YMCA of Reading and Berks County BEFORE & AFTER ......for all. WELCOME: Thank you for choosing the YMCA as your School Age Child Care provider. We look forward to serving you and your

YMCA of Reading and Berks County

BEFORE & AFTER SCHOOL&

YOUTH EDUCATIONAL SUPPORT HANDBOOK

2020 - 2021 EditionYMCA Early Learning Center

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YMCA of Reading & Berks County Youth Educational Support-All Day Care

Parent-Family Handbook Tri Valley YMCA

GENERAL YMCA INFORMATION: Richmond Program Center 14432 Kutztown Road Fleetwood, PA 19522 (610) 944-1075

Branch Executive- Brandon Shurr Child Care Director- Nyree Fernandez

PROGRAM LOCATION:

YMCA Early Learning Center 14432 Kutztown Road Fleetwood, PA 19522 (610)-944-1075

HOURS OF OPERATION: All Day Care: 6:30 AM to 5:30 PM

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COST Daily Weekly PER SESSION PER WEEK

YES Program- Youth Educational Support

$30.00 $135.00

Registration $25.00 per child registration fee, non-refundable ** Please take time to read, review and sign off on our enrollment policy for the 2020-2021 school year. There will

be no reduction in fees for emergency closings, illness and scheduled family vacations **

MISSION: To put Judeo-Christian principles into practice through programs that build healthy spirit, mind, and body for all.

WELCOME: Thank you for choosing the YMCA as your School Age Child Care provider. We look forward to serving you and your family. If you have any questions regarding this or any other YMCA program, please contact your respective YMCA at your earliest convenience.

GOALS & PHILOSOPHY: Goals of the Before & After School Program:

• Support and strengthen the family unit.• Promote the children’s self-image, feelings of self-worth and leadership qualities.• Provide activities which meet the educational, physical, mental, social and emotional

needs of each child.• Provide a safe environment which is warm and stimulating.• Assist and support children, families and local school districts with virtual learning.

Our program also features age appropriate, recreational activities using music, movement, crafts, games and other resources. Children must be able to thrive in a group setting. We do not provide one on one care.

EQUAL OPPORUNITY The YMCA of Reading & Berks County is an equal opportunity provide. Applications for enrollment are accepted without regard to race, religion, sex, disability, sexual orientation, political beliefs, family status, or national origin. We celebrate diversity and know that our children benefit through an enriched learning environment.

LICENSING: All YMCA Child Care sites are regulated by the Department of Human Services and participate in Pennsylvania’s Keystone STARS Quality Rating System.

By enrolling in YMCA Child Care you are agreeing to the terms in our manual and to state regulations.

REGISTRATION PROCESS Each child’s parent or guardian must complete the school age registration packet. The following forms must be completed and returned BEFORE your child attends school age care. We will accept registration on a first come, first served basis as we will have LIMITED ENROLLMENT. Paperwork should be emailed to Brandon Shurr at [email protected] or mailed to our facility.

mailto:[email protected]

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Forms due at time of enrollment • Parent Statement of Understanding Page 14 • Getting to Know You Page 15 • Permission to Post Allergies Page 16 • Getting to Know You and Your Child Page 17 • Emergency Contact/Parent Consent Form/Agreement Page 18 and 19

o Updated every 6 months • Child Health Assessment & Shot Records Page 20

o Updated as required by DHS o This MUST be submitted prior to the start of care!

• Fee Service Agreement Page 21 o Updated at a time of change in fees or service,

at least annually • Acceptance of Handbook Page 22 • COVID-19 Waiver Page 23 • Acceptance of Health and Safety Plan Page 24 • Homework Policy Sign off Page 25 • CACFP Meal Benefit Page 28-33 • Release and Waiver of Liability Page 34 • Code of Conduct Page 35 • COVID-19 Information Release Page 36 • Photo and Visual Release Page 37

Any court order that impacts your child’s enrollment, i.e. a Protection from Abuse for you or your child, a visitation agreement or custody agreement must be supplied at the time of enrollment or at the time the document is in effect.

KEYSTONE STARS The YMCA of Reading & Berks County is a participant of the government rating and funding program called Keystone Stars. Through Keystone Stars we are committed to increasing our standard of care and promoting quality child care environments that contributes to increased social and emotional development, learning skills, and school readiness. Keystone Stars measures our center in 3 ways: staff employed, the everyday environment your child is in, and the way a facility runs its business.

COVID-19 HEALTH AND SAFETY PLAN All parents will receive a YMCA health and safety plan at the time of enrollment.

DROP OFF/ PICK UP Due to COVID-19, we will be limiting the number of people in our building. Before drop off each day, please take time at home to say goodbyes, give hugs and wish your child an awesome morning at the YMCA! Please understand that drop off and pick up will be a more time consuming process than it has been in prior years. Because there may be some wait time, we ask you to please arrive a few minutes early.

Drop off procedures will be as follows:

• Pull up to drop off area along the curb and a director or other member of our team will be waiting to greet you and get your child checked in. If another family is being assisted, please wait in your car until a member of our staff is ready to greet you.

• Prior to entry of the facility, we will check your child’s temperature using an infrared thermometer. We will also ask you and your child some basic health questions to make sure your child is healthy enough to attend care for the day.

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o If your child has a fever of 100.4 degrees Fahrenheit or greater, or any other COVID-19 symptoms (shortness of breath, cough, etc.) your child will not be admitted to care. To return to the YMCA, your child must be evaluated by a physician and return with a doctor’s note stating that your child is allowed to return to care.

• If your child is healthy, a member of our team will then escort your child into the building for a fun- filled morning of care!

Pick up procedures will be as follows:

• Pull up to entryway and ring the bell at the Reed Street Entry. A director or other member of our team will be waiting to greet you. At that time, you will let us know your child’s name. Please have your ID ready—We will only release your child to the individuals listed on their emergency contact form.

• A member of our team will then escort your child out of the building to your vehicle.

REMEMBER: WE CANNOT RELEASE YOUR CHILD TO ANYONE THAT IS NOT ON THIS PAPERWORK. We will contact the parent/guardian for permission if someone not on the list comes to pick up the child. We know that emergencies happen so parents should send written notice (signed and dated by the parent/guardian) when someone not on the pickup list will be coming to pick up their child.

MASKS

According to the Pennsylvania Department of Health, masks are required for our staff and children over the age of 2.

TUITION POLICY Payments can be made by cash or check at the child care location. You may also make payments at the Reading YMCA by cash, check, or credit card.

Payments may also be mailed to: Tri Valley YMCA

607 Crisscross Road Fleetwood, PA 19522

• All families are required to pay the non-refundable $25.00 per child registration fee. • Fees are due the Friday prior to the week of care. All contracted fees are due weekly. • For returned checks a fee of $20.00 will be applied to your account. After two returned checks you

will need to make all payments by cash or money order, checks will no longer be accepted at this point.

