFT Policy: The YMCA of Greater Richmond converts all check payments to a one-time electronic funds transfer No registration can be accepted if there is an outstanding balance due associated with this membership account
/ /
IT IS AGREED THAT THE YMCA WILL NOTIFY THE PARENT(S)/GUARDIAN(S) OF ANY ILLNESS OF THE CHILD AND THAT THE CHILD WILL BE PICKED UP AS SOON AS POSSIBLE THEREAFTER.
Medical Information:Allergies or intolerance to food, medication, etc:
If an allergic reaction occurs, please list steps to take to relieve reaction:
Is your child allergic to: Poison Ivy Poison Oak Sumac Other No
Is your child allergic to bee stings? No Yes If yes, what type of medical treatment is needed?
Chronic physical problems, pertinent developmental information, any special accommodations needed:
Health History (please check if your child has/had any of the following): Asthma Chickenpox Convulsions Frequent Ear Trouble Fainting Spells Frequent Colds Heart Trouble Frequent Sore Throats Frequent Headaches Measles Polio Meningitis Mumps Sinusitis Tuberculosis German Measles Kidney Trouble Diabetes
Does your child take medications or vitamins on doctor’s orders? If so, please specify:
If center is to administer medications, previous contact must be made for proper procedures (An authorization form is available upon request and is required with each medicine.) Has your child had a tetanus shot within the last 5 years? Yes Date of shot: No Has your child in the past six months been under medical care? Yes No
If yes, please provide the details:
Child’s Physician and Office Name: Physician’s Phone: ( )
Parent/Guardian Signature: Date:
Emergency Medical AuthorizationI give the YMCA of Greater Richmond permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member of the YMCA of Greater Richmond. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I authorize the YMCA of Greater Richmond to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may cover only those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts.
I/we will be responsible for payment of medical expenses. Medical treatment costs are covered by:
Insurance Company Name: Policy #:
Parent/Guardian Signature: Date:
Parental Agreement1) The child day care center agrees to notify the parent/guardians whenever the child becomes ill and the parent/guardian will
arrange to have the child picked up as soon as possible if so requested by the center.
(2) The parent/guardian authorize the child day care center to obtain immediate medical care if any emergency occurs when the parent /guardian cannot be located immediately.
(3) The parent/guardian agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, a defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
Parent/Guardian Signature: Date:
Permission Slips
I hereby give my permission for the YMCA to take my child on supervised walking excursions. Yes No
I hereby give my permission for the YMCA to take my child on field trips. Yes No
Parent/Guardian Signature: Date:
Transportation Authorization/Rules Children must follow these basic safety rules while being transported. With the first infraction, a parent will be notified and asked to discuss proper behavior with his/her child. With the second infraction, transportation services may be denied for a mini-mum of two days, and the parent will be notified. With the third infraction, transportation services will be terminated. 1) No fighting, swearing or abusive behavior. 2) Must remain seated properly with seat belt on at all times. 3) Cannot have any part of his/her body out of the vehicle. 4) No eating or drinking on the vehicle. 5) May throw nothing out of the window. 6) Potentially dangerous actions will not be tolerated. 7) Must be respectful to and listen to the bus driver.
My child has permission to be transported by a YMCA vehicle and participate in ALL YMCA program activities and related field trips.
Parent/Guardian Signature: Date:
Swimming/Wading/BoatingRules of the Pool: Check child’s swimming level: Beginner Intermediate Advance 1) All children must pass the swim test in order to participate in free swim. 2) No running, pushing or dunking. 3) No abusive language or rough play will be allowed 4) Lifeguard has the right to dismiss anyone who is careless or dangerous to others. 5) No diving in shallow water. 6) No food or drinks in pool area. 7) No unauthorized flotation devices.
My child has my permission to participate in swimming activities. I HAVE READ AND UNDERSTAND THE POOL/WATER RULES.
Parent/Guardian Signature: Date:
Photography ReleaseI hereby irrevocably consent to and authorize the use and reproduction by the YMCA of Greater Richmond or anyone authorized by the YMCA of Greater Richmond of any and all photographs and videos which might be or have been taken during the program of my child, for any purpose whatsoever without compensation to me for future promotional purposes.
