This enrollment packet requests information about

the Sponsor. Sponsors must be the parent or legal

guardian of the child they are enrolling.

*MCO 1710.30 5 Aug 2015 Chapter 2 designates Pa-

trons who qualify for Child and Youth Programs services

as active duty Military Service members, DoD civilian

employees paid from APF and NAF, Guard/Reserve

Component Military Service members on orders, combat

related wounded warriors, surviving spouses of military

members who died from a combat related incident, eli-

gible employees of DoD contractors, other Federal em-

ployees, and military retirees when space allows.

ELIGIBILITY & ENROLLMENT

School Age Enrollment Package FY2018

RETURN COMPLETED FORMS TO:

CYP Central Enrollment Office

Resource & Referral 229-639-7930 DSN 567-7930

Fax: 229-639-5096

Email: mclbarr@usmc-mccs.org

Hardcopy: 814 Radford Blvd, Building 7600

Suite 20311 Albany, GA 31704-0311

A minimum of two business

days are required to properly process completed enrollment packages, re-newals and returns from

Drop In care.

Mission, Life, Career

CYP SPONSOR HANDBOOK:

To view all other operating guidelines please refer to your Child and Youth Programs

Sponsor Handbook which may be accessed at www.mccsalbany.com

To access this document, click on the Family Care tab, followed by the Child and Youth Programs tab. Once you have reached this

page you will find a link to our most updated Sponsor Handbook.

DOCUMENTS REQUIRED FOR ENROLLMENT:

1. Completed Enrollment Package 2. Total Family Income : Pay

Stubs/LES for all members of the household regardless of martial status

3. Current Immunizations on GA form (Including Influenza Vaccine)

4. Health Assessment 5. Family Care Plan (Single or Dual

Active Duty Members)

2/2018

CHILD AND YOUTH PROGRAMS CONTRACT FOR SERVICES

I, the parent or legal guardian of ______________________________________, contract with MCLB Albany Child and Youth

Programs for the following child care services.

Check all that apply:

Full-Time Care Pre-K Before Care SAC Before Care

Drop-In Care Pre-K After Care SAC After Care

Bright from the Start Pre-K Program Dougherty County School System breaks & camps

Tues & Thurs Part Day (Pre-Toddler/ Toddler/Pre-School) 8am-12pm

Mon, Wed, & Fri Part Day (Pre-Toddler/Toddler/Pre-School) 8am-12pm

MCLB Albany Child and Youth Programs SY2017-18 Fee Schedule

Child Development Center School Age Care

Category Total Household

Income Full Time

Full Time Multi Child

3 Day Part Day

(8-12)

2 Day Part Day

(8-12)

Before Care

After Care

Before & After

Care

DCSS Break Camps

I $0 - $31,794 $128 $115 $38 $26 $13 $45 $58 $59

II $31,795 - $38,604 $160 $144 $48 $32 $16 $56 $72 $74

III $38,605 - $49,959 $199 $179 $60 $40 $20 $70 $90 $92

IV $49,960 - $62,448 $232 $209 $70 $46 $23 $81 $104 $107

V $62,449 - $79,482 $267 $240 $80 $53 $27 $93 $120 $123

VI $79,483 - $91,918 $290 $261 $87 $58 $29 $102 $131 $134

VII $91,919 - $108,138 $299 $269 $90 $60 $30 $105 $135 $138

VIII $108,139 - $135,220 $310 $279 $93 $62 $31 $108 $139 $143

IX $135,221 + $321 $289 $96 $64 $32 $112 $144 $148

enrolled IX CTR

$135,221 + $451 $406 $135 $90 $45 $158 $203 $208

DoD Contractors and specified space available patrons

enrolling as of 5 Feb, 2018 $451 $451 $135 $90 $45 $158 $203 $208

bi monthly fee (1st & 15th) weekly fee

Standard Hourly Care Rate $4 Registration/Annual Renewal $35

Drop-in care is available 8:00 am to 5:00 pm and limited to a maximum of 20 hours per week. Patrons utilizing Drop-in care must

make reservations 24 hours prior to receiving services. Emergency situations will be handled by Management on a case by case basis.

There will be a $6.00 per day late charge for payments made after the due date. If balance due, including late fees, is not paid in full 5

working days after payment due date services may be terminated. If you wish to re-enroll your child, you must pay in full any

delinquent accounts, complete appropriate paperwork and pay registration fee prior to receiving services. Accounts with outstanding

balances will be forwarded to MCCS Accounting for collections.

The center closes promptly at 6:00 pm. Children present after 6:00 pm will initially be charged $5.00. After the first 5 minutes late,

patrons will be charged $5.00 for each additional minute. Please be sure that all children are picked up no later than 6:00 pm.

I have read and fully agree to abide by these guidelines and service contract concerning my obligations to MCLB Albany Child and

Youth Programs.

________________________________________________________________________

Sponsor Signature Date

2/2018

CHILD AND YOUTH PROGRAMS POLICIES & PROCEDURES

PLEASE INITIAL EACH BLOCK BELOW CONFIRMING YOUR UNDERSTANDING OF CHILD & YOUTH PROGRAM

(CYP) POLICIES:

PRIVACY POLICY: AUTHORITY: 5 U.S.C. Sec 301

The information, which will be solicited at registration, is intended principally for the following purposes:

· Determination of those dependents eligible to be placed in the Child Development Center or School Age Care program

maintained by the Marine Corps Logistics Base, Albany, Georgia.

· To provide information to the CYP personnel on any health problem of your child, or youth and to have necessary information

on file to contact parents in case of emergency.

· Other determinations, as required, in the course of naval administrations.

ROUTINE USE: In addition to being used within the Department of the Navy and Defense for the purpose(s) indicated above,

the record may, as appropriate, be furnished to the U.S. Attorney for use in determinations concerning issues of liability.

DISCLOSURE: Disclosure of requested information is voluntary. However, if requested information is not provided,

individuals will not be allowed to utilize the CYP facilities.

UPDATING EMERGENCY INFORMATION: It is important that our staff maintain current and accurate records for each

child so that parents can be contacted in the event of an emergency. It is the parent’s responsibility to make sure that the CYP

has current contact information. If there are any changes to this information, the office must be notified promptly so that

records may be updated. All contact information and/or permission to release your child to other adults is required in writing,

prior to pick up.

DISCIPLINE POLICY: Only managers, direct care staff, or teachers may discipline children. The discipline policy of the

CYP is designed to help the child develop self-control, self-esteem, and a respect for the rights of others. In all cases, CYP

Staff will give positive guidance, allow for redirection, and set clear behavior limits. In no case will any humiliating or

frightening punishment be used to discipline a child. Only acceptable guidance techniques will be utilized to including

talking with a child, temporarily removing the child from stressful situations, and limiting the child’s participation in certain

activities.

Children whose behavior cannot be corrected by these acceptable techniques should be instructed that his or her

parent is a being called to the center. In the case of repeated incorrigible behavior; a child could be restricted from the use of

the CYP facilities. Documentation of such incorrigible behavior, as well as any notification to the parents, is essential.

Behavior will be handled on a case by case basis.

Child and Youth Program personnel will not exceed these acceptable techniques. To do so could result in the

termination of their employment. Child and Youth Program personnel will be constantly mindful of the Marine Corps

policies and Base policies concerning child abuse and will report all instances of suspected abuse, molestation, or neglect to

the Child Development Center Director, Family Care Branch Director or Marine and Family Services Family Advocacy

Program Manager.

ABSENTEE POLICY: Full payment of tuition is required on the 1st and 15th of each month, whether or not the child

attends school each week. There is no absentee credit when school is missed because of holidays, illness, or for any other

reason. There is one exception which is our vacation week.

VACATION WEEK: Patrons will receive one “vacation” week per child each year. To use this week, the patron account

must show a zero balance owed to the CDC prior to redeeming. Patrons must also give the CDC two-week notice before

taking this vacation. To receive the pro-rated amount students must not be in attendance at the CDC during this week.

TOUCH POLICY: The CYP touch policy is based on the premise that positive physical contact with children is absolutely necessary for their guidance: whereas, “no touch” under any circumstances, creates a stark and unacceptable atmosphere for young children. Based on this premise, individuals involved in direct care will provide positive physical contact (appropriate contact) and refrain from inappropriate touch. Children will always have the option to refuse touch except in the case of danger to other children or to themselves.

MEDICAL CARE: Take my child/children for medical treatment in case of an emergency where the child’s condition poses

an imminent or reasonably foreseeable threat to his/her loss of life, serious bodily injury, or other permanent or long term

serious health risk. Additionally, it may be necessary for emergency medical personnel to transport my child/children to the

best available medical facility in the vicinity.

2/2018

VACCINE POLICY: Vaccine documentation is required for all children receiving care at the CDC. Vaccine documentation

must be on the Georgia form (GRITS 3231) and submitted at time of enrollment and whenever the record is updated. The

influenza vaccine (Flu Shot) is required for all registered children.