• Year-end statements will be available for pickup by January 31st for tax purposes. • Termination of services may occur for failure to pay and a claim will be made with the District Court

to collect any outstanding balance • If your account is turned over to a third – party for collections, you are responsible for all incurred

collection costs. • There is no sibling discount. • We accept all forms of subsidy, it is the parents’ responsibility to pay the subsidy co-pay and

update subsidy information or services will be terminated. • Failure to comply with this payment agreement will result in your child’s suspension from the

program in addition to continuing late fees until balance is paid in full. • The YMCA does accept forms of subsidized child care payment such as ELRC, Welfare, & United

Way. o Children who receive ELRC (CCIS) funding are provided 40 paid absent days per year (July 1

through June 30). Absent days exceeding the 40 paid days must be paid by the family. o On holidays and closings parents are still required to pay their weekly copay.

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• The YMCA does NOT reimburse or credit for any unattended days, unless provided with a doctor’s excuse. NO EXCEPTIONS!

• You will not be credited or reimbursed in the event of holiday’s, school delays or closings.

DISMISSAL POLICY The YMCA may terminate care at any time without notice if you or your child violates any policy outlined in this manual or in the Department of Human Services Code Book.

PROGRAM CALENDAR The YES Program will follow the YMCA Early Learning Center’s Calendar along with the Fleetwood Area School District.

INCLEMENT WEATHER POLICY

In the event that the YMCA Early Learning Center needs to close due to inclement weather parents should stay tuned to channel 69 news.

HEALTH & ILLNESS POLICY It is strongly recommended that children are immunized. Children enrolled in YMCA child care programs are required to have a physical examination by a doctor of the parents choosing within one (1) month of enrolling. A new examination will be required bi- annually. The parent shall cover all costs related to the medical care of the child.

Each child shall be observed for signs of illness within the first few minutes of drop off. As a parent, you should discuss any information regarding your child’s health with the child care staff. The YMCA takes measures to prevent illness; however it can be a problem anywhere two (2) or more people gather. Schools where children play closely are especially vulnerable. A child exhibiting signs of illness will not be admitted to the Schools Out program. This is at the discretion of the Director or his/her designee.

In the event that your child becomes sick at the program, you will be notified and your child will need to be picked up from the program immediately. It is extremely important that you have a responsible emergency contact person. An ill child shall be kept at home for a minimum of twenty-four (24) hours or illness specific length of time (whichever is longer) before returning to the child care program. A doctor's note will not be accepted until the minimum twenty-four (24) hour policy is satisfied.

Persons who have a fever of 100.4 degrees Fahrenheit or above, or other signs of illness will not be admitted to the facility. The YMCA will encourage parents to be on the alert for signs of illness in their children and to keep them home when they are sick. YMCA Child Care Staff and Directors reserve the right to send a child home if a child exhibits signs and symptoms of illness at their discretion.

No medication will be administered at the child care site, unless life threatening (Asthma, diabetes, food allergy). A special care plan will be requested for any child who has medical needs requiring extra care. This document should be completed by your child’s health care provider. Please arrange to administer your child’s medication at home or school.

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In case of serious illness or injury, paramedics will be called and your child will be taken to the nearest medical facility. You will be called immediately. A child care staff member will accompany your child to a medical facility and will remain with your child until you or an emergency contact person arrives.

In the case of minor injury, staff certified in first aid procedures will administer first aid. A courtesy call may be made to the parent. An injury report will be completed and kept on file in the YMCA office and child’s file.

SPECIAL CARE PLANS An individual care plan is requested for any child who has medical needs requiring extra care. In cases where a child has a severe allergy or would need life sustaining medication, an Individual health care plan would be completed by your child’s health care provider with your input, and implemented by caregivers. The purpose of the plan is to provide our staff with specific medical information; medications and treatments required routinely, any modifications needed for daily activities and would also list emergency care routines.

SIGN-IN/SIGN-OUT POLICY All children must be picked up by the time on their contract agreement and signed out. Any child that is picked up late after their contracted time will have be given a verbal warning; after the verbal warning will be a written warning. After the third late pick up their will be a fee of a $1.00 per minute/per child. After the programs is closed and a child is not picked up its a $1.00 per minute/per child.

If your child is to be picked up by another person, advance notice must be given to the Director. For safety purposes, children will NOT be released to anyone except their designated persons unless prior written notification is given. Children will not be released to persons under the age of 16. Picture identification will be required.

We will not release children to an individual who appears to be mentally impaired, by drugs, alcohol, or other influence. Police will be contacted.

PARENT NOTIFICATON AREA: As a parent it is your responsibility to ensure that you have all the information you need regarding the YMCA, the YMCA program and your child's progress. Please take the time to ask questions and meet with your child's staff. Each center has a parent notification area that you need to check daily for notices, and other requests.

This daily communication is in addition to our annual 2 parent teacher conferences.

A newsletter will be published and distributed periodically. Please take the time to read it.

LATE PICK UP POLICY

The YMCA understands that lateness is sometimes unavoidable so this policy is in place. Lateness is considered past contracted hours based on the program’s clock.

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A $1.00 late fee will be billed to your account for every minute past the program ending time per child.

MEDIA POLICY There will be times when we photograph and or video this program. The YMCA reserves the right to use this media for marketing purposes. There will be no form of compensation made to a family for the use of a photograph or video clip of their child.

CELL PHONE POLICY Due to the photographic capabilities of many cell phones, video cell phone use is prohibited in all YMCA Child Care locations. Please help us protect our children and staff by keeping all cell phones away or turned off.

SNACKS The YMCA will provide a snack for all program participants in the YES Program. The YMCA has a strict no peanut policy and does not allow any peanut or peanut products to be brought into our programs or served to children. Outside food is not permitted unless the child has a doctor’s note special circumstances.

CHILD ABUSE PREVENTION: Child Abuse is a serious concern for the YMCA and will not be tolerated in any form from Staff, Parents/Guardians, Family, Friends, or another child. Allegations will be taken seriously and will be reported to the proper authorities. Reports of suspected abuse are confidential and the YMCA will not confirm nor deny that a report was made. YMCA and all Schools Out staff are mandated child abuse/neglect reporters as required by Federal and State laws governing the YMCA Schools Out Programs. Please be aware that the YMCA, its staff, members, and volunteers have the best interest of the child at heart.

CLOTHING & FOOTWEAR: The YMCA will not be held responsible for any lost, stolen, or damaged clothing, jewelry, or other personal items. Items will not be replaced; there will be no reduction in fee or other form of compensation. It is strongly recommended that children be dressed in washable, inexpensive, comfortable play clothing and footwear. We believe that sneakers or other closed shoes are the safest and most practical. Because there are so many children involved in this program it is very important that all clothing, jackets, backpacks, etc., be clearly labeled with your child's name.

