YMCA SCHOOL

AGE CHILDCARE Achievement Gap Program

Available at:

D’Ippolito Elementary

Durand Elementary

Lincoln Middle School

Petway Elementary

Rossi Elementary

Winslow Elementary

Dear Parent/Caregiver:

CONGRATULATIONS! Your child’s afterschool program has been selected to participate in the YMCA afterschool’s Achievement Gap program at no additional cost other than the monthly cost of participating in our afterschool program.

What is the Afterschool Achievement Gap Program? It is a program that provides academic support, healthy activities and enrichment opportunities throughout the school

year to kindergarteners through 8th graders, improving their grades, increasing social and emotional skills, and reducing risk-taking activities.

The program is sponsored by the Cumberland Cape Atlantic YMCA in collaboration with the Vineland School District. This Achievement Gap program will start on 9/6/18 and end on 5/31/19. The Achievement Gap program will begin every afternoon at 4:00 and end at 6:00

Monday through Thursday. The location of the program will be at the school. The Afterschool program will continue Monday through Friday from 3:30 – 6:00. This program runs in

conjunction with our existing program. What do I have to do? We believe that family involvement is the key to the positive

development and academic success of any child. So, in order for your child to participate in the program we need your participation, too. Your family involvement will include attending the

initial parent/caregiver orientation meeting, registering your child for the program, understanding the program model and helping provide a way for your child to fully participate by

staying for the full length of the program each day. Kids who are picked up early miss out on valuable enrichment time and a lot of fun as well.

If you have any questions or concerns, please feel free to contact your Site Coordinator or

Ashley Parent at aparent@ccaymca.org or Vanita Moses at vmoses@ccaymca.org. We look forward to working with you and your child this year!

Cumberland Cape Atlantic YMCA 2018-2019 School Aged Child Care

VPS Registration Packet

Child’s Last Name: _____________________ Child’s First Name: _________________________

Address _________________________________ City, State, Zip _______________________________

Birth Date: ________/________/________ Home Phone _______________________________

Cell Phone __________________________ Male Female Grade Entering Sept. ’18 ________________________

Locations:

Elementary Schools: Middle Schools:

D’Ippolito Lincoln Middle

Durand

Petway

Rossi

Winslow

Pricing/Month – Payments are due by the 20th of each month for the upcoming month; late fees

will be applied after the 20th. Elementary School Middle School Before $58.14; After $72.76; Both $130.90 – Sept. Before $43.69; After $87.21; Both $130.90 – Sept.

Before $75.24; After $96.72; Both $171.96 – Oct. Before $56.54; After $115.43; Both $171.97 – Oct.

Before $54.72; After $78.72; Both $133.44 – Nov. Before $41.12; After $92.36; Both $133.48 – Nov.

Before $51.30; After $69.32; Both $120.62– Dec. Before $38.55; After $82.09; Both $120.64 – Dec.

Before $71.82; After $92.44; Both $164.26 – Jan. Before $53.97; After $110.30; Both $164.27 – Jan.

Before $61.56; After $82.16; Both $143.72 – Feb. Before $46.26; After $97.48; Both $143.74 – Feb.

Before $71.82; After $92.44; Both $164.26 – March Before $53.97; After $110.30; Both $164.27 – March

Before $54.72; After $71.04; Both $125.76 – April Before $41.12; After $84.65; Both $125.77 – April

Before $75.24; After $96.72; Both $171.96 – May Before $56.54; After $115.43; Both $171.97 – May

Before $41.04; After $64.16; Both $105.20 - June Before $30.84; After $74.41; Both $105.25 - June

PLEASE

ATTACH PHOTO

ONLY $1.71 PER

HOUR!

Child’s Name ____________________________________________________

Parent 1 or Legal Guardian Information Parent 2 or Legal Guardian Information

Last Name: ___________________________________

First Name: ___________________________________

Relationship: __________________________________

Address: _____________________________________

Home Phone: _________________________________

Cell Phone: ___________________________________

Work Phone: __________________________________

Employer: ____________________________________

Email: ______________________________________

Last Name: ____________________________________

First Name: ____________________________________

Relationship: ___________________________________

Address: _______________________________________

Home Phone: ___________________________________

Cell Phone: ____________________________________

Work Phone: ____________________________________

Employer: ______________________________________

Email: _________________________________________

Joint Custody Information Has there been a divorce or separation? Yes No

If Yes, who has custody? ___________________________________________ The joint/non-custodial parent can be contacted in the event of an emergency Yes No

Emergency Contacts (Other than Parent/Guardian) and Authorized Pick Ups Emergency Contact #1