HEALTH ASSESSMENT POLICY: A Health Assessment (NAVMC 11902) is required for all children receiving care at

the CDC. This document must be signed by a health care provider and submitted prior to the child receiving a start date. This

form expires a year from date signed by doctor. Existing patrons are required to maintain a current Health Assessment.

PAYMENT POLICY: Accounts are billed on the 1st and 15th of the month. Automatic payment is highly encouraged and

can be established by completing an “Automatic Payment Agreement.” Credit card information provided will be secured and

charged according to the agreement. Patrons are responsible to update form if there are any changes. If you opt not to use

automatic payment option, fees are still due in full on the 1st and 15th of each month.

Payment is considered late on the 2nd and 16th of each month. Partial payments will NOT be accepted. A charge of $6 per

day will be applied to delinquent accounts. If the balance due, including late fees, is not paid in full by five working days

after the fifth day, services can be terminated. Accounts with outstanding balances will be turned over to the finance office

for collection.

TOTAL HOUSEHOLD INCOME: is calculated from gross incomes (before taxes) includes BAH and BAS and all wage

earning members of the household regardless of marital status. If patrons do not disclose income of all members of the

household, they may be subjected to investigation and possible removal from CYP.

REGISTRATION FEE: An annual, non-refundable $35 Registration Fee per child is required for CYP Services. This fee

will be paid at the time of registration and on the anniversary date of enrollment each year.

MEDIA RELEASE POLICY: Children are occasionally photographed while in their classrooms or on campus. These

photographs may be used in classroom activities, child portfolios, and/or our newsletter. Occasionally media sources video or

photograph our students during special events as well which may be posted on the installation and/or MCCS Albany website

and Facebook pages. You hereby grant, without limitation, permission for the use of any photographs of your child in any

printed or online material for CYP. You may initial to accept the Media Release Policy or indicate below to decline the

publication of your child’s photograph.

I CHOOSE TO DECLINE THE CYP MEDIA RELEASE

CLOSED CIRCUIT VIDEO MONITORING: Sponsors will be allowed to view live video feed of your child’s classroom

and interactions with other children and staff via the CCTV system located within the foyer of the main lobby. To safeguard

the privacy of others, however, updates to the MCO will no longer allow sponsors to view previously recorded footage upon

demand. If a sponsor wishes to view footage of an incident/accident a written request must be filed with the installation

Freedom of Information Act (FOIA) coordinator.

BASE ACCESS: Sponsors must visit the Pass and Identification office to complete an Authorization to Transport

application with any spouses, alternate guardians and/or emergency contacts that do not have base access privileges.

Individuals approved by Pass and Identification will be issued a pass for restricted base access. CYMS swipe cards will not

be accepted at entry gates for the purposes of base access.

SPONSOR HANDBOOK: To view the full policies and all other operating guidelines please refer to your Sponsor

Handbook which may be found at www.mccsalbany.com. To access, click on the Family Care tab, followed by the Child

and Youth Programs tab. On this page you will find a link to our most updated CYP Sponsor Handbook.

Child Abuse Doesn’t Report Itself

If you see or suspect child abuse, child neglect or a safety violation in your DoD Child and

Youth Programs, please contact the following:

Family Advocacy Program: (229) 639-5252

PMO: (229) 639-5181

DoD Child Abuse & Safety Violation Hotline: (877) 790-1197

2/2018

CHILD AND YOUTH PROGRAMS

SUMMARY OF CUSTOMER RIGHTS

The Family Care Branch strives to care, connect and make a difference in the lives of those we

serve. Please note that your rights as a customer of our services include:

· Receive world class customer service from all employees.

· Receive an explanation of services offered by the program(s) you utilize.

· Be treated with respect and have knowledge that all you say will be treated confidentially as

allowed by law.

· Be informed of limitations of privacy, including mandated reporting and duty to warn.

· Participate in setting goals and evaluating progress when applicable.

· Request copies of records.

· Receive fair treatment that is free from discrimination.

· Provide feedback regarding your experiences with our services.

· Express and practice religious and spiritual beliefs, if so desired.

SUMMARY OF CUSTOMER RESPONSIBILITIES

· Keep appointments or provide a notice of cancellation in advance, as soon as practically

possible.

· Adhere to Base standards regarding appropriate attire while utilizing our services.

· Adhere to the guidelines and policies including: Behavior Policy, Fee Policy, CYP Service

Contract, etc. while utilizing services.

· Be honest with your service providers so they can offer you the best care and support possible.

· Help plan goals, as applicable, and actively participate in follow-through with goals.

I have read and understand the Rights and Responsibilities of MCLB Albany Child Youth

Programs. The Rights and Responsibilities listed above are to be maintained by patrons who use

our services.

Sponsor Signature: ____________________________________ Date: _______________

USMC Children,Youth&Teen ProgramsRegistration Forrn

OMB No 0703-0068

OMB approvai expires31 0CT 2020

Privacy Act StatementAUTHORITY: 10U.S.C.5013,Secretary or he Navy:10U.S.C.5041,Headquarters,Manne cOrpsi DoD lnslruduon 6060.02,Ch‖ d DeveioprrlentPrograms;DoD:nsmuctiOn 6060.4,Youth Progrartsi OPNAV:NST 1700.9 series;Marine Corps Order 1710.30,Marine Corps Chi!d and YouhPrograms(CYP);and SORN NM01754‐ 3

PURPOSE:information pttided is used by Children Youth and Teen Prograrrls(cY¬ D)ゎr purposes of patЮn registration in CY「P programsand adivilies and parent/guardian and errlergency conta“ .

吊紀‖闘腑闘醐 摘需認旧蹴=洗

踊よ dS°utStte d DoD Ⅷ“

oorn口劇e wilh he purposesわ r哺勧he■y app!y to his system oFrecords.

DiSCLOSURE:inbmation is voluntary:however,僣 ‖ure to provide information may adverse:y impad indiudua:s魚 〕m panicipation in cY「Pactivities.

Ihe public reporting burden for this collection of informalim, OMB tlo. 0703{n68, is eslimated to ayerage 1.17 lnurs (/0 nunutes)per respons, includinglhe time br reviewing instuctions, searching existing data sdrroes, gEthering antl mainlairing the datra need€d, and comffiirp and reMewing the colleclionrf information. Send mmments regading this burden estimate or arry burden redrrctisr sug,gestions to the Deparbnent of Defense, WashingtonHeadqusrters Services, at whs-mc-alex.esd-mbx-dd{od-informaticn-collections@mail-mil. Respondents should be aware that notwithstanding any otherrovision of lscv, no person shall be subiect to arry penalty fur failing to cornply with a collectbn of iniormatkrr il tt does not disflay a cunenty valid OMB)onlrol number.

,LEASE DO T{OT RETURil YOUR RESPONSE TO THE ABOVE ADDRESS.

lesoqnses shor.rld be sent lo yurr Reqional Director-

SPONSORINFORMAT:ONl Narrle:(First MI Last) 2 Addぃ 1 3 City/State/Zlp codei 4 Datei

5. Home Phone (with area code): 6 Ce‖ Phorte(Ⅵ耐h area code):10 Shttls:□ Acbve □ DoD OⅦhn 輛:Grade

□ 腱回 □ contraф「7 Address 2:

'll.Brancfr: f] trlaiecorps f] x"ty

I atrrace E nnv I otner8 CommndrUnit/Emp:Oyer 9 WkPh: Ebd

12_Emai!:13 Hougng□ on BaSe □ Off Base

SPOuSE′ GUARD:AN:NFORMAT10N14. Name.(First Ml Last) 15_Address l(if different lに 旧n above) 16 City/State/Zip code

17_Address 2: 1B. Horne Ptpne (with area code): 19_CdI Phone(wlth area code):

2O. Command/U niUEmployer. 21 WkPh: 臼22.Statrs: E eai* ! DoOCMlian Mil Grade

! naireo I Conuactor

23 Emai:: 24_Bmchi tt Mane cOrps L」 Naw

□ Ar Force □ Amv □ Oth∝

LOCAL EMERCENCY CONTACT′ RELEASE DESiCNEES

25. Name (first, last) 26.AddresslnClude city/StaterZip cOde)

27.Home Phonelwith area code'

28.Cell Phone(with area code

29.Relationto Chi:d

FOR OFFiCIAL uSE ONLYPR「rACY SENSmVE¨ Any n洒suse or unaumori2ed

disclosune can『 esult in tx■ h civil and criminal penanies.