Parent/Guardian Signature: Date:
Parent Statement of Understanding• IunderstandtheYMCAStaffandVolunteersareprohibitedfrombabysittingortransportingchildrenintheirpersonalvehicles
at any time outside of the YMCA program(s).
• IunderstandthatIamnottoleavemychildattheYMCAofGreaterRichmondorprogramsiteunlessaYMCAStaffistheretoreceive and supervise my child.
• Iunderstandthatmychildwillnotbeallowedtoleavetheprogramwithanunauthorizedperson.Anypersonauthorizedtopick-up my child must either be listed with the YMCA of Greater Richmond or other arrangements must be made by calling the YMCA office to inform them of a change.
• Failuretoup-datepersonalinformationmayresultinwithdrawalfromtheprogram.Forsafetyreasons,itisextremelyimpor-tant to be able to reach the parent(s)/guardian(s) or emergency contact(s) for a child in our program.
• Iunderstandthatshouldapersonarrivetopick-upmychildwhoappearstobeundertheinfluenceofdrugsoralcohol,forthe child’s safety, staff may have no recourse but to contact the police. Please do not put staff in a position where they have to make this judgment call.
I understand that the YMCA of Greater Richmond and its child care employees are mandated by state law to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.
Parent/Guardian Signature: Date:
Disciplinary and Behavior Management PolicyThe YMCA of Greater Richmond will not tolerate unacceptable behavior and the consequences will be explained to our program participants.
1) Participation in an activity will be denied for repeated poor behavior and the child will be directed to an alternate activity.
(2) The parent(s)/guardian(s) will be informed by phone, in writing and through parent/guardian conferences, if the child continues to display poor behavior. Physical discipline will not be used nor will food be denied as a punishment.
(3) If the unacceptable behavior endangers another’s safety or the child’s safety, immediate suspension/termination may result. The parent/guardian of the child will be notified and the child MUST be picked-up WITHIN ONE HOUR after notifi-cation. If you are unable to pick-up your child immediately, please make other arrangements for someone to pick-up your child immediately. Failure to pick-up your child within ONE HOUR after notification may result in withdrawal from the program.
Failure to comply with the following rules may result in an unacceptable behavior notification: • Repeatedlyengaginginfighting(physicalaggression)asawaytosolveanissue.• StealingordefacingYMCAorother’sproperty.• Refusingtofollowbasicsafetyrules.• Repeateddisrespectforstafforrudeanddiscourteousbehaviortowardotherchildren.• Repeatedlydisplayinganinabilitytofollowestablishedguidelines.• Anyact(s)thatis(are)deemedunsafeorunacceptableasdeterminedbythestaff.
The YMCA requires the support of the parent(s)/guardian(s) in encouraging appropriate behavior of their child. The YMCA staff will strive to provide a safe and fun environment for all program participants; however, the YMCA will not allow children who continually display disruptive behavior to hinder the safety or enjoyment of others.
We encourage parents’ comments. Please do not hesitate to discuss any concerns you may have with the Child Care Director . Thank you for you cooperation.
Parent/Guardian Signature: Date:
Parent HandbookI have received the parent handbook and it is my responsibility to read and understand/be aware of ALL policies in the parent hand-book. If you have any questions, please contact the Association Child Care Director of the YMCA of Greater Richmond at (804) 474-4417.
Parent/Guardian Signature: Date:
Release From LiabilityRecognizing that the YMCA of Greater Richmond will do its best to ensure a safe experience, I understand that accidents may occur both from my child’s participation in activities and from transportation to and from the program. I agree to assume these risks. By signing below, I release the YMCA of Greater Richmond, its employees, volunteers, independent contractors, directors and agents from all liability based on any damage, loss or injury whether it is the result of ordinary negligence or otherwise, caused to my child from participation in the program.