CANDY, GUM, TOYS, & ELECTRONICS: The YMCA requests that no additional candy, gum, toys, and/or electronics be brought to the program and/or facility.

INCLUSION AND EXPULSION The YMCA of Reading and Berks County strives to offer quality developmentally appropriate educational programs to children. One of the main components to success is our partnering with parents to help their child grow within our center and at home. We also recognize that, "one size does not fit all", meaning our childcare environment although inclusive (within the scope of our personnel’s expertise/education under DHS staff requirement for Childcare Centers and DHS staff educational training requirements :

“Commonwealth of Pennsylvania Code Chapter 3270 Child Day Care Centers” 3270.31-3270.31a- 3270.34-37 and within the extent of the law) may not meet the expectations you envision for your child's program. Therefore, in an effort to clarify our program capabilities, facilitate your child's success, allow The

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YMCA of Reading and Berks County to do an effective job collectively meeting the health and safety needs of all persons in our program, and OCDEL Announcement # 17, we have established the following policies:

*In an effort to eliminate and reduce child suspension and or expulsion the following behavior management policies:

BEHAVIOR POLICY: Based on the Golden Rule “Treat others as you would want them to treat you.” Children will respect the rights and feelings of others and will avoid disruptive behavior that would interfere with program activities. Aggressive behaviors and unsafe behaviors will not be tolerated and will result in dis-enrollment. Children shall demonstrate self-control and shall follow all directions given by the teachers regarding safety procedures and shall stay with the group for all scheduled activities. The YMCA provides opportunities for children to thrive in a group setting. We do not provide one on one care.

The YMCA wants every child to succeed and our staff tries their hardest to make sure that every child is enjoying themselves. Unfortunately, there are times that this is tested and certain behaviors make it necessary for disciplinary actions to be taken. For each instance there are consequences. Most behavior will not be severe and will follow the steps listed below. At times, severe behavior such as fighting may cause staff to determine that a higher consequence level is warranted.

The YMCA follows the following consequences for children’s behavior; however the YMCA reserves the right to skip any and all of these steps as they see necessary:

Consequence #1: Warning.

Consequence #2: Written Documentation

Consequence #3: After three written notices, child will be suspended for three days.

Consequence #4: Once child returns, after first suspension, if another written notification occurs, child will be suspended for one week.

Consequence #5: Once child returns, after second suspension, if another written notification occurs, child will be terminated for the rest of the program.

Please understand that suspension and termination are steps we hope to not have to take, however the safety of all the children and staff is our priority.

Please Note: All disciplinary issues are at the discretion of the Branch Executive, Program Director, and Child Care staff.

Parents will be notified of inappropriate behaviors.

PARENT CODE OF CONDUCT: As a parent please conduct yourself in a manner that is consistent with YMCA policies while you are on YMCA property or YMCA program sites. Please refrain from inappropriate conduct; using harsh, demeaning, threatening or abusive language; speaking at a level that is not appropriate; physical violence towards staff, a child (your own or another), another parent, member or volunteer, materials or property.

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If inappropriate behavior is displayed on YMCA premises your service may be terminated. We also require that you come to the center dressed appropriately and fully covered.

PARENT PARTICIPATION Parents are a vital role in young children’s learning. YMCA Child Care invites and encourages parents to participate in the program in whatever way is possible. We have at least 2 parent conferences per year to keep you informed of your child’s progress.

FAMILY GROUPS Parents are invited and encouraged to ask about participating in center family groups and are always welcome to attend meetings. The purpose of child care center family groups is to make sure long and short term goals and decisions are made in accordance with the YMCA’s philosophy and mission. See center director for additional information.

GRIEVANCES If you have a comment or question about your child's care please bring this to our attention in a timely manner. You may speak to the Director, or the senior staff in charge. If you feel your concern was not handled satisfactorily, you may speak with the Branch Executive Director and/or the Director of Early Education. A grievance may be taken to the highest level.

CHILD RECORDS All of our centers are licensed by the Department of Human Services, DHS. We are required to keep confidential files on your child. At the time of registration, you will receive an intake packet with all of the required documentation that must be in your child’s file. Please return this paperwork to the YMCA office prior to the first day of program attendance.

As a participant in Keystone Stars and licensed child care center, we are required to do various observations and assessments on your child. These include but are not limited to: 45 Day Observations, 6 Month Observations, Ages & Stages, Work Sampling & Ounces, and monthly observations. This information will be shared with parents when required and is available for your review at any time.

The YMCA participates in Keystone Stars and is proud that all of our centers are currently Keystone Stars rated. In an effort to continuously improve the quality of our programs and to better serve you and your child, we may ask you to provide a current copy of an Individualize Education Program (IEP) or Individual Family Service Plan (IFSP) for your child’s file. Please be assured that this information is kept strictly confidential and is only available to program administrators.

In addition, copies of relevant information will be transferred or shared upon your written request completing an “Authority to Transfer Education/Childcare Records form. Please ask a YMCA administrator for more information.

TRANSITIONS We feel transitioning takes time, preparation, planning and patience. Adults can help a child by supporting them before, during and after transitions occur. These transitions occur when starting at a new environment, every day transitions from home to daycare setting, transitioning into a new age group and classroom, with a new provider, and transitioning to school. We are committed to assisting our families and children in making these transitions as seamless and comfortable as possible.

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INDIVIDUAL EDUCATION PLAN (IEP): In an effort to continuously improve the quality of our programs and to better serve you and your child, we ask that the program be provided a current copy of an IEP or IFSP (Individualized Service Family Plan). Please be assured that this information is kept confidential and is only available to program administrators.

HOME LANGUAGE At any given time visitors to the center may hear a variety of languages spoken, particularly when families are dropping off or picking up their children. The center embraces family’s home languages and we desire to incorporate home languages in the program. Opportunities for sharing languages include, but are not limited to songs/music, books or items from home countries, utilization of everyday words in the different languages represented in the program, and sharing these opportunities with everyone. Additionally, we shall make every effort to communicate effectively with all families in a language that they understand. We shall use community resources for translation and interpretation when we do not have sufficient resources. As the YMCA of Reading and Berks County’s community is diverse, the teachers and staff of the YMCA have much experience supporting English language learners and their families.

PARENT EDUCATION Baby University We understand that parenting is the toughest job any one can do, but we also know that it can be the most rewarding.

Baby University is offered 5 times per year and is a 6 weeks workshop that supports parents, offering

them education on their child’s early development and helping strengthen their current skills in order to address any concerns or issues that may arise during these early but critical years.

The philosophy is to create a learning environment that is fun, interactive, and where participants can share experiences, learn from each other, have open discussion with our educators, and do hands-on activities that help parents learn about themselves and their child.

PLUS the Baby U Home Visitors will meet with each family at their home once a week to give one-on-one instruction and encouragement in addition to reinforcing the information learned in the classroom.