Page l of3

… ―eDemer9NAVMC 1750′5(Rev.11‐ 2017)(EF)

|

| |

30 Ch‖d/Youthtteen l First&Last Namei Nick Name:

@nder- E rrr"r. f rernan EtirlMate: School Grade: ((12)or N/A

I rut Daycare E part Day Presctrool I Family Chitd Care f, Hourty Care

I scnool Age care (BF/AF) [ sctrool Age care (BF) [ scmor Ag€ care (AF) [ s*nor A6e Day camp

f Youth Program f, reen Program I otner: I Otf Base Family Chitd Care

31 Ch‖d/YouthlTeen 2 Frst&Last Narrle: Nick Name:

Gen<ter: E rrr"r" ! rernan Erthdate: School eade: (K‐ 12)or N/A

Program Enrolirrlent

□ Ftt Day caЮ E part Day Presctroot fl Fami! Cnild Care □ Houdy CaЮ

f Sctroot Age Care (BFiAF) [ Scnoor Agp Care (BF) fJ Sctrmt Age Care (AF) f, Scnmr Age Day Camp

I VoumPrognam ! feen Program f] otrer: I Off ease Family Chitd Care

32 Ch‖d/Youth/Teen 3 First&Last Name: Nick Name:

Gerx,er E *r"B ! female Elirtffiate: Schooi Grade: ((12)or N/A

Program Enro::menti

□ FJ:Day care f] p"rt Dry Preschool I family Chitd Care □ Hou"CaЮ

I scrroot Age care (BF/AF) ! s*root Age care (BF] [ sctroor Ag€ c€re (AF) [ sctrco Age Day cEmp

! voutn Program E r"*Program I otrer: I Of ease Family Chitd Care

33. Please answer the following questions by checking the correct box. Yes No

I allor,v use of video and phdographs of my child within the CYTP program.

l approve my ch‖ d/youth to attend偽 ld trips.

I have received a copy or was given lhe websile on where lo get a "Parent Handbook".

I give my permissircn for child to use supeMsed computerc ard intemel.

I have received two CYMS cards per child.

34. ParenUGuardian Sigrnature 35 Date

Registration Fee: Ch‖d Care Feei Receipt#: Amount Pald: Paid on. Received by:

Pass rssued: ! cv-cnm I cv-sec tr cy-yr tr cy-yzzpri\rtege pass

FOR OFF'C:AL uSE ONLYPWACY SENSFrIVE‐ ′hり mば ws● ●r una―日

c.n rrc i h bodr cMl rd crimin l FrEfb.Page 2 of3

轟―

eDesur9NAVMC 1750r5{Rev.11_20171(EFl

CH:LDRENJYOUTHttEEN INFORMA¬ ON

ForofFce trso only

lNSttRUCT:ONS FOR COMPLETINC NAVMC 1750/5

The l.lAVMC 11903 is completed by the parenUlegal guardian or custodian, or Agent acting pursuant to a power of Ettrrney- lnfonnation provrded is usedby Chtrdren Youth and Teen Programs (CYTP) for purpces of particilant regishati:n in CYTP prognarns and adivities. At least annually or when theinformation is ou6ated, E nely fofm will be cornpleted, sigrr€d, and dated.

Item't -9- Self-explanatoryItem 10. lndicale Sponsofs stalus in the Military. lf applicaUe, please provide Grade or Rarfi in tie'Mil Gradef box, othenrvise please type "tl/A-"Item '11. ldicate Branch Sponsor is afnliated with.Item 12. Self-eplanatoryItem 13. Indicale if famify lives on base housing or off-

SPOUSE'GUARDIAi{

Please ffilow instrucfions for llems 1-13 above.

LOCAL E}IERGENCY COiITACT/RELEASE DESreNEES

Item 2+28. Self-erghnatory- Ttese indiMduab will be sfiacied when the parenugutrdians are trtavailSb and also have permbsion depart thepremases with the partiqpanl There arB three rms for nrultipb eneruency contacts/rdease &sinees. F{l out me rw for each enErgency contact/release tlesignee-Item 29. Provide the relationship lhat the Emergency contacUrelease designee has with the ptrtbapant.

CHILDREIII/YOUTHTTEEN INFORMATION

There are tiree sedions provided on the forrn if the family is regislering multiple participants- Please fill in one sec{ion for each participanlItem 30-32. Self-explanatoryItem 33- Ansner Yes if use of video and photogaphs arc anovyed- Ofrrcnrise, answer No-An$rverYes if participant is allowed to atlend lield bips. O0pnvise, rrswer No-AnswerYes if you received the Parcnt Handbook- Ohe*wise, ansaver No-Ansiwer Yes if participant is allored to use computers and intenet. Otherwise, answer No-AnsrerYes if you received two CYMS cards per participantItem 34-35 Self- exdanatory.

FOR OFFICE USE OilLY (to be cornpbted ry CYIP desrgnated personnel)

FOR OFFiCIAL uSE ONLYPWACY SENSmVE‐ Any口面suse or unau衝●FLed

can r€sult in bodr civit and criminalPage 3 of3

Adobe Lit@@ Detiper9NAVMC 1750r5(Rev.112017)〔 EF)

APPLICAT10N FOR DEPARTMENT OF DEFENSE CHILD CARE FEESfReadあSrruc″οns οη bac々 beFore complerlng Fo″ ηリ

0ハ″8Ⅳo Oア04-05′ 501″B aρρ″va′ exρlres

May 3, 20イ ア

The pubic repo● ng burden forlh s∞ leclon oF nO● nauon s estimaled to avera9o 5 m nutes"f reSpon" nc ud ngい o lmefOr Юv e″ ng nstrud ons seaich ng ex slng data sour∞ s galhenng and

ma nta n ng he da● needed a“ comp elng mdrev“ η the c010C on of nfomaton Smd∞ mments regad ng lh s burden eStimate y any olher aspeclび th s coleelon Or nfamaton nc ud ng

Su990Sll。。sf●rreduc o9 he burden to the Deparlment of Oelense rvash n90輸 Headquaners se～ ices Ex― tve Services D re.orate nfOmaton Management D v sion 4800 Maは Center Onve

A exandla vA 235C 3100(0704つ 515)RespOndents sh∞ d be ttare that ndwihstand ne any other prov s on oflaw no persOn shal le suⅢ eCtto any penaty fOrfattn9 to comp y wth a∞ led on Ol

inlomat onイ l does not d sp ay a curren‖ yva d OMB con● o number

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS RETURN COMPLETED FORM TO THE APPROPR:ATE CHiLD AND YOUTHPROGRAM REPRESENTATIVE

PRIVACY ACT STATEMENT

AuTHOR:TY: `OU S C 3013.Secretary ofthe Amyllo u S C 5013,Secretary ofthe Navy:10 u S C 5041,Headquarters Marine Co「 ps:10U S C

8013.Secretary ofthe Air Force DoD lnstruction 6060 02,Ch‖ d DeVelopment Pro9ramsi Amy Regulaton 608‐ 10 Ch‖ d Development Servl∝ s:

OPNAV nstruction 1700 9 senes.Ch‖ d and Youth Programsi Manne Corps Order P1710 30E,Ch‖ dren,Youth,and Teen Program(CYTP)Air Fo「 ce

lnstruction 34‐ 248 Ch‖ d Development Programsi and Ai「 Force lnstrudion 34-249 Youth Programs,and 34‐ 276.Fam‖ y Ch‖ d Care

PR!NC!PAL PURPOSE(S): TO CO‖ ecl totalfamly in∞ me to deteFnine Ch‖ d care fees VVhen records are covered by one of theappropriate soRNs: Department of the Army:Department of the Navy: h[p-Department ofthe Air Force: I

ROUTINE USE(S): Department ofthe Army records may be disclosed to civilian health and welfare departments/agencies in emergencies.Department ofthe Navy records may be disclosed to local, state and Federal officials involved in child care services, if required, in the performance oftheir official duties relating to child abuse reporting and investigations. Department of the Air Forc€ records may be disclosed to civilian health andwelfare departmentsi/agencies in emergency situations.DoD Blanket Routine Uses 1 (Law Enforcement), 4 (Congressional lnquiries), 6 (Required by lnternational Agreement), 9 (Department of Justice forLitigation), 12 (National Archives and Records Administration), and 15 (Data Breach Remediation) specifically apply to this system. Other DoD BlanketRoutine Uses found at http://dpclo.defense.gov/Privacy/SORNslndex/BlanketRoutineuses.aspx may apply to these records. Any release under a

blanket routine use will be compatible with the purpose ofthe collection.

DISCLOSURE: Voluntary; however, failure to furnish all requested information will result in applicataon ofthe highest fee range.