Parent/Guardian Signature: Date:
Financial AssistanceThe YMCA of Greater Richmond wants to provide services for everyone and does not want to turn anyone away due to his/ her inability to pay for programs. It is the YMCA of Greater Richmond’s policy to provide services for any youth who desires to participate in a YMCA program. Through the generosity of the YMCA of Greater Richmond’s annual giving campaign we are able to offer a limited number of financial assistance spaces. For additional information, please contact the Financial Assistance Coor-dinator.
Identity Verification(Not required for children enrolled in a Virginia public school if Y program is transporting child directly to/from public school)
Place of Birth Birth Date Birth Certificate Number Date Issued
Other Form of Proof Date Documentation Person Viewing Documentation Viewed
If proof of identity is required and a copy is not kept, please fill out the following.
Date of Notification of Local Law-Enforcement Agency (when required proof of identity is not provided):
Date
Proof of the child’s identity and age may include a certified copy of the child’s birth certificate, birth registration card, notifica-tion of birth (hospital, physician or midwife record), passport, copy of the placement agreement or other proof of the child’s identity from a child placing agency (foster care and adoption agencies), record from a public school in Virginia, certification by a principal or his designee of a public school in the U.S. that a certified copy of the child’s birth record was previously presented or copy of the entrustment agreement conferring temporary legal custody of a child to an independent foster parent. Viewing the child’s proof of identity is not necessary when the child attends a public school in Virginia and the center assumes responsibility for the children directly from the school (i.e., after school program) or the center transfers responsibility of the child directly to the school (i.e., before school program). While programs are not required to keep the proof of the child’s identity, documentation of viewing the information must be maintained for each child.
Section 63.2-1809 of the Code of Virginia states that the proof of identity, if reproduced or retained by the child day program or both, shall be destroyed upon the conclusion of the requisite period of retention. The procedures for the disposal, physical destruction or other disposition of the proof of identity containing social security numbers shall include all reasonable steps to destroy such documents by (i)shredding,. (ii) erasing, or (iii) otherwise modifying the social security numbers in those records to make them unreadable or indecipherable by any means.
Accounting PoliciesThe Annual Registration fee and one week’s fee for each child is due upon enrollment, and is non-refundable. A fixed weekly payment is due each week, whether a child is in attendance or not. This payment is due on Monday prior to the week services are to be rendered. There are no vacation or free weeks.
Important Note: There is an additional fee per day for full day care when schools are closed due to inclement weather. If you choose to bring your child to the YMCA for care the additional fee per day will be drafted from your childcare account that is on file.
Member/Participant Signature: Date:
Draft Authorization
Member/Participant Name:
Address: City: State: Zip:
Home Phone: ( ) Work Phone: ( )
Child’s Name:
I would like for have my remaining balance automatically drafted from my:
Checking Account (Please attach a voided check)
Routing Number:
Account Number:
Bank Name:
Name of Account Holder:
Credit/Debit Card (please attach a copy of card)
VISA Master Card AMEX Discover
Credit Card Issuer:
Credit Card Number:
Expiration Date:
Name of the Account Holder:
All draft will be taken on the Monday prior to the week of service.
Draft Begins Draft Ends I understand that this draft will remain in effect until all payments have been made for the enrolled program, or for the time we are participants. I understand that if I wish to terminate or change my draft, I must give the YMCA a 15 day written notice. Questions regarding your draft should be addressed to the Childcare Office Manager, as soon as possible. Any error must be identified no later than 10 days from the posted bank or credit card statement date.
Should my bank or credit card issuer for any reason not honor my draft, I realize that I am still responsible for that payment, plus a $25 return service fee and $10 late fee applied by the YMCA. This is in addition to any service fee my bank may charge. I also realize that my account will be automatically re-debited on the next drafting cycle for payment of a draft not honored. I understand that after two unresolved drafts services to my child will be terminated.
Written Medication Consent Form
This is a double-sided form
• This form must be completed in a language in which the child care provider is literate. • One form must be completed for each medication. Multiple medications cannot be listed on one consent form. • Parents MUST complete #1 through #23 (omit #18) for medication to be administered 10 days or less OR for non-prescription
topical medication including sunscreen, diaper ointment or insect repellent. • The child’s health care provider MUST complete #1 through #18 for Long-Term medications or when dosage directions state
“consult a physician.” The parent completes #19 through #23.