Name: ____________________________________________ Relationship: _______________________________________ Cell Phone: ________________________________________ Work Phone: _______________________________________ Address: ___________________________________________

Emergency Contact #2

Name: ____________________________________________ Relationship: _______________________________________ Cell Phone: ________________________________________ Work Phone: _______________________________________ Address: ___________________________________________

Medical and Behavior Questions to help us provide the best care possible Has your child been diagnosed or treated for the following: Asthma Allergies Special Dietary Needs Allergies to Insect Stings Seizures Spectrum Disorder Allergy to Poison Ivy ADD/ADHD Other

Please provide details for any of the above checked boxes: Signs or symptoms to watch for: Please list current medications, prescribed or over the counter that your child is currently taking:

Parent/Guardian Signature: ___________________________________________

Parent/Guardian Information

Emergency Medical Information

Insurance Carrier: ___________________________

Policy Number: __________________________

Group Number: __________________________

Cumberland Cape Atlantic YMCA Emergency Contact & Health

Dear Parent/Caregiver:

Thank you for participating in the YMCA Afterschool Signature Program. As you know, the program is focused on helping to increase your child's academic success and

develop his or her social and emotional skills as well in a way that supports a child’s overall youth development. We believe that family involvement is the key to the success of any child. So, in order for your child to most effectively participate in the program we need your participation too. Your family involvement will include attending the initial parent/caregiver orientation meeting, registering your child for the program, understanding the program model and helping provide a way for your child to fully participate by staying for the full length of the program each day. Kids who are picked up early miss out on valuable enrichment time and a lot of fun as well. We are also intending for your child to have FUN, be ACTIVE and make HEALTHY

CHOICES—during the program AND at home!! Please take a moment to review and sign the agreement below. We look forward to

working with you and your child this year!

PARENT/CAREGIVER AGREEMENT

I, ________________________________ (please print first and last name)

understand and agree to the following:

To attend the program ORIENTATION

To register the child for the program,

To understand the program model with help from the YMCA staff

To provide a way for the child to fully participate by staying for the full length of

the program each day.

____________________________ __________________________ Child’s Name Parent or Caregiver Signature

________________________ __________________________

Today’s Date Phone Number

YMCA AFTERSCHOOL PROGRAM REGISTRATION/DATA FORM

Please complete the following information for each child enrolled in the program

Child’s Name ____________________________________________________________ (Please Print) Last First Middle

Grade:

☐ Kindergarten ☐ First Grade ☐ Second Grade

☐ Third Grade ☐ Fourth Grade ☐ Fifth Grade

☐ Sixth Grade ☐ Seventh Grade ☐ Eighth Grade

Does your child qualify for free or reduced lunch? ☐ Yes ☐ No

Ethnicity Information

Please check the ethnic group the child most identifies with:

☐ Caucasian/White ☐ African American/Black

☐ Hispanic/Latino ☐ Native Hawaiian or other Pacific Islander

☐ American Indian or Alaska Native ☐ Asian

☐Two or More

Primary Language Spoken at Home:

☐ English ☐ Polish ☐ French ☐ Japanese ☐ Chinese

☐ Spanish ☐ Unknown ☐ Other, please specify ____________________

Secondary Language Spoken at Home:

☐ English ☐ Polish ☐ French ☐ Japanese ☐ Chinese

☐ Spanish ☐ Unknown ☐ Other, please specify ____________________

-FOR YMCA USE ONLY-

Primary Priority Factor for Referral (Answer by checking yes or no for each applicable primary

factor listed below). IMPORTANT – this information will be needed when entering data in the

Program Data Management (PDM) system

☐ Yes ☐ No 5+ School Days Absent

☐ Yes ☐ No 5+ School Days Tardy

☐ Yes ☐ No 5+ Behavioral Referrals

☐ Yes ☐ No State Assessment Reading Score (Non-Proficient)

☐ Yes ☐ No State Assessment Mathematics Score (Non-Proficient)

☐ Yes ☐ No Other factor, please describe (required):

APPROVED BY INTEGREVIEW IRB

MAY 3, 2018

Dear Parent,

We are inviting your child/children to participate in a research study called YMCA Afterschool Achievement

Gap (AG) Program: Determining the Impact of Y-USA’s Out-of-School Time Approach (“you” refers to you

or your child/children throughout this consent form). The Achievement Gap (AG) research study is designed

to determine if the program is increasing your child’s academic achievement and social competence. Your

child/children was/were selected to participate in this study because s/he is participating in the YMCA’s AG

afterschool program.