SECT:ONl‐ DEPENDENT CHILDREN

l NAME OF EACH CHILDrLASr Fl● 4 Mlddleわ lllaリ2 DATE OF BIRTH

`γ

Oイ‐ 1/MO② 3 ACE 4 CARE REQUESTED(OR ENROLLED)

b

SECT:ON‖ ‐ANNUAL FAMILYINCOME

5 SPONSORa NAME r_ASI Fl● 4 Mlddle"lllall b YEARS OF M LITARY′ CiVIL SERVICE

c INCOME(1) lncome Data (2)BasiC A‖owan∝ for Housing

(BAH)

(3) Basic SubsistenceAllowanc€

(4) Other Earned lncome °磯鮮賜[沖ns∝

6 SPOuSE OR OTHER ADULT LIVINGIN THE HOME

a NAME ILASt F161 Vlddle"lrfall b lNCOME

7 0THER EARNEDINCOME 8 TOTALINCOME ″nc″de"CO″e From a10cぉ 5oand Z To Oe conρ leFd Oソ Progran S●″,

SECT10N‖ :‐ CERTIFICAT:ON OF SPONSOR′ DES:GNEE侭。9υlred For Caregο″′‐lX Please read“ e rollowlng starenent careル lly Oerore slgn力 gリ

I certiry that allof the above information is true and correct and that allfamily income ofthe spouse and sponsor is reported. I understand that thisinformation is being given in order to determine child care fees to be paid and that Federal funds are used to subsidize the cost of child care. lalsounderstand that the installation commander may verify the information on the application; and that deliberate misrepresentation ofthis information maysubject meto prosecution under applicable State and Federal laws. See 18 U.S.C. Section 1001.

9 SIGNATURE OF SPONSOR 10 SIGNATURE OF SPOuSE 1l DATE SICNED ry、 4/ソ昴″i″0切

SECT:ON iV‐ FOR CHILD DEVELOPMENT PROGRAM uSE ONLY

12 CATEGORY OF APPROVAL 13 AUTHORlZED FEES 14 DATE OF APPROVAL

`YYYYVν

DD,15 NAME OF CHlLD DEVELOPMENT

PROGRAM OFFICIAL

ED:T10N IS OBSOLETE

INSTRUCTIONS

Per Department of Defense lnstruction 6060.02, Child Development Programs, this form is utilized to determine fees for DoD ChildCare Programs.

To determine child care fees for your childGen), or and child(ren) you legally claim as dependents, this from must be completed, signedand returned to the facility for which your child is enrolling.

Fees are determined based on your Total Family lncome OFI) as defined below. lf you choose not to disclose your family income,your rate for child care will be set at the highest iee level.

Total Family lncome (fFl) - For the purpose of determining child care fees in DoD Child Development Programs, total family income isdefined as all earned income including wages, salaries, tips, special duty pay (flight pay, active duty demo pay, sea pay) and activeduty save pay, long-term disability benelits, voluntary salary deferrals, relirement or other pension income including SSI paid to thespouse and VA benellts paid to the surviving spouse before deductions for taxes. TFI calculations must also include quarterssubsistence and other allowances appropriate for the rank and status of military or civilian personnel whether received in cash or inkind.

DO NOT INCLUDE alimony, and child supporl received by the custodial parent, SSI received on behalf of the dependent child,reimbursements for educational expenses or health and wellness benefits, cost of living (COLA) received in high cost areas, temporaryduty allowances, or reenlistment bonuses.

For households in which unmarried couples or pairs are living as a family, the income for both adults should be used to determine TotalFamily lncome CfFl).

Sections l, ll, and lll are to be completed by the sponsor or their designee.

Section l.

1. Provide the last name, Ilrst name and middle initial for each child who is receiving care in a DoD child care program.

2. Provide the date of birth for each child who is receiving care in a DoD child care program.

3. Provide the age of each child on the date of application who is receiving care in a DoD child care program.

4. Provide the type of care being request or in which each child is currently enrolled.

Section ll.

\/vhen completing Section ll, include all military and civilian income for both the sponsor and spouse or other adult living in the home.

5.a. Provide the sponsor's lasl name, firsl name and middle initial.

5.b. Provide the total years of military/civilian service as applicable.

5.c.(1) Provide your most recent income data and indicate if income is received weekly, biweekly, monthly or twice per month.

5.c.(2) Provide the current year BAH RT/C. For dual military living in government quarters include BAH RC/T of the senior memberonly; in locations where military members receive less than the BAH RC/T allowance, use the local BAH rate; for Defense civilianOCONUS include either the housing allowance or the value of the in-kind housing.

5.c.(3). Provide lhe basic subsistence allowance or in-kind equivalent.

5.c.(4) Provide any other earned income.

5.c.(5) To be completed by program slaff.

6.a. Provide the last name, first name and middle initial of the spouse or other adult living in the home, who contributes to the welfareofthe child.

6.b. Provide the income of the spouse or other adult living in the home, who contributes to the welfare of the child.

7. Provide any additional income.

8. To be completed by program staff.

Section lll.

9. Provide the sponsor's signalure.

10. Provide the spouse's or other resident adult's signature

'l 'l . Provide the date of signatures.

USMC Chi!dren,Youth&Teen Programs(CYTP)Heaith AssessmentЭMB No 0703つ 068

υ■lb approval exp:res

31 0CT 2020

Privacy Act StatementAUTHORrTY: 10 U S_C駅〕13,Secretary ofttЮ Navy:10 U S C 5041,Headquarters,Manne cOrps;DoD insncuOn 6060_02,Chnd DevelopmentPrograrrls;DoD instttcton囲 4,Youth Programsi OPNAV:NS丁 17∞ 9 senesI Manne Corps Oder1710_30,Manne cOrps Child and Youth Programs(CYP)and SORN NM01754●

PURPOSE:丁 he infomatlon collected on this fom is used by children,Youth and Teen Programs(CYttP)and inc:usion Acton tteam personne!to

Jeterrnine tt general health status of pamms pattdpaung in cYI P actMbes and r necessary the appropnate accornmodatons for he patron for他 ‖

9町oyrrlent of CYrP seMces

ROu¬ NE USES:Any release ofinforrrlaton contained in his ttβ tm ofreoords outside of DoD面‖be∞mpaib:e wth the purposes for which the

nfOr7Fla10n is coliected and rrlahbined The DoD Blanket Rouune uses口 田y apply to nis system ofrecords_

DISCLOSURE: !nfomalon is voiuntary;however,fa‖ ure to provlde lnfomatlon■ ■v adversely impad individuals from participatlon in CYttP actl颯 ies_

Ihe public reporting burden for this collectim of informatirn, OMB No. 07m{n68, is estimated to average 1-17 hours (70 minutes)per response, indudinghe time for reviewing instrudbns, searching existirg data sources, gntherirp and maintaining the data needed, and mmpleting and reviewing the oollectionrf information. Send comments regarding this burden estimate or arry burden reduction suggestions lo the Departrnent of Defense, WashingtonHeadquarters Services, at whs-mc-alex-esd.mbx.dd-dod-jnfonnatio+collection@mail.mil- Respondents should be aware that nottrrithstanding arry other)rovrsion of law, no person shall be s:bject to any penalty for failing to comply with a collection of information if it does not display a cunenUy vali<l OMB;ontrol number-

PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.

Responses should be sent to your Regbnal Dircctor.

SPONSOR ttFORMA■ ON(pleaSe pmt)

1. NameofSponsor 2 Horle rnone 3 5pOnSOr unll

4_Ce‖ Phone 5 D呻″Vtt PhOne

CHL動ⅣOLrrH INFORMAT10N(pleaSe pn威 )

5 Name orじ n‖dlYoutn blttnり are a-Eu.n Er.nol. 9 Enrol:ed h PuЫ c Sch∞:□ Yes □ No

CHlLD卿 TH'S MEDICAL「ISrORY(Chαま att tlat app!y)

10 Any hOspib:lzaton or operations 23- Heat slroke or exhaustion 36. lf any apply, please explain

1l Alle□ les to rnedttne,insed bltes,:atex orf00d(please explain reacOons)

24_ Benign Skin Co:oralons

(e_g birthma雌

12. Development delays/Leaming problems 25_JolntinJunes

13 Eye or vislon Probierns(G!assesrcontacts) 26_Restncted physica:activity

14. Eat $ hearing problerns 27 [)iabetes

15, Seizures or Conwlsions 28. Cancer

16. Diziness or faintng with exercise 29- Dental problems

17 Heedaches 3O. t\tlental Heatth lssues1 B. Head injury or loss of consciousness 31. Sleep problems

19 Neck or backlnlury 32_ Behavlora!problems

20. Asthma o dffiartty breathing 33_ADD/ADHD21. Heart or blood pressure problems 34- Broken bones or sprains22. Chesl pain with exercise 35_Other prob:ems

37_L tte由‖dryOuh enrolbd m ExcettonJ Fa面 けMember P咽にm? □

Yes □

No 38 in what branch of Sen′ ice

39_Does the childryouth have ongoing ntedica:∞ncems orspea:needJoonsideratons hat have required the care of a Heathcare Prouder wihin the!astyeaρ (r Yes,exphn drcumstances and currett sta仙 9 □Yes □ No

lfthere an3 special oonsiderdions,a Health Screening To● l forinclusion Action Team (page s〕 must be cOrnp:eted by the Healthcare Provider.