For more information, contact Baby University 610-378-4748

REFERRALS Resource and referral services are a “front door” to all child care, early learning programs and community resources available to families that participate in YMCA of Reading and Berks County Programs. The YMCA Directors and Staff have additional referrals to connect them with other community resources such as food, medical care, workforce support, housing assistance, financial assistance options and more.

CHARACTER DEVELOPMENT: YMCAs across the nation are committed to teaching and building values. The four core values: Caring, Honesty, Respect, and Responsibility are modeled and taught throughout all program areas. The YMCA is committed to a positive approach to improving our community. Character Development is challenging people to accept and demonstrate positive values.

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NONDISCRIMINATION IN SERVICES: Admissions, the provisions of services, and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin, age or gender.

Program services shall be made eligible to persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides, and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.

Any client who believes they have been discriminated against may file a complaint of discrimination with the following:

YMCA of Reading and Berks County Department of Human Services 631 Washington Street Bureau of Equal Opportunity NE RO Reading, PA 19603 331 Scranton State Office Building 610-378-4700 100 Lackawanna Ave

Scranton, PA 18503-1923

Office for Civil Rights PA Human Relations Commission U.S. Dept. of Health and Human Serv. Harrisburg Regional Office Suite 372 Public Ledger Building Fifth Floor Riverfront Office Complex 150 S. Independence Mall West 1101-125 S. Front Street Philadelphia, PA 19106-9111 Harrisburg, PA 17104

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YES Frequently Asked Questions

Q1: How will the YMCA create a classroom environment for my child? A1: Our classrooms are arranged so that each child has their own individual work “station” where they will engage in virtual learning, work on homework and store their belongings. Children will have the opportunity to decorate their station and make it their very own!

Q2: Will my child learn with other children his/her age? A2: Based on the number of children who enroll and their ages, our classrooms will be organized by age/grade.

Q3: What will my child do during their break times? A3: Our goal is to get children up out of their seats and away from their devices during break times. We recognize that children using these devices for the whole day is not ideal, so we will provide games, activities and more to keep minds and bodies active during downtimes.

Q4: How many children will be accepted into the YES Program? What is the capacity for each “classroom?” (i.e. How many kids will be in each group?) A4: We will operate our classrooms at limited capacity to make sure that children are socially distanced as much as possible.

Q5: Can my child attend the YES Program some weeks, but not others? A5: We ask that, like many other childcare programs, that you enroll your child on a consistent, contracted basis. We do not allow flexible schedules or drop in care for this program due to limited space and resources.

Q6: What should my child bring with them every day? A6: Please bring the following items (ALL labeled with your child’s first and last name): A backpack, electronic device (laptop/tablet), headphones, and any learning materials needed for their school work. The YMCA will have some commonly used supplies, like pencils, paper, etc., but if there is something required for your child’s learning, please send those items along with them in their backpacks.

Q7: What will the daily schedule look like for my child? A7: We will have each child’s schedule posted in their station. Our staff will make every effort to make sure that children are following their classroom schedule, as determined by the school district. We strongly encourage you to do a “test run” with your children at home before the first day of school, to make sure they are familiar with the virtual school day. As mentioned above, we will have fun activities and games planned for break times.

Q8: Who are your staff and how will they be trained? Are background checks required? A8: All of our staff are required to provide a FBI clearance, PA Child Abuse clearance, PA Criminal Background Check, National Sex Offender Registry Clearance, proof of credentials and experience, a

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clean drug and alcohol screen, and health assessment. All employees also undergo various trainings including CPR/First Aid, mandated reporter training, D2L, emergency response training, health and safety trainings and more!

Q9: What is your staff to student ratio? A9: As recommended by the PA Department of Human Services, we follow a 1:12 ratio.

Q10: Do you offer financial assistance? A10: Yes! Please contact the program director or branch executive director for more information.

Q11: Can my child be in the same group as one of his/her friends? A11: We cannot guarantee your child will be pair with his/her friends, but we will try to accommodate each family’s request.

Q12: What is your cell phone policy? Can I communicate with my child throughout the day? A12: We prohibit the use of cells phones during our program. Please encourage children to leave cell phones at home. If you need to communicate with your child at any point throughout the day, please call the YMCA.

Q13: Will the YMCA offer supply food/meals for my child? A13: Yes. The YMCA participates in the Child and Adult Food Program (CACFP). Breakfast, lunch and an afternoon snack will be provided.

If you have any further questions, please contact us directly!

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**Sign & Return**

PARENT STATEMENT OF UNDERSTANDING

The following information is important for the safety and protection of your child. Please read the information, sign this form and return it to the YMCA.

Please keep and refer to your copy of the YMCA Program Policies in your Parent/Guardian Handbook. Your signature below indicates that you have received and read them.

I understand that the YMCA staff and volunteers are not allowed to baby sit or transport children at any time outside of the YMCA program. Immediate disciplinary action will be taken by the YMCA toward staff and volunteers if a violation occurs.

I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff or volunteer is there to receive and supervise my child.

I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child must either be listed with the YMCA or other arrangements must be made by contacting the YMCA or program site and informing them of the change.

I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the child’s safety, staff may have no recourse but to contact the police. (Note: please do not put staff in a position where they have to make this judgment.)

I understand that the YMCA is mandated, by law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.

I have received a copy of the YMCA Before & After School Parent/Guardian Handbook.

____________________________________ ____________________ Parent/Guardian Signature Date

I have read and understand the statements above and the YMCA Program Policies detailed in my handbook.

____________________________________ ____________________

Parent/Guardian Signature Date

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**Sign & Return**

YMCA of Reading & Berks County Child Care Getting To Know You

Child’s Name ___________________________Nickname (if any)____________

Parent Name(s) ________________________ Date _____________________

Family Composition Questions:

1. Please list your child’s household members (including relations and ages of siblings).

2. Are there any custody situations that you would like to share with us?

3. Is there any other information about your family’s composition that you would like to share?

4. Does your family have pets?

Child Information:

1. Has your child been in an early learning program before? Yes_____ No_____2. If so, which of the following? _____Family Home Care _____Relative? Neighbor ______ Licensed Provider3. Are there any special concerns we should be aware of?

4. Any special needs (medical, developmental, social, mental health)?

5. Does your child have an IEP (Individualized Education Plan) or ISFP (Individualized Family Service Plan)?_________________

If so; we would like a copy of this plan so we can provide the best possible learning experience for your child.

6. Does your child have any allergies?_____Food Allergies _____Environmental Allergies _____Allergies to Medicine

Questions for the Parent: 1. What are your expectations of our program?

2. Is there any other information you would like to share about your child or do you have questions aboutthe program?

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**Sign & Return**

PERMISSION TO POST Allergies & Medical Needs

Child’s Name: ____________________________

To further ensure the safety of all children in the YMCA’s Child Care programs, I give the YMCA permission to post any special medical needs, including allergies, which pertain to my child. I understand that these will be posted in a confidential manner and is only available for staff to see. I agree to update the YMCA’s Child Care program with any new and important information regarding my child’s medical needs as well.