This research is being conducted by Y-USA (Dan Cantillon, Ph.D.) and is funded by Y-USA’s Strategic

Initiatives Fund (SIF). For the 2018-19 program year, there will be approximately 51 YMCA associations

implementing the AG ASP program at 130 sites with up to 10,000 participants/students.

CONSENT TO PARTICIPATE IN PROGRAM EVALUATION

Your local YMCA and YMCA of the USA evaluate our programs to see what we are doing well, to identify

areas of the program that we can improve, and to make sure that the children we serve are benefitting from

this program. Participant demographics and attendance will be collected as part of participation in this

program. The evaluation, for which we are seeking consent, involves collecting additional information from

program participants and their parents/caregivers.

WHAT YOU WILL BE ASKED TO DO

For evaluation purposes, we ask your permission to use your child’s social-emotional learning (SEL)

assessment results, which is completed by the YMCA group leader at the beginning and end of the program

year. We also ask you to complete a short anonymous survey about your satisfaction with the afterschool

program at the end of the program year. Finally, we also ask your permission to use your child’s standardized

reading and math test scores, along with school attendance records, for program evaluation purposes. Y-

USA will comply with all state and federal laws in collecting, storing, analyzing and presenting data. Your

expected participation in this research study will be one hour or less.

BENEFITS

A benefit means that something good happens to you or your child. By participating in the afterschool

program, your child will receive academic and SEL programming and exposure to enrichment activities, field

trips, and other school-related activities. For the evaluation component, you or your child will not receive

any direct benefit. However, future afterschool participants may benefit from changes to the program that

were implemented a result of the evaluation. That is, the evaluation may make the program better for future

afterschool participants.

APPROVED BY INTEGREVIEW IRB

MAY 3, 2018

KEEPING YOUR INFORMATION CONFIDENTIAL

Y-USA will follow all applicable federal and state laws that protect your child’s personal and school related

information (e.g., FERPA), including maintaining appropriate physical, electronic, and procedural

safeguards. Student information is confidential and will not be shared or discussed with anyone outside of

the approved study researchers, their partners, and data collectors. All collected data for this project will be

securely stored in lockable locations, secure computer files, or on computer servers accessible only to the

approved and trained researchers and authorized staff. Y-USA plans on keeping this data indefinitely, in

order to identify trends in program participation, fidelity, quality, and outcomes over time.

We will not use your child’s name in any report or publication; rather, your child’s data will be aggregated

with other students enrolled in the program. This data may be included in Y-USA site and national program

reports, as well as in peer-reviewed education and evaluation journal articles.

There is a very small risk that confidential data will be compromised. We will minimize this risk by ensuring

that only approved local-Y and Y-USA evaluation staff involved in the program have access to student

information. As required for evaluation purposes, we may share your child’s information with our evaluation

partners, who we also require to protect your child’s privacy and confidentiality to the maximum extent

allowable by law.

The Institutional Review Board (IRB), IntegReview, and accrediting agencies may inspect and copy your

records, which may have your name on them. Therefore, absolute confidentiality cannot be guaranteed.

PAYMENT FOR BEING IN THE STUDY

You will not be paid for being in this study.

LEGAL RIGHTS

You will not lose any of your legal rights by signing this consent form.

ALTERNATIVES TO PARTICIPATING IN THE STUDY

Since this study is for research only, the only other choice would be not to be in the study.

YOUR RIGHT TO WITHDRAW FROM THE PROJECT

Participation in the evaluation is voluntary and you can withdraw your consent to participate at any time.

Your child’s participation in the program will not be affected. You have the right to refuse your child’s

participation in program evaluation. You will not lose any of your legal rights by signing this consent form.

CONTACT INFORMATION

If you have questions about the research at any time, or if you have a visual or other impairment and

require this material in another format, please contact Dan Cantillon Ph.D., Evaluation Director of Youth

Development at Y-USA (Dan.Cantillon@ymca.net; 312-419-8328).

If you do not want to talk to the investigator or study staff, if you have concerns or complaints about the

research, or to ask questions about your rights as a study subject you may contact IntegReview.

IntegReview’s policy indicates that all concerns/complaints are to be submitted in writing for review at a

convened IRB meeting to:

APPROVED BY INTEGREVIEW IRB

MAY 3, 2018

Mailing Address: OR Email Address:

Chairperson

IntegReview IRB

3815 S. Capital of Texas Highway

Suite 320

Austin, Texas 78704

integreview@integreview.com

If you are unable to provide your concerns/complaints in writing or if this is an emergency situation regarding

subject safety, contact our office at:

512-326-3001 or

toll free at 1-877-562-1589

between 8 a.m. and 5 p.m. Central Time

IntegReview has approved the information in this consent form and has given approval for the investigator

to do the study. This does not mean IntegReview has approved your being in the study. You must consider

the information in this consent form for yourself and decide if you want to be in this study. If your child is

aged 10 or older, s/he will also have the opportunity to decide if they want to participate themselves. This

process is called assent.