FOR OFFEC:AL uS■ ONLYPR「rACY SENSlnVE‐ Any misuse or unamttЮ rized

can rE5ult in both civil and criminal penalties.NAVMC 1750r4(Rev.11‐ 2017〕 〔EFl Page 1 of4

USMC Children,Youth&Teen Programs{CYTP)Hea:th Assessment

40 Height: 41 WOight 42_8P: 43 HR:

Normal Abnormal N/A Normal Abnormal N/A 58_Based on this examinaton,the fo::(測 Ⅵngabnorrrlallies were found

44_ Eyes51. Chesu

Abdomen

45 ENT 52 Genita:ia

46. Hearing 53 Skin

47 Mouth/Teeth 54 Lymphaic

48_ Neck 55_ Spine

49. Cardiovascular 56 Extremites

50. Respiratory 57 Neurologica!

59. lmmunizations are cunent and up to date ! Yes f] No (if no, please explain) A copy of the childtlouth immunization must be glven to CYTP.

60_Ch旧焔 dhも aЫe b pattdpate h nofTvlal CY「 P progttrrls?□ Yes□ No ffno,口ease expblnl

31.Date 62. Parent or Guardian Signafure 67.Healthcare Provider Stamp or Printed Narrle&Add…

33.DaL 64.Healthcare Provider Signature

65.Date 66.Healthcare Provider Signatu腱

FOR OFFICIAL USE ONLYPRIVACY SEN$TfVE - fury misllse or uneuthorized

disclosure can resuh in bodr cMl ard crimind Penakies.NAVMC 1750J4(Rev.112017)(EF〕Page2of 4

PHYSiCAL EXAM:畔 A■ON o「o be 00mpleted by Healtllcare Pmttdeo(May attaclnlast physical r ttin Lst 12 months)

USMC Children,Youth&Teen Programs(CYTP)Health Screening Toolfb『 lnclusion Action Team(:AT)

REQU:RED ONLYIF THE CH:LDrYOUTH HAS SPECIAL NEEDgcONSiDERATЮ NS.TO BE COMPLETED BY PARENT AND HEALTHCAREPROViDER OR APPROPRIATE SPECIALiST

:dentittcation of Ch:]drYouth Stta:Heed〔 s)(use prOvided space to elaborato on the special need〕

Asthma/Reactive Airway Disease trDevelopmental (e.9. Autism/PDD/Delays) ♂ 躙鵬躙鴨?

Behavioral □ Neurologicd f

69 Bnefsummary of he child'」 youth's needs

Medicataon

70 Ch‖ dも on medicatbns ttbted b spectt needs?□ No□ Y∝ ぐЫ mediCatlons“ low and lndi“ b whにh reqttЮ

“

面面straton dun∞ ch同 ∞Ю hOus)

71. For medically diagnced allegies, b Epinephnne rcquired? ! ruo tr Yes

72-Forotherdiagnoses,areanyernergencymedicationsrequired(e.g.Glucagon,Diastat,Alfuterol)? E Uo !Vescじ― Nr MED:CAT10NS iNCLUDiNG EMERGENCY(lf more space 3S needod,please a油 Ⅸわ add曲γ口l doalnents)

73_Name 74_Dosage 75. Frequency 76 Dunng ch‖d care

□

□

□

77. Assistance with activities of daily living? E f.f" E vo (explain) 78. lvledi}d Dretary modificEtions? L-l No L-.1 vr. (explain)

79. Environmental adaptations (e.g. room lemperature, wtreelcirair acoess)Z E ruo E Vo (explain)

80- Ofter condfions/adaptatinngmodifcations/recomrnendatbns/conoems or @mments to ensure frc child's^/outh's needs are met? E No I Ves(specify End explain)

81. Healthca.c Provider or Specialist Signafure 82.Date 83_Providerrspecialist SLmp or Printed Na871e&Address

84- Phone 85E― man

86.ctt and Self‐ A山口哺口blorAuthorizatton cto be initialed by tlle hea田 lcare providerl

I lraxi insfir.lchd &b yqrEr in the proper uqf to use hi9ter medicdinn, lt Ls my prdes$mal odnirn fet he/sho SHOULD be dlcnred tocryry and sdf dminbbr his/tpr medbdlrfL Th[s )lol.dl t6 been irstucfed rd to slwe rnedi:*ixts-

It is $y gofesstund opinkt fut this child routh SHOT U) NOT carry o self dninisler his/her mecf catim.

棚脚講 i購剛押轟

Earty lnterrcntion and Speciel Educdion

87_Chほ has an hdMduJlzed Famiv SeⅣiOe Plan oFSP),indMdua:lzed Educatlon Plan oEP),5“ 口an or Beha宙 oral Πan? □

No [Yes88. lf yes, does he/she have an aide, skills trainer, or addilional assistance? E N" E Y*89. For Special Ed/Early lntervention, is the child cunenlly seeing a thraplst? E ruo f] Yot unOerstana trat all reasonable efurb urill be rnde b acomnrodate all properly daurnenbd specid neetb based m IAT delerminaticns- ParenUgrrdian(s) will be ncilif€d if

uouH be srsideled skilled nursang o. betnvioral, aopati:nal, q plryslcal tterapyI undersiand lhat ths form mr.d be rpdated annudty, or earlier, if ttrre is a cfiange in conditirn or need-

90 Parent/Guadlan Signature 91 Date

Gffice Usc Onlyi,evianrcd by CYTP Nurse or Other Detignabd Personnel

92, Signature 93 Date 94- LAT Meebrq date il required

FOR OFFECIAL uS■ ONLYPRPrACY SENSI■ VE‐ Any misuse or unamttЮ rized

can rrsult in bodr civil and criminal penalties.NAVMC 1750J4(Rev.112017)(EF〕Page 3 of4

MCO P1710.30

:NSTRUCT:ONS FOR COMPLETING NAVMC 1750r4

GENERAL

The NAVMC 1750/4is comp!eted by the perentnegal guardian or custodan,

or Agent acting pursuantto a power of attomey;and he Hea!thcare Provlderofthe Chi!dren,Youth and Te(抑 Programs(CYIP)parlldpant l heinfomation provided is used by USMC personne1lo:(1)Venfy ch‖ d required

immunlzatlons per admisslon requirerllents;(2)be used by the:nciuslon

Action Team(lAr)to deterrnine neoessary and appropnate acoommodaむ onsin CY「 P actlvnies:(3)execute em"ency rledica!pFOOedure for chronicⅢnesses/∞ ndttionsi 14)refer Child for enro::mentin Exceptona:Family

Member Programi and(5)detemine r at■ me of enrol!ment ch‖ d is

physica:ly itto pettdpatein USMC CY「 P prograrrls_

SPONSORINFORMA■ ON(丁o be cornp!eted by the pa聞切ega:guardian

or custodian,or Agent adlng pじ 円uantto a power of attomey)

item l_Self explanatory

:tem 2_Ser explanatory_

:tem 3 Narrle ofspOnsOr m‖lary ottFnlzaton,othenvise N/A

item 4_Ser exp:anatory

item 5_SelF exp:anatory

CHlLDIYO囲 INFORMAT10Nき、be cOmpleted by he parent/1egal

guardian or custodian,or Agent acting pursuantto a power of attomey)

!tem 6_NerFle Of CY「 P Parbdpantitem 7_Self expianatory_

item 8_(X one)Self exp:anatory

itenn 9_(X orle)Answer Ves if participantis en【 メied in a pub“ c school

system or a Depattnent of Defense Educaton Actvlty(DODEA)sch∞ |

system,otherwise answer No

CHILDⅣOUTH MEDiCAL HISTORY卜 、 be cOmp:eted by the parenJegalguadian or custodian,or Agent acting pursuantto a power of attomey)_

ltem 10-35 !ndicate wth an X those hat apply to lhe CYI P participant_

ltem 36 Exp:anaton for any iterns 10 35哺 h Xs_

item 37 α one)Answer Yeslfthe CYIP participantis enroled in EFMP;othenuse,answer No_ltem 38 Self exp:anatory_

ltem 39体 one)(USed tO help deterrnine r EFMP referra:is necessary)

Answer Yes IFthe CY「 P participant has ongOing rnedical concerns or special

needs/consideratlons that have required he care of a Heatthcare Provlder

n囃hin the lastyear Othenuse answer No ifyes,pro宙 de exp:anatlorl of the

medical oonoerns or specai needs/consideratlons and indicate r the matter

has been resolved_r yes,Page 2 must be oompleted by the HeanhcareProvider ofthe CY「 P partlclpant