______________________ ___________________ GUARDIAN’S SIGNATURE DATE

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** Sign & Return**

Your child’s teacher will observe your child within 45 days and will provide you with a copy of this document.

GETTING TO KNOW YOU AND YOUR CHILD

Name of Child: ______________________

Group: ______________________________

Teacher(s): __________________________

Date of Enrollment: ___________________

Date of Observation: __________________

Child has made friends Child has learned rules (if applies) Child knows names of Teacher(s) Child knows where to put belongings Child has adapted to the program Teachers have met pick up/drop off person/s

___________________________________________ __________ Teacher Signature Date

___________________________________________ __________ Parent Signature Date

# ‘s Required

Must be the same as the Health HistoryForm

If the persons are the same the info must be the same.

# ‘s Required

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AGREEMENT **Complete, Sign &

Return**

55 PA CODE CHAPTERS 3270.123 & 181(C); 3280.123 & 181(c); 3290.123 & 181(C)

Name of Child: Circle One: Male Female

Child’s Weekly Schedule: Please circle the SET schedule your child will be attending weekly

Mornings: Monday Tuesday Wednesday Thursday Friday

Afternoons: Monday Tuesday Wednesday Thursday Friday

Day Payment to be made: FRIDAY, BEFORE CARE

Fee per Session, per child:

Weekly Contracted Tuition Fee:

Services to be provided as part of the day care fee (examples: transportation, care, meals, etc.) -Before School Care-Before School Breakfast-After School Care-Afternoon Snack (PM care only)-Virtual/Educational Support

Child’s Arrival Time: Child’s Departure: Person(s) designated by parent to whom child may be released:

Late Fee: $1.00 PER MINUTE, PER CHILD

Extra services to be provided at an additional fee if applicable:

REGISTRATION- $25.00 per child

SCHOOL:

GRADE:

I, the parent/guardian:

_____ Received complete written program information at the time of enrollment (§3270.121, 3280.121, 3290.121)

_____ Agree to update the emergency contact/parental consent form information whenever changes occur or every 6 months, at a minimum. (§3270.124, 3280.124, 3290.124)

_____ Understand that all fees are due weekly, up front, and are to be paid in full regardless of holiday, closing, vacation, illness, or in-service.

_____ Agree to give you two weeks’ notice of care termination.

_________________________________________________________________ ___________________________________________________________________________ Signature- Operator Date Signature-Parent/Guardian Date

Date of Child’s Admission:

Date of Child’s Withdrawal:

PERIODIC REVIEW Sign here at 6 month update:

Signature-Parent/Guardian Date

21

**Completed by a PHYSICAN, Sign & Return**

22

**Complete, Sign & Return**

School Age Child Care Registration Agreement Form YMCA Early Learning Center

2020/2021

YMCA Early Learning Center 14432 Kutztown Road Fleetwood, PA 19522 Start Date: ____________________ Weekly Fee: ___________________

Please Print:

Child’s Name: ______________________________ Birth Date: _________________________________ School Name: ______________________________ Grade: _________________ M/F: ____________ Teacher’s Name: ___________________________

Please indicate what you are registering for by checking days of set

attendance. PLEASE NOTICE CHANGES FOR 2020/2021.

All Day YES Program (6:30AM-5:30PM) M_______ T_______ W_______ TH_______ F_______

DROP IN CARE NEEDED ONLY _______

2020/2021 Rates PER DAY PER WEEK

Parent Signature: ____________________________________________________________ *** BY SIGNING YOU ARE AGREEING TO THE TERMS ABOVE ***

$135.00

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**Sign & Return**

Acceptance of Handbook

Child’s Name: __________________________

I have received and understand the YMCA of Reading & Berks County’s Parent Handbook for the Before & After School Programs of the 2020/2021 school year. I understand and agree to comply with all of these requirements set forth by the YMCA of Reading & Berks County and their program. If I have any further questions and/or concerns regarding this handbook I know that I am to speak with the Center or Program Director for further explanation.

_______________ ________________ Guardian’s Signature Date

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COVID-19 WAIVER **Sign & Return**

Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue

PLEASE READ CARFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING THE YMCA OF READING & BERKS COUNTY FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR

Assumption of Risk

I, in my legal capacity as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of The YMCA of Reading & Berks County facilities, services, equipment and premises (“Facilities”) and any participation in The YMCA of Reading & Berks County programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all ccother risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.

Waiver, Release, Indemnification & Covenant Not to Sue In consideration of Minor’s use of Facilities and participation in Programs I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that The YMCA of Reading & Berks County its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs.

I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees.

In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs.

Minor Name (Print Clearly) Date

__________________________________________ ______________________________________________ Parent/Guardian Signature Parent/Guardian Name (Print Clearly)

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**Sign & Return**

Acceptance of Health and Safety Plan

Child’s Name: __________________________

I have received and understand the YMCA of Reading & Berks County’s Health and Safety Plan for the Before & After School Programs of the 2020/2021 school year. I understand and agree to comply with all of these requirements set forth by the YMCA of Reading & Berks County and their program. If I have any further questions and/or concerns regarding this handbook I know that I am to speak with the Center or Program Director for further explanation.

_____________________________ ________________ Guardian’s Signature Date

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**Sign & Return**

Homework Policy Agreement

Child’s Name: __________________________

Among the many activities available to children in the program, assistance with virtual learning is typically provided Monday-Friday between 9:00AM and 3:00PM, where 1-2 staff will be available to provide children a quiet space away from the rest of the group to complete virtual learning and homework assignments. It may be held in one of the school classrooms, or in the gymnasium when the other children are outside. Rather than assigning your child to this time, we request that parents inform us if this is a priority for their child on this form. Discussion between the parent(s) and child is encouraged so that there is an understanding of parents’ expectations. Staff do not have communication with your child’s teacher and cannot know the assignments of every child. Staff do their best to assist children with the completion of assignments, however, constant one-on-one help is not available, and it remains the responsibility of the child to take advantage of the time and support that is offered. Please indicate your preference after discussion with your child:

____ Yes, I would like my child to participate in the designated time to complete virtual learning assignments. **Please provide a copy of your child’s virtual learning schedule.** ____ No, I prefer to have my child do their homework at home.

PLEASE NOTE: It is the responsibility of the parent/guardian to send children to our program with the materials needed to complete virtual learning assignments. In addition to those items, please provide a pair of headphones for your child to use during the program. Additionally, the YMCA is NOT responsible for personal items brought to the program by your child that are lost, stolen, or damaged. Please label all personal items with your child’s first and last name in advance.

______________________________________ _________________ Guardian’s Signature Date

x-apple-data-detectors://0/

CACFP Meal Benefit Income Eligibility Form Instructions

The Child and Adult Care Food Program (CACFP) makes good food a regular part of your child’s day care! Please fill out the CACFP Meal Benefit Income Eligibility form. It helps us find out if your household qualifies for free or reduced-price meals. This lets us know how much money CACFP will give to support your day care home or center.