1. Child’s first and last name:
2. Date of birth: 3. Child’s known allergies:
4. Name of medication (including strength):
5. Amount/dosage to be given: 6. Route of administration:
7A. Frequency to be administered: OR
7B. Identify the symptoms that will necessitate administration of medication: (signs and symptoms must be observable and, when possible, measurable parameters)
8A. Possible side effects: □ Parent must supply package insert (or pharmacy printout) for complete list of possible side effects AND/OR
8B: Additional side effects:
9. What action should the child care provider take if side effects are noted: □ Contact parent □ Contact prescriber at phone number provided below □ Other (describe):
10A. Special instructions: □ Parent must supply package insert (or pharmacy printout) for complete list of special instructions
AND/OR
10B. Additional special instructions: (Include any concerns related to possible interactions with other medication the child is receiving or concerns regarding the use of the medication as it relates to the child’s age, allergies or any pre-existing conditions. Also describe situations when medication should not be administered.)
11. Reason the child is taking the medication (unless confidential by law):
12. Does the above named child have a chronic physical, developmental, behavioral or emotional condition expected to last 12 months or more and requires health and related services of a type or amount beyond that required by children generally? □ No □ Yes If you checked yes, complete #33-#34 on the back of this form.
13. Are the instructions on this consent form a change in a previous medication order as it relates to the dose, time or frequency the medication is to be administered? □ No □ Yes If you checked yes, complete #35-#36 on the back of this form.
14. Date consent form completed: 15. Date to be discontinued or length of time in days to be given (this date cannot exceed 6 months from the date authorized or this order will not be valid):
16. Prescriber’s name (please print):
17. Prescriber’s telephone number:
18. Licensed authorized prescriber’s signature: Required for Long-Term medication or when dosage directions state “consult a physician”.
Written Medication Consent Form
This is a double-sided form
PARENT/GUARDIAN MUST COMPLETE THIS SECTION (#19 - #23) 19. If Section #7A is completed, do the instructions indicate a specific time to administer the medication? (For example, did the prescriber write 12pm?) □Yes □ N/A □ No Write the specific time(s) the child day program is to administer the medication (i.e.: 12pm):
20. I, parent/legal guardian, authorize the child day program to administer the medication as specified in the “Licensed Authorized Prescriber Section” to . (child’s name)
21. Parent or legal guardian’s name (please print):
22. Date authorized:
23. Parent or legal guardian’s signature:
CHILD DAY PROGRAM TO COMPLETE THIS SECTION (#24 - #30)
24. Provider/Facility name:
25. Facility telephone number:
26. (leave blank)
27. I have verified that #1-#23 and if applicable, #33-#36 are complete. My signature indicates that all information needed to give this medication has been given to the child day program.
28. Authorized child care provider’s name (please print):
29. Date received from parent:
30. Authorized child care provider’s signature:
ONLY COMPLETE THIS SECTION (#31-#32) IF THE PARENT REQUESTS TO DISCONTINUE THE MEDICATION PRIOR TO THE DATE INDICATED IN #15
31. I, parent/legal guardian, request that the medication indicated on this consent form be discontinued on
. Once the medication has been discontinued, I understand that if my child (date) requires this medication in the future, a new written medication consent form must be completed.
32. Parent or Legal Guardian’s Signature:
LICENSED AUTHORIZED PRESCRIBER TO COMPLETE, AS NEEDED (#33 - #36) 33. Describe any additional training, procedures or competencies the child day program staff will need to care for this child.
34. Licensed Authorized Prescriber’s Signature:
35. Since there may be instances where the pharmacy will not fill a new prescription for changes in a prescription related to dose, time or frequency until the medication from the previous prescription is completely used, please indicate the date by which you expect the pharmacy to fill the updated order. DATE: By completing this section the child day program will follow the written instruction on this form and not follow the pharmacy label until the new prescription has been filled.
