BOYS AND GIRLS CLUBS OF DELAWARE REGISTRATION PACKET CHECKLIST. Child s Name Date

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1 BOYS AND GIRLS CLUBS OF DELAWARE REGISTRATION PACKET CHECKLIST Child s Name Date Did you fill out everything listed below? Handbook/Registration packet (form located in back of parent handbook) Signed Policy and Procedure Commitment (form located in back of parent handbook) Enrollment Agreement (with both parent/guardian signatures) Registration Form Child Information Card Health Appraisal (or note stating we may obtain from school nurse) Emergency Authorization Form Permission Slip/Sunscreen Authorization Form Tuition Payment Form **THIS SIDE FOR OFFICE USE ONLY** Pull Registration Form Pull EFT Form Pull Membership Form Copied Reg. Form Copied Mem. Form Added to E Binder Added to Master List Added to Attend. Sheet Mail Box Made Right to Know Notice, Movie & Computer Permission Form Boys & Girls Club Membership Form Getting To Know Your Child Form Permission to Request IEP/504 (if applicable, please request form) Request To Give Medication (if applicable, please request form) Electronic Funds Transfer Authorization Form (if applicable) Notes:

2 Enrollment Agreement: School Year Child s Name Parent/Guardian Address: Phone Number: Date: Grade: Teacher: My child listed above will be attending the Boys & Girls Clubs of Delaware School Site Program for the school year or 2013 Summer Fun Club Program. CONTRACTED HOURS: Drop off Time to BGC: Pick up Time from BGC: Part Time Enrollment (5 hours or less with the Boys & Girls Club): $100/week Full Time Enrollment (5 ½ hours or more with the Boys & Girls Club): $160/week POC Plus: Tuition based on parent co-pay, plus providers difference 3 year old Extended Day Friday: additional $20/week (added on to the $100/week if you are PT enrollment) Membership fee of $15 is due at time of enrollment. Purchase of Care families are NOT required to pay the $15 membership fee. Program hours are from 6:30 a.m. until 6:00 p.m. Children are transitioned into and out of class throughout the day. Parents that arrive after contracted pick up time will be charged a late fee of $1.00 per minute per child. A cash payment will be due before the child may return to the program. If your child is not picked up and no communication has been made with the program director 30 minutes after your contracted pick-up time, the authorities will be notified for assistance. Tuition payments are accepted through electronic funds transfer, check, cash, or money order and are due on the Friday prior to the next week s care. We do not refund or credit tuition for illnesses, absences, or unannounced vacations. Any returned checks or electronic funds transfer will get an additional $25 charge. Once one check is returned, you no longer have the option to use that payment method. Withdrawals from the program require one week written notice. Vacations require a one-week written notice. If notice is not received, you will still be expected to pay your full week tuition. The program will be CLOSED for the following holidays: Labor Day, Thanksgiving and the day after, Christmas Eve, Christmas Day, New Years Day, Martin Luther King Jr. Day, Good Friday, and Memorial Day. Tuition for these weeks is due in full. Boys & Girls Club of DE hold the right to terminate enrollment for failure to follow policies and procedures Parent/Guardian Signature Director s Signature Date (Both Parents MUST sign)

3 Please complete the registration form: Boys & Clubs of Delaware School Site Program REGISTRATION INFORMATION FOR THE 2013 SUMMER FUN CLUB AND THE SCHOOL YEAR Type of care needed (Circle One): Part Time, Full Time, 3 yr old extended day Friday Hours Care is needed: Drop off with BGC: Pick up from BGC: Child s Name: Date of Admission: Child s Age: Date of Birth: Sex: Grade, Teacher, & RM #: With whom does the child reside? Mother Father Other Mother s Name: Employer: Business Phone: Business Address: Hours of Employment: Mother s Home Telephone #: Cell/Pager: Mother s Home Address: Father s Name: Employer: Business Phone: Business Address: Hours of Employment: Father s Home Telephone #: Cell/Pager: Father s Address: EMERGENCY CONTACTS MUST BE WITHIN 20 MINUTES OF THE SCHOOL Alternative Emergency Contact: Phone #: Relation & Address: Alternative Emergency Contact: Phone #: Relation & Address: Name of Person(s) authorized to pick-up child other than parents: (Child will not be released if person s name is not listed.) Does your child have any allergies? Y/N (circle one) Please describe: Does your child have any special needs? Y/N (circle one) Please describe: IN THE CASE OF AN EMERGENCY, IT IS EXTREMELY IMPORTANT FOR US TO HAVE THE FOLLOWING INFORMATION: Name of Family doctor: Phone: Name of family Dentist: Phone: Insurance Provider: Policy Number/Group Number: Hospital Preference:

4 CHILD INFORMATION CARD State of Delaware Department of Services for Children, Youth and Their Families Name of Child (Last, First, Middle Initial) Birthdate Date of Admission Date of Discharge Name of Parent(s) Home Address Home Phone Number 1. Employer Hours of Employment Business Address Business Phone Number 2. Employer Hours of Employment Business Address Business Phone Number Person Other Than Parent to be Notified in Emergency Situation When Parent is not Available Name Address Phone Number Names of Persons Other Than Parent to Whom Child May be Released Emergency Medical Care: I,, the parent (or legal guardian) of who is my minor child, hereby authorize emergency medical treatment for my child in the event I cannot be contacted to give permission to treat. I understand I will be financially responsible for the cost of such treatment. Transportation: I, the parent (or legal guardian) of who is my minor child, hereby give permission for my child to be transported with his/her caregiver. Signature of Parent or Guardian Date Name of Child s Physician Address Phone Number Office Hours Special Medical Information (Allergies, etc.) Health Insurance Identification Information

5 The above information is essential for your child s protection - Be sure to keep the information current EMERGENCY AUTHORIZATION FORM I hereby give my consent to The Boys and Girls Clubs of Delaware to call Dr. at the following phone number, or to take my child to a hospital emergency room for medical or surgical care should any emergency arise where such service is indicated. I understand that the cost of this care will be paid by me. It is understood that a conscientious effort will be made to notify me before such action is taken, if time permits. I understand that The Boys and Girls Clubs of Delaware will contact me or the names I have designated on the enrollment application form to be called for emergencies if we can be reached, and time permits. In order to meet all legal requirements, I hereby authorize an acting representative of The Boys and Girls Clubs of Delaware to give consent for any and for all necessary emergency medical care for my child named while said child is in the care of The Boys and Girls Clubs of Delaware. Parent/Guardian Signature Date

6 BOYS & GIRLS CLUBS OF DELAWARE, INC. PERMISSION SLIP/TRANSPORTATION I, the undersigned, give permission for my child or ward,, to go on various field trips scheduled throughout the school year and summer months by the Boys & Girls Clubs of Delaware School Site Child Care Program. Parents will be informed of the cost and destination two weeks prior to the trip. Parents/Guardians signature releases the Boys & Girls Clubs of Delaware from any liability should an accident/injury occur. Transportation for Field Trips will be provided through Sutton Bus Company. Sutton Bus does not always have harnesses readily available for use. State Law does not require that children preschool age or younger be harnessed in school buses, but the National Highway Traffic Administration recommends it. (Signature) (Date) AUTHORIZATION FOR DESPENSING SUNSCREEN During the Boys and Girls Clubs of Delaware Summer Fun Program, we will supply and apply one brand of sunscreen (Banana Boat SPF 50) for all enrolled children. We are not able to apply individual brands of sunscreen for each child. A staff person will administer sunscreen only if written authorization is given. I give permission for a medication-certified staff member of the Boys and Girls Clubs of Delaware to apply the above listed sunscreen to my child on swimming days just before leaving for the pool. Child s Name Parent Signature Date *Please remember to apply your child s sunscreen at home every morning before he/she attends our program. Thank you.