APPROVED BY INTEGREVIEW IRB

MAY 3, 2018

AGREEMENT TO BE IN THE STUDY

This consent form contains important information to help you decide if you want to be in the study. If you

have any questions that are not answered in this consent form, ask one of the study staff.

_____ I have read and understand this consent information, and I agree to participate in the Achievement

Gap research study

OR

_____ I have read this and understand this consent information, but I do not agree to participate in the

Achievement Gap research study

Printed name of Parent(s)/Caregiver(s):

Signature:

Print student name:

School:

Date: __________________________________________________

There are two copies of the consent form and both need your signature. The first copy needs to be returned

to the afterschool program staff. Since there is important information in this consent form, including contact

information if you have questions or concerns, we want you to keep the second copy for your records.

We appreciate you taking the time to consider being a part of the YMCA Afterschool Achievement Gap (AG)

Program: Determining the Impact of Y-USA’s Out-of-School Time (OST) Approach project.

APPROVED BY INTEGREVIEW IRB

MAY 3, 2018

Dear YMCA Afterschool Member, You are being asked to be in the Achievement Gap (AG) research study. It is designed to determine whether afterschool programs can improve how you learn things and help your achievement in school. This involves things like personal responsibility, goal setting, and getting along with others, while achievement is measured through your math and reading test scores. Your afterschool program is designed to improve these two things and we want to see if this is true. What You Will Be Asked To Do And What Will Happen In The Study We ask that you give your okay (permission) for your group leader to conduct social-emotional learning (SEL) assessments at both the beginning and end of the afterschool program year. SEL measures things like goal setting and getting along with others. We also ask your okay (permission) to use your test scores for reading and math. Finally, we ask if it is okay to survey your parents/caregivers about their satisfaction with this program. This survey should take your parents less than 10 minutes to complete. You will not be asked to do anything else for this research study. Keeping Your Information Private We will reduce the risk of other people seeing your responses by being sure that only YMCA research staff and our evaluation partners will have access to data. We will keep it safe in a locked office. Before we look at the data, your name and any other information that can identify you will be removed. In other words, researchers will not know who the data belongs to. Finally, to protect your privacy, we will follow all the rules that have been created regarding your privacy and personal information.

Benefits

A benefit means that something good happens to you. By participating in the afterschool program, you will

receive lots of benefits like academic help and support, fun activities, field trips, and other school-related

activities. For the evaluation part, you will not receive any direct benefit. While you may not directly benefit,

you may make the program better for future afterschool participants. Your Right to Withdraw from the Project You do not have to be in this study if you do not want to be. You can say no and no one will be mad at you. If you decide to stop after we begin, that's okay too. No one will be mad at you if you decide not to participate or to stop participating in the study after you start. Being in the study or not will not affect your program participation. Your parents and guardians also have the right to refuse your participation in the study.

APPROVED BY INTEGREVIEW IRB

MAY 3, 2018

I have read (or someone has read to me) this assent form. Additionally, the YMCA group leader (teacher) has explained the study to me and has answered all of my questions. ______ I agree to be in this study. OR ______ I do not agree to be in the study. Printed name of Child/Afterschool member: _____ Signature: School: _____

Date: __________________________________________________ There are two copies of the consent form and both need your signature. The first copy needs to be returned to your afterschool program staff. Since there is important information in this consent form, including contact information if you have questions or concerns, we want you to keep the second copy for yourself.

PHOTO AND VIDEO/AUDIO RECORDING RELEASE

I am 18 years of age or older and, if not, my Mother/Father/Legal Guardian has also signed below.

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) , I hereby give my permission and

consent, now and for all time, to YMCA of the USA and collaborating third parties to make, reproduce,

edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of

me and/or my narrative account of my experience within said activities, for publication, display, sale or

exhibition thereof in promotions, advertising, education and legitimate business uses without any

compensation to, and/or claim, by me. I may, or may not be, identified in such reproductions; however, I

shall not be stated by name to have endorsed any particular commercial products or commercial services.