PHYSICAL― MlNAT10N卜、 be cOmp:eted by Healthcare PЮ vider)

ltem 40 Height_Self explanatory ifthe CY「 P participant has had a physlcal

輛 hin the:ast12 months,the Heanh∽ re Pro宙 der「露y rrlark through the

lem and attach a copy of hat physicalin meu Of∞ mretlng his bm_ltem 41 Welght_Se:f explanatory_rthe cYIP parbdpant has had aphysical面thin he:ast 12 rrlonths,the Heatthcare R枷 祠er剛町 rlark

through he tem and attach a oopy ofthat phys:cal in‖ eu of sign,date and

stamp(r app:icable)the fOnn

ltem 42 BP_CYI P participant's blood pr― ure ifthe CY「 P participant has

had a physical within the last 12 months,he Hea:thcare Provider may mark

through he nem and abch a copy Ofthat physicalin neu of∞ mpleting this

lem_ltem 43 HR_CYIP pattdpanrs heart nie ifthe CYIP pattcipant has hada phメJcal wthin the:ast 12 rlonths,the Heathcare Pronder rrlay mark

hrough he ltem and attach a copy ofthat physicalin meu Of∞ mpleting his

lemltem 44-57_(Xa‖ that apply)XN/A IF area unexarnined lfthe CVTPparbdpant has had a physに al wlthin the last 12 months,the Healhcare

PЮvider may matt through these nems and atach a oopy ofthat physicalin

ileu of cornpletng these lterrls

ltem 58 Explanaton ofany ttms 44-57,lf abnorrnal :fthe CYIPparbdpant has had a physlcal within the last 12 months,the Healthcare

Provider may markthЮ ugh the item and abch a∞ py ofthat physlca:in“ eu

of comp!etng this ltem

item 59_(X one)Answer Yes r a‖ Ofthe CY「P participanrs immunLatons,induding tuben‖ n skin test(r applicabie),am up tO date atthe ume thd

this brm is being∞mpleted_ OthenMsel answer No and provideexpianation_ A copy Ofthe CYIP paniciparsimmunizations must beprouded lo CYrP lfthe cYrP patticipantis on a catch―じp schedule,a copy

ofthe schedu!e must be provided to CY「 P_

:tem 60_Answer Yes r CYTP pa癒 cipant wl‖ be abie to participate in

NORMAL CY「 P programs Othemlse,answer No and provlde exp:areuon_item 61-62 ■le parettega:guardian or custodian,or Agent attngpursuantto a pOwer of attomey rnust slgn and date he fOrm_

Item 6366 Serexplanatory_‖ more than one Healthcare Prowder

cornpleted fom,each rrlust sign and date the forln

item 67 Self exp:anatory

H鳳 Ⅲ SCREENING T00L FOR:NCLuS10N ACT10N TEAM(lAD

「

O be COmpleted by paЮ nt and Heamcatt PrOvlder or appЮ pnate

specia!ist)

item 68_(Xa‖ that apply)Se:「exp:anatory_

:tem 69_Provide exp:anation of a‖ Xs in!tem 63_

MEDiCATЮ N(to be COmp:eted by Healhcare Provlder or appopnate

Specialist)

iten1 70 Answer Ves Ff participantis medicatlons related to spedai needs

notated in hems 68-69_ Othettse,answer Noitenn 71_Answer Ves lf participant has a prescnbed Epineph嗜 ne inJector_

OlhenMse,answer No_:ten1 72_Answer Yes r participant has prescFbed errlergency medlcatons

otherthan epinephnne_ ohettse,answer Nonem 7376_Comp:ete r parbclpantis taklng any med:α ttions_H Vesis

chosen fbritems 70-72,cornpiete Pronde narrle,dose and how onen

medicaton is given_X r medicdion wi‖ need or possibly need to be given

dunng chi:dcare hours_

:tem 77 Answer Yes lf participant ttquires as● stance面ha薇前ies hat are

typica‖y part of evwday:fe for a ch‖ d ofthat age Ohenttse,answer No_ lf

Yes,exp:ain the assistanoe thatis need_

item 78_Answer Ves lf participant requires modiicalons to diet due to

speclic rnedica:reasons_ Otherwse,answer No lf Yes,expiain required

modttcatlms_ DO NOT provide dietary modlfcalons that are due to

re:igious,cu:tura:or phibsOphica:reasons_

:tem 79_Answer Ves r paltlcipant requires envIDnrrlental adaptatlons_

Othettse,answer No_I Ves,explain_:tem 80_Answer Yes r panicipantrequitt any other adaptatons or

modttcatlons,or lf the資 )are any other reoomrnendaton or cornrtentsneeded to exp:ain spedai needs of chiid_men面 se,answer No_ :f Ves_exp:ain_

item 81 85_Self exp:anatory_Must be coFnpleted forfonn to be鴨 誦ditem 86_CARRY AND SELF‐ ADMiNISTER AUTHORIZAl10N cto beinitaied by the Heanh∽ 博 PrOvlder)_innia:Orle_Parbdpant must be

considnd a Youth(inciuding Teens)and NOT bein Ch‖ d Deve:opmentProgに rlls(Ch‖ d Deve:oprlent centers,Family Child Care,or sch∞ !AgeCa腱)_Self e191anatory_

EARLY INTERVENr10N AND SPECiAL EDuCAT10N(to be 00mpleted byparenVlegal guardian or custodian,or Agent ading pursuantto a power of

attomey)

ttem 87 Answer Yes r parbOpant hasIFSP or:EP_ Ohen面 se,answer No_if Yes,pに Юeed toltem 8389_:tem 38_ Self exp!anatory_

:tem 39 Self explanatory_

item 9C1 91 Ser explanatory_

OFFICE USE ONLY lto be COmpleted by CYrP Nurse or Oher DesignatedPersonneり

FOR OFFrCIAL uSE ONLYPRIVACY SENSlrIVE‐ Any misuse●r una山 od2ed

can lEsult in both civil and criminal penalths.NAVMC 1750/4(Rev.112017〕 (EF)Page 4of 4

10/2017

Bright from the Start: Georgia Department of Early Care and Learning

Child and Adult Care Food Program

Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

Name: (Last, First and Middle Initial) Food Stamp, TANF, or FDPIR case number, Assistant Unit (AU), or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers.

Head Start

Participant

Foster Child

PART II A: A. Name (List everyone in household, including foster and non-foster children)

B. Gross income and how often it is received Example: $100/monthly, $100/twice a month, $100/every other week, $100/weekly

C. Check if NO Income

1. Earnings from work before deductions

2. Welfare, child support, alimony

1. 3. Social Security, pensions, retirement

4. All other income

1. _______________________________

2. _______________________________

3._______________________________

4. _______________________________

5. _______________________________

6. _______________________________

7. _______________________________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/__________

$______/_________

$______/_________

$______/_________

$______/_________

$______/_________

$______/_________

$______/_________

$______/_________

$______/________

$______/________

$______/________

$______/________

PART III: ENROLLMENT INFORMATION: Children Only My child is normally in attendance at the facility between the hours of _______ [am/pm] to _____ [am/pm] on the following days:

Check here if only before/after school care is provided.

(Circle all that apply). Sunday Monday Tuesday Wednesday Thursday Friday Saturday

My child will normally receive the following meals while in care:

(Circle all that apply): Breakfast AM Snack Lunch PM Snack Supper Evening Snack

PART IV: Signature and Social Security Number (Adult MUST sign). An adult household member must sign this form. If Part II is completed the adult signing the form must also list his or her Social Security number or mark the “I don’t have a Social Security Number” box. (See Privacy Act Statement on next page).

I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This signature also acknowledges that the child(ren) listed on the form in Part I are enrolled for care .

Signature: X____________________________________ Print Name _____________________________________ Date:_________________________

Address: _________________________________________ ___ City: ________________________ State: GA Zip:__________ Phone: ____________________

Last four Digits of Social Security Number XXX-XX___________ I do not have a Social Security Number

PART V: Participant’s ethnic and racial identities (optional)

Mark one ethnic identity:

Hispanic/ Latino

Not Hispanic/ Latino

Mark one or more racial identities:

Asian White Black or African American American Indian or Alaska Native Native Hawaiian or other Pacific

Islander

Official Use Only Section for Provider: Annual Income Conversion: Weekly x 52, Every 2 weeks x 26, Twice a month x 24, Monthly x 12

Total income: ____________________ Per: Week Every 2 weeks Twice a month Month Year Household Size: _______

Categorical Eligibility: (check if applicable) ______ Date withdrawn: _____________ Eligibility: (check one) Free _____ Reduced _____ Paid ______

Day Care Homes Only: (check one) Tier I _____ Tier II ______

Determining Official’s Signature: ____________________________________________ Date:_______________________________

Confirming Official’s Signature: _____________________________________________ Date:_______________________________

Follow Up Official’s Signature: ______________________________________________ Date:_______________________________

10/2017

The participant in the day care facility may qualify for free or reduced price meals if your household

income falls within the limits on this chart.

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on

this application. You do not have to give the information, but if you do not, we cannot approve your

child for free or reduced price meals. You must include the social security of the adult household

member who signs the application. The social security number is not required when you apply on behalf

of a foster child or you list a Food Stamp, Temporary Assistance for Needy Families (TANF) Program or

Food Distribution Program on Indian Reservations (FDPIR) case number for your child or other (FDPIR)

identifier or when you indicate that the adult household member signing the application does not have

a social security number. We will use your information to determine if your child is eligible for free or

reduced price meals, and for administration and enforcement of the Program.