Instructions Here are instructions to help you fill out the form. Before you begin, turn the form over to learn why we ask for this information. It tells you how we use the information and what rights you have. It also tells you how to contact USDA if you believe you are treated unfairly. Please make sure to fill in all of the requested information. Use a pen to mark your answers on one form. When you are finished, please return the form to us.

Step 1: List all the children from your household in the day care. Use one line for each child’s name. Write one letter in each box. Stop if you run out of space. If there are more children, add their names on a second piece of paper. Do you have any foster children? If you answer Yes, mark the Foster Child box next to the child’s name. If you are only applying for foster children, finish Step 1 and go to Step 4. If you are applying for both foster and non-foster children, go to Step 2. Are any children migrant, runaway, homeless, or enrolled in Head Start? If Yes, mark the correct boxes next to the child’s name and go to Step 4.

Step 2: You qualify for free meals if you live in a household that receives Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian Reservations (FDPIR). Do any household members, including you, currently receive SNAP, TANF, or FDPIR? If Yes, write the case number in the box and go to Step 4. You only need to provide one case number. If No, go to Step 3.

Step 3: Report current income for all household members. Skip this step if you answered Yes in Step 2. How do you report child income? Turn the form over and use the Source of Income for Children chart to see if your household has income to report. Write the amount in the boxes in part A of the form. Mark how often the amount is earned. Write 0 in the box if there is no income to report.

This institution is an equal opportunity provider.

How do you report income of adult household members? Turn the form over and use the Source of Income for Adults chart to see if your household has income to report. In part B, list all the adults in your household, including you, even if each of you doesn’t receive income. Include all adults, such as grandparents, other relatives, and friends who live with you and share household income and expenses. Write the amount of income each of you receives, in the boxes next to your names. Mark how often the amount is received. Write 0 in the box if there is no income to report. Make sure you report the current amount of money you get before taxes. Don’t include SNAP, FDPIR, WIC, student financial aid, or money you receive for a foster child as income. Count the number of all children and adults in your household. Include all infants, children, students, and adults. Write the total number in the box under the list of adult household members. Do you or another adult household member have a Social Security number? Write the last four digits in the boxes. If there is no Social Security number, mark the Check if no SSN box.

Points to Remember:

If: Then:

Your income isn’t always the same

List the amount of money that you normally get. For example, don’t include overtime pay, if you don’t normally get it. If your income is normally higher or lower, you can report annual income instead.

Your household includes members who aren’t citizens

You or your children don’t have to be U.S. citizens to qualify for meal benefits.

You are in the military Don’t include your Family Subsistence Supplemental Allowance (FSSA), combat pay, or the money you receive for privatized housing. If deployed, count the amount of pay that is made available to your household as income.

Step 4:

An adult household member must sign this form. The signer promises that all information is true and complete. Print the name, address, and telephone or email of the adult signer. Sign and write today’s date in the marked boxes.

Optional We ask about your children’s ethnicity and race to make sure we do our best to serve our community. Providing this information is not required. You won’t be denied benefits based on your race, color, national origin, sex, age, or disability.

CACFP Meal Benefit Income Eligibility Form Sharing Information with Medicaid and SCHIP

This institution is an equal opportunity provider.

Children who get Child and Adult Care Food Program (CACFP) free or reduced-price meals may also qualify for low cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP).

We may share your child’s CACFP eligibility information with Medicaid or SCHIP, unless you tell us not to. Medicaid and SCHIP only use the information to find out if children are eligible for their programs. Their staff may contact you to offer to enroll your children in these health insurance programs.

If you do not want us to share your information with Medicaid or SCHIP, fill out this page. You should send this page with your CACFP Meal Benefit Income Eligibility form when you apply. Sending in this page will not change your child’s eligibility for free or reduced-price meals.

☐ No! I do not want my child’s CACFP eligibility information shared with Medicaid orSCHIP.

If you checked no, fill this out:

Child's Name: ________________________________________________________________

Child's Name: ________________________________________________________________

Child's Name: ________________________________________________________________

Child's Name: ________________________________________________________________

Today’s Date: ________________________________________________________________

Print Your Name: ________________________________________________________________

Address: ________________________________________________________________

Signature of Parent or Guardian: ________________________________________________________________

26

Child and Adult Care Food Program Sponsor:_______________________________ Child Enrollment Form (Sample) Center:________________________________

ENROLLMENT FORM FOR CHILDREN IN CHILD CARE (SAMPLE) This document does not have to be completed for children in Emergency Shelters, Outside School Hours, and/or At-Risk programs. It is recommended to have new CACFP Annual Enrollment Forms completed each year during the Household Eligibility Application renewal period. Review completed enrollment form and enter the effective date in lower right hand section. PARENTS: This institution participates in the Child and Adult Care Food Program (CACFP) and receives reimbursement to provide more nutritious meals for your child(ren). Federal CACFP regulations require all parents and guardians to complete a CACFP Annual Enrollment Form when enrolling their child(ren) and again every year thereafter. This information will help ensure all children receive appropriate meals during their care. Please complete all areas to include signing and dating same.

FULL NAME OF ENROLLED CHILD (Include Birth Date/Age

DAYS OF WEEK IN ATTENDANCE

TIMES CHILD NORMALLY ATTENDS DURING WEEK

MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS

SCHOOL

AM PM TIME AM PM TIME LEAVES CENTER

RETURNS TO CENTER

FIRST CHILD MONDAY

TUESDAY

NAME WEDNESDAY Yes No I work multiple shifts and child(ren) may be in care different days/hours BREAKFAST

THURSDAY Other:

Enrollment Date: Withdrawal Date:

A.M. SNACK

BIRTH DATE FRIDAY LUNCH

SATURDAY P.M. SNACK

AGE SUNDAY SUPPER

EVENING SNACK




MEALS RECEIVED

TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL

Same Times as Above


RETURNS TO CENTER

SECOND CHILD Same as Above Same Meals as Above

MONDAY

NAME TUESDAY Yes No I work multiple shifts and child(ren) may be in care different days/hours BREAKFAST

WEDNESDAY Other:


A.M. SNACK

BIRTH DATE THURSDAY LUNCH

FRIDAY P.M. SNACK

AGE SATURDAY SUPPER

SUNDAY EVENING SNACK




MEALS RECEIVED


Same Times as Above


RETURNS TO CENTER

THIRD CHILD Same as Above Same Meals as Above

MONDAY


WEDNESDAY Other:


A.M. SNACK


FRIDAY P.M. SNACK

AGE SATURDAY SUPPER





MEALS RECEIVED


Same Times as Above


RETURNS TO CENTER

FOURTH CHILD Same as Above Same Meals as Above

MONDAY


WEDNESDAY Other:


A.M. SNACK


FRIDAY P.M. SNACK

AGE SATURDAY SUPPER





MEALS RECEIVED


Same Times as Above


RETURNS TO CENTER

FIFTH CHILD Same as Above Same Meals as Above

MONDAY


WEDNESDAY Other:


A.M. SNACK


FRIDAY P.M. SNACK

AGE SATURDAY SUPPER


Signature

Signature of Parent or Guardian Date Telephone Number of Parent or Guardian

CHILD CARE REPRESENTATIVE USE ONLY:

Name of Representative/Signature Date

The effective date can be made retroactive back to the first day the child participates in the CACFP as long as it occurs in the same month this form is received.