I further agree to the following:

Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative

account of my experience during said activities, I authorize, according to this Release, shall belong to

YMCA of the USA and collaborating third parties. Therefore, they will have full right of disposition of

any video film, footage, sound track recordings and photo reproductions of me and/or my narrative

account of my experience within said activities;

Any video film, footage, sound track recordings and photo reproductions of me and/or my narrative

account of my experience within said activities will not be subject to any obligation of confidentiality

and may be shared with and used by YMCA of the USA and collaborating third parties;

YMCA of the USA and collaborating third parties collaborating shall not be liable for any use or

disclosure to a third party of any video film, footage, sound track recordings and photo reproductions

of me and/or my narrative account of my experience; and

YMCA of the USA and collaborating third parties shall exclusively own all known or later existing rights

to worldwide and shall be entitled to the unrestricted use any video film, footage, sound track

recordings and photo reproductions of me and/or my narrative account of my experience for any

purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge YMCA of the USA

and collaborating third parties from any and all claims in connection with the uses and reproductions, any

video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of

my experience as described herein.

Signature: ____________________________________ Date: __________________

Printed Name: ________________________________ Age: ________

Address: ________________________________________________________________________

________________________________________________________________________________

I am the Mother/Father/Legal Guardian of ______________ _[ child’s name].

For the consideration contained herein, I hereby consent to the foregoing on behalf of my minor child.

Signature of Mother/Father/Legal Guardian: _____________________________________________

Cumberland Cape Atlantic YMCA Rules & Authorizations

Before and After Rules In order for all participants to have the best possible experience, all participants and parents need to be aware of the rules and agree to follow them. If a participant or parent consistently or excessively breaks the rules and chooses not to take part in the program, they negatively impact other participants by jeopardizing their physical or emotional safety. When this happens, all other participants fail to receive the best possible experience. Rules: 1) Treat myself, and others, with Caring, Honesty, Respect, and Responsibility 2) Follow direction and instructions from staff 3) Keep hands, feet and all other body parts to myself 4) Respect all facilities, equipment, and property 5) Have FUN!

Consequences: 1) Redirection 2) Verbal warning or thinking time 3) Visit with director and/or call home. Child may speak to parents at that time 4) In the event that a second phone call is necessary, the child will be sent home 5) In the event of consistent/excessive failure to follow the rules, the child will be sent home and a suspension may be issued 6) If a child or parent endangers the physical, mental or emotional health of themselves or others, the child may be immediately

suspended or expelled Parent Signature: __________________________________ Child Signature: _____________________________

Authorizations My child is in good health and can participate in the normal activities of the program (including Healthy U & Boks) _________ Initial Here I agree to follow the Payment Policies; if not I will be subject to fees _________ Initial Here I have received and reviewed a copy of the YMCA Parent Handbook _________ Initial Here

I understand that my child must be physically signed in and out of the program by an authorized adult daily _________ Initial Here I understand that the YMCA is not responsible for lost, stolen or damaged personal articles _________ Initial Here My child and I have reviewed the Discipline/Behavior & Expulsion Policies and my child will participate in all daily _________ Initial Here activities I give permission for the Cumberland Cape Atlantic YMCA to: Seek medical treatment for my child, in my absence, in the event of an emergency ________ Initial Here Use any photo, voice recordings or videos taken of my child for any and all promotional purposes ________ Initial Here Allow my child to go on short walks under Y Staff supervision ________ Initial Here I hereby agree, and accept, responsibility in above initialed items. Parent Signature ______________________________________ Date _____________________________

Licensing Statement In keeping with New Jersey’s child care licensing requirements, we are obligated to provide you, as the parent/caregiver of a child enrolled in our program, with the attached informational statement. The statement highlights, among other things: Your right to observe our center at any time without having to secure permission The center’s obligation to be licensed and to comply with licensing standards and The obligation of all citizens to report suspected child abuse of all forms (physical, sexual, emotional, and neglect) to the DCP&P Name of child: ___________________________________ Name of Parent (s)/Guardian (s): __________________________

I have read and received a copy of the Information to Parents statement prepared by the Bureau of Licensing and the DCP&P Parent Signature _________________________________ Date _________________________________________________

Cumberland Cape Atlantic YMCA

YMCA Policies

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 the original to the Cumberland Cape Atlantic YMCA (CCA YMCA). A copy will be filed with your child’s records.

I understand that CCA YMCA staff and volunteers are not allowed to baby-sit or transport children at any time outside the CCA YMCA program. If a violation is discovered, the Y will take immediate disciplinary action toward staff and/or volunteers.

I understand that staff and volunteers are not allowed to initiate contact with members and program participants outside the CCA YMCA, unless necessary in certain limited cases for the smooth operation of a CCA YMCA program. If deemed necessary, contact should be made with the program participant’s parent or guardian. Contact includes, but is not limited to, sharing of phone numbers, email addresses, personal websites and/or web logs. If a violation is discovered, the Y will take immediate disciplinary action toward staff and/or volunteers.