Non-discrimination Statement: 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 employees,

and institutions participating in or administering USDA programs are prohibited from discriminating

based on race, color, national origin, sex, 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 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.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint

Form, (AD-3027) found online at: http://www.ascr.usda.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 form. To request a copy of the complaint form, call (866) 632-9992. Submit your

completed form or letter to USDA by mail: U.S. Department of Agriculture, Office of the Assistant

Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; fax: (202) 690-

7442; or email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Household Size Yearly Income

1

2

3

4

5

6

7

8

Each additional person Add:

10/2017

INSTRUCTIONS

Households that receive Food Stamps, TANF, FDPIR, SSI or Medicaid: Complete the following:

Part I: For family day care home and child care center, list participant’s name and a Food Stamp, TANF, or FDPIR case

number. For adult day care, list participant’s name and a Food Stamp, TANF, FDPIR, SSI or Medicaid case number.

Note: foster children (children placed in the household by the court system) can be included in this section. A

separate form is no longer needed for foster children.

Part II: Skip this part.

Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate

the meals he/she normally receives while in care.

Part IV: Sign the form. A Social Security Number is not necessary.

Part V: Answer this question if you choose to.

All other Households, including WIC households, complete the following:

Part I: For family day care home, child care center or adult day care, list participant’s name.

Part II: To report total household income from last month, complete the following:

Column A-Name: List the first and last name of each person living in your household as an economic unit. You must

indicate yourself and all children living with you (including foster and non-foster children). In the case of an adult

participant, the adult participant, and if residing with the adult participant, the spouse and dependent(s) of the adult

participant. Attach another sheet if necessary.

Column B-Gross Income last month and how often it was received: Next to each person’s name, list each type of

income received last month, and how often it was received.

Box 1: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the

amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you.

Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).

Box 2: List the amount each person got last month from welfare, child support, alimony.

Box 3: List Social Security, pensions, and retirement.

Box 4: List all other income sources including Worker’s Compensation, unemployment, strike benefits, Supplemental

Security Income (SSI), Veteran’s benefits IVA benefits), disability benefits, regular contributions from people who do not

live in your household. Report net income from self-owned businesses, farming, or rental income. Next to the amount,

write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing

allowance.

Column C-Check if no income: If the person does not have any income, check the box.

Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate

the meals he/she normally receives while in care.

Part IV: An adult household member must sign the form, and list the last four digits of his/her social security number.

Or, mark the box if he/she does not have one.

Part V: Answer this question if you choose to.

Privacy Act Statement: This explains how we use the information you give us.

10/2017

SHARING INFORMATION WITH MEDICAID/SCHIP

Dear Parent/Guardian:

If your children qualify for free or reduced price meals, they may also be able to get free or low cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP).

Children with health insurance are more likely to get regular health care and are less likely to

become sick.

Because health insurance is so important to children's well-being, the law allows us to tell Medicaid

and SCHIP that your children are eligible for free or reduced price meals, unless you tell us not

to. Medicaid and SCHIP only use the information to identify children who may be eligible for their

programs. Program officials may contact you to offer to enroll your children in this health insurance program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll

your children in health insurance.

If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send it with your Income Eligibility Form to [address] by [date]. (Sending in this form will not change

whether your children get free or reduced price meals.).

No! I DO NOT want information from my CACFP Meal Benefit Income Eligibility Form

shared with Medicaid or the State Children's Health Insurance Program.

If you checked no, fill out the form below.

Child's Name: ____________________________________________________

Child's Name: ____________________________________________________

Child's Name: ____________________________________________________

Child's Name: ____________________________________________________

Signature of Parent/Guardian: _______________________________________

Today’s Date: __________________________

Print Your Name: _________________________________________________

Address:________________________________________________________

For more information, you may call _________________ at ________________October 2008

CACFP Meal Benefit Income Eligibility Form Sharing Information with Medicaid/SCHI

Updated 9/2015

Georgia Division of Family and Children Services

Community Programs Unit

Afterschool Care Program

Youth Participation Eligibility Form

Page 1 of 3 - DFCS Afterschool Care Program Eligibility Form

MCLBA Child and Youth Programs and the Georgia Division of Family and Children Services (DFCS) are partnering to provide

valuable out-of-school programs for youth in Georgia. The information provided on this form will help ensure that eligible youth are

benefiting from the partnership. Please complete this form in its entirety and return it to the identified staff person at the program

site. We thank you for your cooperation.

Form to be completed by Parent/Custodian/Caregiver

Youth Information – This section must be completed in its entirety.

Name of Youth Participant (Last) ___________________________ (First) ___________________________ (MI) _____

Social Security Number ______ - ______ - ______ Gender: ______ Male _______ Female

Date of Birth (mm/dd/yy): ___ ___ /___ ___ /___ ___

Is the youth named above in Foster Care within the state of Georgia Yes No

Note: If the youth is in Foster Care but not in the care of Georgia, please provide the state name _____________________________

Section 1

A. Is the youth applicant a U.S. citizen or qualified alien? Yes No

B. Is the youth applicant a Georgia resident? Yes No

C. Does the youth applicant fall into one (1) or more of the three categories below (Answer YES or NO and check all

categories below that apply to the youth)?: Yes No

____Youth applicant is between the age of 5 and 17 years old; OR

____Youth applicant is 18 years old and currently enrolled in school (high school, GED program or equivalent, or post

secondary institution) and will be enrolled in AND attend school during the upcoming academic year (Verification

of school enrollment includes a letter from the school on official school letterhead): OR

____Youth applicant is 18 - 19 years old and has a dependent child AND is the custodial parent

If the one (1) or more answers to the questions in Section 1 is NO, the youth IS NOT eligible to participate in the DFCS funded

services. If the answer to ALL of the questions in Section 1 is YES, please complete the remainder of the form.

Section 2

Does the youth currently receive benefits or services under any of the programs listed below (Please Note: you will have to provide

official verification to the afterschool/summer program):

Yes No

A. Temporary Assistance for Needy Families (TANF) B. Supplemental Nutrition Assistance Program (SNAP) (also known as Food Stamps) C. Medicaid or Social Security Income (SSI) D. Reduced or free lunch program at school – Note: This eligibility is only for single youth

eligibility. Please do not utilize the universal school eligibility.

E. Peachcare for Kids

If the answer to at least one question in section 2 is YES, the youth is eligible to participate in the program and the

parent/custodian/guardian may complete Section 5. Verification for receipt of services checked in Section 2 must be provided and a copy

of the verification must be attached to this eligibility form. If the program does not receive verification of items checked in Section 2, the

youth will not be able to participate in the program.

Updated 9/2015

If the answer to ALL of the questions in Section 2 is NO, the parent/custodian/guardian MUST complete Section 3, Section 4 and

Section 5 for eligibility determination. Verification for items listed in Section 3 and Section 4 must be provided and a copy of the

verification must be attached to this eligibility form.

Page 2 of 3 – DFCS Afterschool Care Program Eligibility Form

Section 3

If you answered NO to ALL of the questions in Section 2, please review the chart below and enter your family unit size, gross

household yearly income and gross household monthly income to determine eligibility.

Family Income Eligibility for the DFCS Afterschool Care Program Income Eligibility Guide

Number of Persons

in Family Unit

Federal

Poverty Level *

DFCS Afterschool Care Program

Annual Household Income Guidelines **

DFCS Afterschool Care Program

Monthly Household Income Guidelines

1 $11,770 $35,310 $2,943

2 15,930 $47,790 $3,983

3 20,090 $60,270 $5,023

4 24,250 $72,750 $6,053

5 28,410 $85,230 $7,103

6 32,570 $97,710 $8,143

7 36,730 $110,190 $9,183

8 40,890 $122,670 $10,223

Each additional

person, add

$4,160 $12,480 $1,040

* Income based on the Office of the Secretary, U.S. Department of Health and Human Services (HHS) 2014 Poverty Guidelines for

the 48 Contiguous States and the District of Columbia. (Source: 80 FR 3236, Page 3236 – 3237, Document Number: 2015-01120) ** 300 % of the federal poverty level. Released January 22, 2015.

Family Unit Size* _____

Gross Household Yearly Income $_______________ Gross Household Monthly Income $________________

* See Appendix A for definition of family unit.

Section 4

Please complete Section 4 by listing your name, the name of the child (ren) who live with you, and the other parent of the child (ren) if

s/he lives with you. List any gross monthly income for each.

Household Composition and Income

Gross Monthly Income is income before taxes and deductions.

Name (First, Middle, and Last) Relationship Date of Birth

(MM/DD/YY) Income Source

Amount

(Gross Monthly

Income)

How often

received?