7 Tuition Payment Form Child(ren) s Name(s): Mother/Guardian s Name: Father/Guardian s Name: Person Responsible for Payment: How are you planning on making payments: CASH CHECK MONEY ORDER ELECTRONIC FUNDS TRANSFER (EFT) ***For EFT Parents (Our preferred method of payment) Do we have your account on file? YES NO (if no, please attached a voided check) What is the amount you are authorizing us to debit from your account every Thursday? (ex. $75, $98, $150, $196, etc) Do you have a schedule that differs than a normal week to week schedule or do you have a different day you prefer to have your account debited on? YES or NO For example, do you pay on a particular day for the entire month? Do you pay bi-monthly? Or do you have a particular situation for payment? If so please let us know. Please include the DATE, AMOUNT, and any other information you can. Will you be including the $15 membership fee with your first week tuition? YES or NO? If no, how will you be paying for membership? Did you pay it with your summer camp registration? FEES FOR SCHOOL YEAR ARE AS FOLLOWS: WEEKLY FEES: Part Time: $100/week Full Time: $160/week 3 year old extended day Friday (with Part Time Enrollment): $20/week (in addition to the $100/week) Parent/Guardian Signature Date

8 MOVIE & COMPUTER PERMISSION FORM Hello parents, With information readily available for us on the Internet, the Boys & Girls Club School Site will occasionally have the opportunity to use the computer or tech lab at the school. Because of this, we need your permission to allow your student to use the Internet. Please fill out the following information. I,, parent/guardian of, hereby give permission for my child to use the Internet during The Boys & Girls Club School Site program hours. Parent Signature: Date: As you all know, showing a movie on a Friday afternoon can be a fun option to extend to your children. We would love to continue to show movies in our program, but in order to do so, and to please your children, we need all parents to fill out the release form at the bottom of this paper. Filling out this form will give the chance to choose a variety of movies that could be more appealing to your children. Without this form, we will continue to show movies (once in a while), but they will always be a G rated film. My Child,, will be allowed to watch G movies. will be allowed to watch G and PG movies. Parent Printed Name Parent Signature Date: *** Please note, we do not typically show movies, but in the event of a field trip we are required to have you sign this form by licensing.

9 Boys & Girls Clubs of DE School Site Program Getting to Know Your Child Record My name is: My nickname is: I have brothers & sisters, their names and ages are: My favorite activity is: My favorite food is: My least favorite food is: My favorite person is: I am afraid of: I enjoy/ participate in the following activities: Sports/Physical Activities/Gym Games: Dance/Drama/Theather: Band/Instrument/Singing: Art/Crafts/Drawing: Other: Does your child have a special diet? Due to your child s tastes, allergies, reactions, and/or religious beliefs, are there any foods, which should not be served to your child? Please list these foods: Please list any personal habits, thumb sucking, nail biting, etc. What are your main expectations of this program: Please list anything else that you feel is important for us to know about your child:

10 BOYS & GIRLS CLUBS OF DELAWARE School Site Child Care IEP Request Form To help us with the education and tutoring of your child I am asking permission to retrieve the IEP or 504 accommodation of your child. If you have any questions, please feel free to call me at (302) or me at rwilczynski@bgclubs.org. Thank you in advance for your cooperation. Rebecca Wilczynski Program Director I agree to allow Boys and Girls Club to obtain a copy of my child s IEP or 504 accommodations. Child s Name: Parent/Guardian s Name: Parent/Guardian s Signature: Date:

11 ELECTRONIC FUNDS TRANSFER AUTHORIZATIONS FORM Yes, I would like to take advantage of the security and convenience of electronic funds transfer scheduled or periodic payments. As a duly authorized check signer on the financial institution account identified herein, I authorize the Boys & Girls Clubs of Delaware to perform scheduled or periodic electronic funds transfer debits from my account identified below for payments due or when applicable, apply electronic funds transfer credits to same. Furthermore, if any such electronic debit(s) should be returned as NSF, I authorize the Boys & Girls Clubs of Delaware to collect such debit(s) by electronic debit and to subsequently collect a returned debit item fee of $25.00 per item by electronic debit from my account identified below. For accounting purposes, all electronic debits will be reflected in the monthly bank statement that corresponds with the financial institution account identified herein. I authorize $ to be withdrawn from my checking account starting on, and on every Thursday thereafter for the School Year. I understand and authorize all of the above as evidenced by my signature below. AUTHORIZED SIGNATURE DATE Financial Institution account identifying information : Please attach a blank VOIDED check below.