I understand that I am not to leave my child* at the CCA YMCA or program site unless a CCA YMCA staff or volunteer is there to receive and supervise my child. I understand that my child must be escorted to and from the program area by me or another person on my authorized list. Children may not just be dropped off at the door. *Note: The CCA YMCA’s policy is that children under the age of 12 may not be alone in our facilities/program sites.

I understand children should not receive excessive gifts (e.g. toys, video games, jewelry) from CCA YMCA staff or volunteers, and I should report this to a supervisor if they do.

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, including relatives, must be listed with CCA YMCA and must be at least 18 years of age required by the CCA YMCA. Any other alternate pick-up arrangements must be made in writing by a parent/guardian. Phone notification of an alternate pick-up arrangement is only accepted in an emergency.

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 my have no recourse but to contact the police. Please do not put staff in a position where they have to make this judgment call.

I understand that I can help ensure my child’s safety by taking an active interest in his or her CCA YMCA experience. I too will monitor volunteer and staff interactions with my child and ask my child specific questions about program activities and volunteer or staff relationships with my child.

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

I have received a copy of the CCA YMCA Youth Program Handbook and/or Program Policies and Procedures and will keep it for future reference.

Parent Signature ________________________________________ Date ___________________________

Parent Notification of Communications Policy

Families entrust their children to the Cumberland Cape Atlantic YMCA’s care for child care, camp, and other youth programs. Our promise to those we serve is to provide a safe environment in which all participants are treated in a caring, honest, respectful and responsible way.

CCA YMCA staff, volunteers, program participants and parents must work together to ensure adherence to this policy.

CCA Staff and Volunteers: Will block any personal websites or blogs and mark them as private, denying access to any CCA YMCA program participants Will not disclose personal email, telephone, cell phone or website information to any program participants Will not attempt to contact any participant via phone, text message email, website or blogs for non-program related business Will not use any photos taken for CCA YMCA programs or marketing purposes for personal use Will not use cell phones for personal calls during business hours Will not use cell phone cameras to take photos of program participants for any reason Will notify his/her supervisor immediately if a youth attempts to communicate with an employee via e-mail, instant message, cell phone

or social network site

CCA YMCA Program Participants and Their Parents Agree: Not to contact any staff via staff’s personal telephone/cell phone, text message, email, websites or blogs

Not to use cell phones during program hours (except for emergency situations) They will not sure photos, logos or images of the CCA YMCA or its program participants Personal photos may only be taken with consent and may not be displayed in any derogatory fashion Will not take cell phone photos of staff or program participants while engaged in CCA YMCA programs

Of course, the CCA YMCA does not mean to interfere with anyone’s private life, but publicly observable communications, actions or words are not private, and personal expression can have legal consequences, including defamation, copyright infringement and trademark infringement.

Parent Signature ________________________________________ Date ____________________________

Membership Fees

$25/Youth Program Member $50/Family Program Member Current Program Member Current Full Facility

Member All participants must be YMCA members. Membership fees are non-transferable and non-refundable

Financial Assistance

Third party Rutgers Southern Regional Child Care Resource & Referral (856-462-6800). If denied by Rutgers, Financial Assistance is available through the Y - applications are available at the Member Service Desk and on our website, www.ccaymca.org.

Funds are limited – APPLY EARLY

Parent Checklist

Parent/Guardian please initial next to each item that you are handing in today.

_________ Completed Registration Form

_________ Photo Release (see page 3)

_________ Signed Medical Information – including insurance carrier, policy and group number

_________ Expulsion Policy

_________ Any notes or information to be filed on your child (optional)

_________ Correct payment and/or deposit amount

_________ Automatic bank draft form is completed (if using automatic monthly payment option)

Parent Signature

Parent is to sign off that all paperwork is filled out completely.

Parent Signature: ______________________________ Date: _____________________

Staff Signature

Staff member receiving the paperwork is to sign off that all papers are filled out completely and correct

money is remitted.

Staff Signature: _______________________________ Date: ______________________

Cumberland Cape Atlantic YMCA

Checklist

Cumberland Cape Atlantic YMCA

2017-2018 SCHOOL REGISTRATION

Additional Emergency Contacts

For ______________________ Emergency Contact #5

Name: _____________________________________

Relationship: ________________________________

Cell Phone: _________________________________

Work Phone: ________________________________

Address: ___________________________________

Emergency Contact #6

Name: _____________________________________

Relationship: ________________________________

Cell Phone: _________________________________

Work Phone: ________________________________

Address: ___________________________________

Emergency Contact #7

Name: _____________________________________

Relationship: ________________________________

Cell Phone: _________________________________

Work Phone: ________________________________

Address: ___________________________________

Emergency Contact #8

Name: _____________________________________

Relationship: ________________________________

Cell Phone: _________________________________

Work Phone: ________________________________

Address: ___________________________________

Please use this sheet only to add additional contacts and

pick-up people for your child. We will not accept it written on a separate piece

of paper.