SELF

Updated 9/2015

Page 3 of 3 - DFCS Afterschool Care Program Eligibility Form

To be Completed by DFCS Funded Afterschool/Summer Service Provider

By signing below, I certify the information presented within this form was reviewed, verified and confirmed** and meets the DFCS

Afterschool Care Program Eligibility rules and guidelines indicated within this form. I also certify this form will be kept in the youth

participant’s file in a confidential and secured location.

_____________________________________________ _______________________ __________________

Authorized Program Staff Signature Title Date

** See Appendix B for income verification proof sources

Section 5

Please review and sign Section 5 as notification and signature of verification.

Applicant Notification and Signature

We are asking for your youth’s Social Security number because any person applying for or receiving federal benefits must give

us his or her Social Security number. Federal law 409(a) (4) of the Social Security Act and federal regulations (45 CFR

264.10) allow us to collect this information.

By signing this application,

I swear, under penalty of perjury, that to the best of my knowledge, all the information and statements I’ve provided in this

application are true, and

I promise to cooperate with any effort to verify the information provided.

If selected to participate in the program, I promise to abide by all rules and guidelines.

Parent/Guardian/Caregiver Information – This section must be completed in its entirety.

Name of Parent/Guardian/Caregiver (Last, First, MI) _________________________________________________

Street Address __________________________________ City ______________ State ______ Zip Code ________

Home Phone # _______________________ Work # _______________________ Cell# _____________________

________________________________________________ _________________

Parent/Caregiver/Guardian Printed Name Date

________________________________________________ _________________

Parent/Caregiver/Guardian Signature Date

Updated 9/2015

Page 1 of 2 - DFCS Afterschool Care Program Eligibility Form Appendix

APPENDICES

*Appendix A: Family Unit

The Department of Human Services Temporary Assistance for Needy Families (TANF) definition of family includes the dependent child

for whom assistance is requested and certain other individuals living in the home with the child who are required to be included in the

family.

The following individuals are considered members of the Family Unit:

A biological or adoptive parent of the dependent child for whom assistance is requested;

An eligible minor sibling, (whole, half or adoptive) of the dependent child for whom assistance is requested;

Other children living in the home who are within the specified degree of relationship to the grantee relative but who are not

members of the Family Unit; and

A non-parent relative who is the caretaker if there is no parent in the home or if the only parent in the home receives SSI.

An individual documented as the youth’s caregiver. A caregiver is considered a person who provides direct care to the youth.

This provision includes foster parents.

**Appendix B: Income Proof Sources and Applicable Income Sources

Income verification must be obtained and a copy must be attached to the youth’s income eligibility form.

Examples of earned income verification are:

Pay stubs or receipts for the most recent four weeks of earnings;

W-2 Forms;

Employer’s issued, signed and dated documentation;

Personal income ledger or tablet (e.g. self-employed)

Quarterly income tax returns;

Annual income tax returns when presented in January – March quarter;

Letter/statement from employer;

Documentation from other DFCS staff such as the eligibility CM; and/or

Form 809 or itemized statement completed by the employer.

Examples of unearned income verification are:

Copy of current check with check stubs (within last 4 weeks);

Award letters or written, signed and dated statement of payer;

Social Security Records;

Worker’s compensation records;

Form 139 – Contribution statement;

Unemployment insurance claim records;

SUCCESS screen information; and/or

STARS.

See page 2 of Appendix B for applicable income sources.

Updated 9/2015

Page 2 of 2 - DFCS Afterschool Care Program Eligibility Form Appendix

Applicable Income

Each of the following sources of income is budgeted in determining eligibility:

Earned

Wages or salary – Gross income of the applicant is used to determine eligibility

Net Income from Self-Employment

Employee commission

Jury Duty

Rental Income – (regular and ongoing payments – if engaged in management of property for an average of 20 hours or more per

week)

Roomer Income – (regular and ongoing payments)

Unearned

Military Allotments

Cash gifts Charitable gift exceeding $300 received from and organization receiving state or federal funds

Inheritances

Insurance Benefits due to Loss of Income – benefits paid from an insurance policy due to loss of income

Social Security Benefits

Unemployment Compensation

Worker’s Compensation

Alimony – (regular and ongoing payments)

Child Support – (regular and ongoing payments)

Farm Allotment – payments received from government-sponsored programs, such as Agricultural Stabilization and

Conservation Services

Veteran’s Benefits

Capital Gains

Interest/Annuity

Capital Gains/Dividends

Pension

Trust Fund

Disability Payment

Boarder Income – (regular and ongoing payments)

Rental Income – (regular and ongoing payments - if engaged in management of property for an average of 20 hours or less per

week )

Deferred compensation through retirement plan

.

December 2017 Version

MEMORANDUM:

FROM: Marine Corps Logistics Base, Albany GA

[ Ins e r t nam e o f i n s t a l l a t i on , s choo l , camp, f ac i l i t y]

SUBJECT: Child and Youth Behavioral Military & Family Life Counselor

1. This letter is to inform you about the Child and Youth Behavioral Military and

Family Life Counseling (CYB-MFLC) program services. Due to the unique

challenges faced by military families, the Department of Defense is offering this

private and confidential non-medical counseling service to military service

members, military families, and military family service member’s children in

Child and Youth Programs, Department of Defense Education Activity schools,

Local Education Agencies, DoDEA CYP summer programs, National Military

Family Association Operation Purple Camps, Guard/Reserve camps, and

Operation Military Kids Camps.

2. The CYB-MFLC counselors may support the centers, schools, summer programs

and camps and work with military children and their families in the following

ways:

Observe, participate and engage in activities with children and youth.

Provide direct interaction with military children.

Model behavioral techniques and provide feedback.

Suggest courses of age appropriate behavioral interventions to enhance coping

and behavioral skills.

Provide outreach to military parents when they are available such as

when they drop off or pick up their children or at family events.

Be available for military parents to contact for guidance and support.

Facilitate psycho-educational groups.

Conduct training for staff and parents.

Recommend referrals to military family programs and other resources

as needed.

3. The counselor may assist military parents, military children and centers with the

following type of issues:

Communication

Self-esteem/self-confidence

Resolving conflicts

Behavioral management techniques

Bullying

Helping children deal with angry feelings

Sibling/parental relationships

Deployment and reintegration issues

4. The counselor may also work with military children in settings such as field trips

and other center, camp, or school sponsored activities.

December 2017 Version

5. The counselor is available to accommodate appointments and meetings/activities

after hours and on weekends with advance notice.

6. At no time will the counselor meet individually with a child without being in line

of sight of a CYP, DoDEA, LEA, or camp employee or a parent/guardian.

7. The counselor may use only OSD approved materials for trainings, groups, and

any other activities.

8. With the exception of mandatory state, federal, and military reporting

requirements (i.e., domestic violence, child abuse, and duty-to-warn

situations), as well as oversight review by DoD of the service you received

should an adverse or harmful event occur, MFLC support is private and

confidential to encourage the greatest level of participation.

Print Name of Child:

Select only one check box below:

I understand the above CYB-MFLC program description and

authorize my child to participate in CYB-MFLC services. This

authorization is valid for the duration of my child’s enrollment. I

understand I can revoke this authorization at any time in writing.

I do not authorize my child to participate in CYB-MFLC services.

_______________________________________ ___________

PARENT OR GUARDIAN SIGNATURE DATE

2/2018

CHILD AND YOUTH PROGRAMS YOUTH SPONSOR VOLUNTEER

APPLICATION

AUTHORITY: Title 10, United States Code, Section 3012

PRINCIPLE PURPOSE: To record essential background information on youth desiring to volunteer as sponsors.

ROUTINE USES: Coordination of Youth Sponsorship Program at MCLB Albany.

DISCLOSURE IS VOLUNTARY: Individuals not providing the requested information may not be utilized as youth sponsors.

Name: ___________________________________________ Birth Date: ________________________

Gender: ________________ Current Grade: ________________ School Attending: _________________

Email Address: ____________________ Parent Email Address: _____________________

Do you use Facebook? Yes No

Address: _____________________________________________________________________________

Home Phone Number: ________________________ Parent Contact Number: __________________

Hobbies, Talents & Interests: _____________________________________________________________

_____________________________________________________________________________________

Dislikes:

______________________________________________________________________________

Sports, Music, Clubs/programs I participate in are: ______________________________

_____________________________________________________________________________________

What do you like to do in your free time? __________________________________________________

_____________________________________________________________________________________

Where else have you lived? ______________________________________________________________

Where did you move from? _____________________________________________________________

What did you like about the other locations? ________________________________________________

Parent Permission: I the parent/guardian of ______________________________ give my child

permission to serve as a MCLB Albany Child and Youth Program Youth/Teen Sponsor. The purpose of

the program is to provide transition and relocation assistance to other youth relocating to our duty station.

I am aware that my child will utilize various methods of communication which may include email, postal

mail, chat, and/or Facebook, in order to facilitate discussion and information sharing to support the

incoming youth’s transition needs.

_________________________ _____________________________ ____________

Sponsor Name Sponsor Signature Date