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This portion of the form can be used to capture multi-year annual updates.

**************************************************************************************************

**********

Annual Time Period Covered by Signature: ___________________ to ___________________

Signature Parent/Guardian___________________________________________ Date ____________________

Signature Center Administrator/Home Provider___________________________ Date ____________________

**************************************************************************************************

**********




**************************************************************************************************

**********




**************************************************************************************************

**********




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The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for

employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and

where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an

individual’s income is derived from any public assistance program, or protected genetic information in employment or

in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all

programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination

Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call

(866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the

form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office

of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at

[email protected].

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay

Service at (800)877-8339; or (800) 845-6136 (Spanish).

USDA is an equal opportunity provider and employer.

28

http://www.ascr.usda.gov/complaint_filing_cust.html


CACFP Meal Benefit Income Eligibility (Child Care) APPLY ONLINE: Insert URL Here Complete one application per household. Please use a pen (not a pencil).

STEP 1 List ALL children in day care (if more spaces are required for additional names, attach another sheet of paper)

Child’s First Name MI Child’s Last Name Foster Child Migrant Runaway Homeless Head Start Definition of Household Member: “Anyone who is living with you and shares income and expenses, even if not related.”

Children in Foster care and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals.

Che

ck a

ll th

at a

pply

STEP 2 Do any household members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?

IF NO > Go to STEP 3 IF YES > Write case number here and proceed to STEP 4 (do not complete STEP 3) CASE NUMBER:

Write only one case number in this space.

STEP 3 Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)

VA Benefits Weekly Bi-Weekly Monthly 2x Month

Child Income Weekly Bi-Weekly Monthly Bi-Monthly

Weekly Bi-Weekly 2x MonthMonthly Support/Alimony

X X XX X

Are you unsure what income to include here? Flip the page and review the charts titled “Sources of Income” for more information.

The “Sources of Income for Children” chart will help you with the Child Income section.

The “Sources of Income for Adults” chart will help you with All Adult Household Members section.

STEP 4 Contact information and adult signature. MAIL COMPLETED FORM TO YOUR SCHOOL AT:

How often? A. Child Income

Sometimes children in the household earn or receive income. Please includethe TOTAL income received by all Household Members listed in STEP 1 here. $

B. All Adult Household Members (Including yourself) List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes)for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.

Pensions/Retirement/ How often? Welfare/Child How often? Social Security/SSI/ How often?

Name of Adult Household Members (First and last)

$

Earnings from Work Weekly Bi-Weekly Monthly 2x Month

$ $

$ $ $

$ $ $

$ $ $

$ $ $

Last Four Digits of Social Security Number (SSN) of Check if no SSNTotal Household Members (Children and Adults) Primary Wage Earner or other Adult Household Member

“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that CACFP officials may verify (check) the information. I am aware that if I purposely give false information, the participant/center may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”

Print Name of Adult Signing the Form Signature of Adult Today’s Date

Address City State Zip Phone/Email 129

Karen.Smith2

Highlight

Source of Income for Children

Sources of Child Income Examples

Earnings from work • A child has a regular full or part-time job where they earn

a salary or wages

Social Security - Disability Payments - Survivors Benefits

• A child is blind or disabled and receives Social Security benefits • A parent is disabled, retired, or deceased, and their child receives

Social Security benefits

Income from person outside of household • A friend or extended family member reguarly gives

a child spending money

Income from any other source • A child receives regular income from a private pension fund,

annuity, or trust

Source of Income for Adults

Earnings from Work Public Assistance/Alimony/ Child Support

Pensions/Retirement/ All other sources of income

• Salary, wages, cash bonuses • Net income from self-employment

(farm or business)

If you are in the U.S. Military:

• Basic pay and cash bonuses (do NOT include combat pay, FSSA, or privatized housing allowances)

• Allowances for off-base housing, food, and clothing

• Unemployment benefits • Workers compensation • Supplemental Security Income (SSI) • Cash assistance from State or local

government • Alimony payments • Child support payments • Veterans benefits • Strike benefits

• Social Security (including railroadretirement and black lung benefits)

• Private Pensions or disability benefits • Income from trusts or estates • Annuities • Investment income • Earned interest • Rental income • Regular cash payments from

outside household

Children’s Ethnic and Racial Identities (Optional) OPTIONAL

We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community. Responding to this section is optional and does not affect your children’s eligibility for receiving meals during care.

Ethnicity (check one): Hispanic or Latino Not Hispanic or Latino

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander WhiteRace (check one or more):

The Richard B. Russell National School Lunch Act requires the information on this In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and

application. You do not have to give the information, but if you do not, the funds your child employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,

care center/provider receives may be impacted. You must include the last four digits of disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the the social security number of the adult household member who signs the application. The Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda. Reservations (FDPIR) case number or other FDPIR identifier for your child or when you gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the

indicate that the adult household member signing the application does not have a social form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

security number. We will use your information to determine the meal reimbursement for your child care center/provider. We MAY share your eligibility information with education,

MAIL*: U.S. Department of Agriculture FAX: (202) 690-7442; or *Only use this address ifhealth, and nutrition programs to help them evaluate, fund, or determine benefits for their Office of the Assistant Secretary for Civil Rights EMAIL: [email protected]. you are filing a complaintprograms, auditors for program reviews, and law enforcement officials to help them look of discrimination.1400 Independence Avenue, SW This institution is an equal opportunity provider. into violations of program rules. Washington, D.C. 20250-9410

For official use only DO NOT FILL OUT

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12

How often? Eligibility Total Income

Weekly Bi-Weekly 2x MonthMonthly Household size

Categorial Eligibility Free Reduced Denied

Determining Official’s Signature Date Confirming Official’s Signature Date Follow-up Official’s Signature Date

30


http://www.ascr.usda.gov/complaint_filing_cust.html

YMCA Release and Waiver of Liability

You have registered your child for a YMCA program that involves physical activity and interaction with children and others. This document is a release of claims, and by signing it you do the following:

1. Acknowledge that when performing any physical component of this YMCA program, your child may

suffer injury.

2. Present to the YMCA that your child is in good health and physical condition, sufficient to engage in such activities and that your child is not suffering from any condition that would prevent your child from engaging in such activities or that your child’s participation in such active potentially dangerous or harmful to your child.