(Childs name)

Parent/Guardian Signature: _________________________ Date:___________

10:122-6.8 Expulsion Policy May be used to inform parents of the center’s policy on the expulsion of children from enrollment

EXPULSION POLICY Name of Center: Cumberland Cape Atlantic YMCA of Vineland

Name of Child: ________________________________

Signature of Parent: ________________________________ Unfortunately there are reasons we have to expel a child from our program either on a short term or a permanent basis. We want you to know we will do everything possible to work with the family of the child(ren) in order to prevent this policy from being enforced. The following are reasons we may have to expel or suspend a child from this center. IMMEDIATE CAUSE FOR EXPULSION - The child is at risk of causing serious injury to other children or himself/herself. - Parent threatens physical or intimidating actions toward staff members. - Parents exhibits verbal abuse to staff in front of enrolled children. PARENTAL ACTIONS FOR CHILD’S EXPULSION - Failure to pay/habitual lateness in payment. - Failure to complete required forms. - Habitual tardiness when picking up your child. - Physical or verbal abuse to staff. - Correcting, reprimanding, or yelling at a child CHILD’S ACTIONS FOR EXPULSION - Failure of a child to adjust after a reasonable amount of time. - Uncontrollable tantrums/angry outbursts. - Ongoing physical (fighting) or verbal abuse to staff or their children. - Excessive biting. - Dangerous activity, threats, theft, vandalism/mistreatment of property, possession of weapons, or

illegal substances SCHEDULE OF EXPULSION - If after the remedial actions above have not worked, the child’s parent/guardian will be advised

verbally and in writing about the child and or/parent’s behavior warranting an expulsion. An expulsion action is meant to be a period of time so that the parent/guardian may work on the child’s behavior or to come to an agreement with the center.

- The parent/guardian will be informed regarding the length of the expulsion period. - The parent/guardian will be informed about the expected behavioral changes required in order for

the child or parent to return to the center. - The parent/guardian will be given a specific expulsion date that allows the parent sufficient time to

time to seek alternative child care - Failure of the child/parent to satisfy the terms of the plan may result in permanent expulsion from

the center

A CHILD WILL NOT BE EXPELLED - If a child’s parent/guardian:

- Made a complaint to the Office of Licensing regarding a center’s alleged violation of the licensing requirements

- Reported neglect or abuse occurring at the center - Questioned the center regarding policies and procedures - Without giving the parent/guardian an adequate amount of time to make other child care

arrangements PROACTIVE ACTIONS THAT WILL BE TAKEN IN ORDER TO PREVENT EXPULSION - Staff will try to redirect child from negative behavior - Staff will reassess classroom environment appropriateness of activities and supervision - Staff will always use positive methods and language while disciplining children - Staff will praise behaviors - Staff will consistently apply consequences for rules - Child will be given verbal warnings - A brief time out may be given so child can regain control - Child may lose certain privileges - Child’s disruptive behavior will be documented and maintained in confidentiality - Parent/guardian will be not notified verbally - Parent/guardian will be given copies of the disruptive behaviors that might lead to expulsion - Director, parent/guardian and classroom staff will have a conference to discuss how to promote

positive behaviors - Parent/guardian will be given literature or other resources regarding methods of improving behavior - Recommendation of evaluation by professional consultation on premises - Recommendation of evaluation by local school district child study team

OOL/INFORMATION TO PARENTS/APRIL 2017

Department of Children and Families Office of Licensing

INFORMATION TO PARENTS

Under provisions of the Manual of Requirements for Child Care Centers (N.J.A.C. 3A:52), every licensed child care center in New Jersey must provide to parents of enrolled children written information on parent visitation rights, State licensing requirements, child abuse/neglect reporting requirements and other child care matters. The center must comply with this requirement by reproducing and distributing to parents and staff this written statement, prepared by the Office of Licensing, Child Care & Youth Residential Licensing, in the Department of Children and Families. In keeping with this requirement, the center must secure every parent and staff member’s signature attesting to his/her receipt of the information.

Our center is required by the State Child Care Center Licensing law to be licensed by the Office of Licensing (OOL), Child Care & Youth Residential Licensing, in the Department of Children and Families (DCF). A copy of our current license must be posted in a prominent location at our center. Look for it when you’re in the center.