3. Assume the risk of, and release the YMCA and its associates harmless from, any liability for physical or

other injury that has been suffered by your child during, or as a consequence of, participation in this YMCA program required in the curriculum of this course and you agree that the YMCA nor any other person involved in organizing or teaching in this program, shall have any liability or responsibility for any injury or harm.

4. I authorize the YMCA to photograph or video that both myself and my child and understand that all

photos and video footage are property of the YMCA and may be used for publicity purposes.

5. I give the YMCA and its staff permission to post my child’s allergies in an area for staff awareness. I understand that there will be a cover sheet to protect my child’s confidential information.

6. I give the YMCA and its staff permission to walk to and from the park on days when the curriculum

allows it.

Child’s Name: __________________________________________________________________

Parent’s Signature: __________________________________________________________

Date: ______________________________

:

Code of Conduct

This form contains two separate codes of conduct- one for students, and one for the parents. The group supervisors have already agreed to make a commitment to working with your children and have signed code of conduct forms. Their forms are on file at our YMCA. It is important for you and your child to make a commitment to following the code of conduct that is appropriate for you. It is good for parents to know what is expected of their children, and for children to know what is expected of them. This form will be kept on file at the YMCA. Your child will NOT be able to participate in the program without a completed form on file. All of the codes of conduct are part of the application and authorization to participate in Before and After School/Y.E.S. Care. Failure to comply with the code of conduct may result in removal from the program.

Parent/Guardian Code of Conduct: • I will place an emphasis on the fun of participation and keep the emotional and physical well-being of all

the children ahead of my own personal desires.• I will inform the center director of any physical disability or ailment that may affect the safety of my

child, or the safety of others.• I will require my child to treat other children, staff, presenters, bus drivers, etc. with respect without

regard to gender, race, religion, culture, or ability.• I (and my guests) will be a positive role model for my child at all times while on YMCA property.• I (and my guests) will not engage in any kind of disrespectful behavior with any staff member, director,

student, etc. such as bullying, physical acts, using profane language, or using profane gestures.• I will support an assist the experience however I can… by attending programs or volunteering whenever

possible.• I will not encourage any behaviors or practices that would endanger the health and well-being of the

students.• I will teach my child to resolve conflicts without resorting to hostility or violence.• I will pick my child up and drop them off on time, according to YMCA policies.• I will pay my child's fees weekly, according to YMCA policy.• I will praise my child for competing fairly and trying hard, and make my child feel like a winner every

time.• I will never ridicule or yell at my child, other children, staff, or directors, for making a mistake.• I will demand an environment for my child that is free of tobacco, alcohol, and drugs and I will refrain

from their use while on YMCA property.• I will respect the staff and their authority while working with their groups and will never question,

discuss, or confront staff in front of their groups. I will take time to speak with staff at an agreed upontime and place.

Child Code of Conduct: • I will not intentionally hurt or be mean to any child, staff member, or another person.• I will respect others by not purposely causing harm or unhappiness to other students or staff.• I will respect property by not damaging any part of the center or the other places we go and by

keeping these places clean.• I will listen to my group supervisor by staying in and with my group at all times and following the camp

rules.• I will be kind and polite to everyone, no matter what! If I have a problem with someone else that I

cannot solve, I will tell my group supervisor.• I agree that if I break this code, I will be subject to disciplinary action.

Child’s Name: _________________________________________________________

Parent’s Signature: __________________________________________________ Date: __________________________

Covid-19 Information Release

Dear Parents & Families, In an effort to reduce the spread and risk of COVID-19, the YMCA will maintain open lines of communication with your child’s school district regarding their health. We will notify your child’s school if/when the following situations arise.

• Your child arrives to our program ill • Your child becomes ill during our program • You inform the YMCA that your child is ill and/or has COVID-19

symptoms • You inform the YMCA that your child has COVID-19 • You inform the YMCA that anyone in the household has COVID-19 • You inform the YMCA that you are quarantining due to a COVID-19

exposure To be accepted into the YMCA Childcare program, this release must be reviewed, agreed to and signed. If you do not wish to review, agree to and sign this release your child will not be admitted the YMCA childcare program.

By signing below, you agree that the YMCA may communicate the above information about your child to the school district and also for the school to communicate information about your child to the YMCA.

I give permission for the YMCA to share information with my child’s school district.

I do not give permission for the YMCA to share information with my child’s school district.

Child’s Name: ______________________________________ Child’s School: _____________________________________ Parent/Guardian Signature: ____________________________________ Date: _________________________

YMCA PHOTO/AUDIO VISUAL/NARRATIVE RELEASE I am 18 years of age or older and, if not, my parent or legal guardian has also provided their consent by signing below.

Consent & License. For my participation in activities to be conducted by the National Council of Young Men’s Christian Associations of the United States of America (“YMCA of the USA”) or any of its chartered member associations in the United States (collectively “the Y”), and collaborating third parties, I consent, now and for all time, to the making, reproduction, editing, broadcasting or rebroadcasting of:

• video film or footage of me, • sound track recordings of me • photo reproductions of me • any narrative account of my experience

My consent includes a perpetual license to the Y and collaborating third-parties for the use of the above materials for publication, display, sale or exhibition in promotions, advertising, education and commercial uses. Use includes reproductions in any form and media currently existing or later conceived, adaptations and/or revisions, throughout the world in perpetuity.

I understand and agree there may be no additional compensation for this license, and I will not make any claim for payment of any kind from the Y or collaborating third-parties. I may, or may not be, identified in such licensed uses; however, my name will not be used to endorse any particular products or services.

Ownership, Confidentiality, and Shared Use. With respect to any of the above uses, I further agree:

• All works shall belong to YMCA of the USA; • The Y has no duty of confidentiality regarding any licensed uses; • YMCA of the USA shall exclusively own all known or later existing rights to the uses throughout the

world; • The Y and collaborating third-parties may use any video film, footage, sound track recordings and

photo reproductions of me and/or my narrative account for any purpose without additional compensation to me.

Release from Liability. I agree that my consent is irrevocable. I hereby release and discharge The Y and collaborating third-parties, from any and all claims, actions, lawsuits or demands of any kind arising out of my consent, license grants, uses, or the shared uses of any works or materials referenced herein.

Signature: ____________________________________ Date: __________________

Printed Name: ________________________________ Age: ________

Address: ________________________________________________________________________

________________________________________________________________________________

I am the parent or legal guardian of (child’s name). I hereby consent and grant the licenses detailed in the foregoing on behalf of my minor child.

Signature of parent or legal guardian: _____________________________________________

Printed name: _____________________________________________________________________

071808 6/18

YMCA of Reading and Berks County BEFORE & AFTER ......for all. WELCOME: Thank you for choosing the YMCA as your School Age Child Care provider. We look forward to serving you and your

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