To be licensed, our center must comply with the Manual of Requirements for Child Care Centers (the official licensing regulations). The regulations cover such areas as: physical environment/life-safety; staff qualifications, supervision, and staff/child ratios; program activities and equipment; health, food and nutrition; rest and sleep requirements; parent/community participation; administrative and record keeping requirements; and others.

Our center must have on the premises a copy of the Manual of Requirements for Child Care Centers and make it available to interested parents for review. If you would like to review our copy, just ask any staff member. Parents may view a copy of the Manual of Requirements on the DCF website at http://www.nj.gov/dcf/providers/licensing/laws/CCCmanual.pdf or obtain a copy by sending a check or money order for $5 made payable to the “Treasurer, State of New Jersey”, and mailing it to: NJDCF, Office of Licensing, Publication Fees, PO Box 657, Trenton, NJ 08646-0657.

We encourage parents to discuss with us any questions or concerns about the policies and program of the center or the meaning, application or alleged violations of the Manual of Requirements for Child Care Centers. We will be happy to arrange a convenient opportunity for you to review and discuss these matters with us. If you suspect our center may be in violation of licensing requirements, you are entitled to report them to the Office of Licensing toll free at 1 (877) 667-9845. Of course, we would appreciate your bringing these concerns to our attention, too.

Our center must have a policy concerning the release of children to parents or people authorized by parents to be responsible for the child. Please discuss with us your plans for your child’s departure from the center.

Our center must have a policy about administering medicine and health care procedures and the management of communicable diseases. Please talk to us about these policies so we can work together to keep our children healthy.

Our center must have a policy concerning the expulsion of children from enrollment at the center. Please review this policy so we can work together to keep your child in our center.

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OOL/INFORMATION TO PARENTS/APRIL 2017

Parents are entitled to review the center’s copy of the OOL’s Inspection/Violation Reports on the center, which are available soon after every State licensing inspection of our center. If there is a licensing complaint investigation, you are also entitled to review the OOL’s Complaint Investigation Summary Report, as well as any letters of enforcement or other actions taken against the center during the current licensing period. Let us know if you wish to review them and we will make them available for your review or you can view them online at https://data.nj.gov/childcare_explorer.

Our center must cooperate with all DCF inspections/investigations. DCF staff may interview both staff members and children.

Our center must post its written statement of philosophy on child discipline in a prominent location and make a copy of it available to parents upon request. We encourage you to review it and to discuss with us any questions you may have about it.

Our center must post a listing or diagram of those rooms and areas approved by the OOL for the children’s use. Please talk to us if you have any questions about the center’s space.

Our center must offer parents of enrolled children ample opportunity to assist the center in complying with licensing requirements; and to participate in and observe the activities of the center. Parents wishing to participate in the activities or operations of the center should discuss their interest with the center director, who can advise them of what opportunities are available.

Parents of enrolled children may visit our center at any time without having to secure prior approval from the director or any staff member. Please feel free to do so when you can. We welcome visits from our parents. Our center must inform parents in advance of every field trip, outing, or special event away from the center, and must obtain prior written consent from parents before taking a child on each such trip.

Our center is required to provide reasonable accommodations for children and/or parents with disabilities and to comply with the New Jersey Law Against Discrimination (LAD), P.L. 1945, c. 169 (N.J.S.A. 10:5-1 et seq.), and the Americans with Disabilities Act (ADA), P.L. 101-336 (42 U.S.C. 12101 et seq.). Anyone who believes the center is not in compliance with these laws may contact the Division on Civil Rights in the New Jersey Department of Law and Public Safety for information about filing an LAD claim at (609) 292-4605 (TTY users may dial 711 to reach the New Jersey Relay Operator and ask for (609) 292-7701), or may contact the United States Department of Justice for information about filing an ADA claim at (800) 514-0301 (voice) or (800) 514-0383 (TTY).

Our center is required, at least annually, to review the Consumer Product Safety Commission (CPSC), unsafe children’s products list, ensure that items on the list are not at the center, and make the list accessible to staff and parents and/or provide parents with the CPSC website at https://www.cpsc.gov/Recalls. Internet access may be available at your local library. For more information call the CPSC at (800) 638-2772.

Anyone who has reasonable cause to believe that an enrolled child has been or is being subjected to any form of hitting, corporal punishment, abusive language, ridicule, harsh, humiliating or frightening treatment, or any other kind of child abuse, neglect, or exploitation by any adult, whether working at the center or not, is required by State law to report the concern immediately to the State Central Registry Hotline, toll free at (877) NJ ABUSE/(877) 652-2873. Such reports may be made anonymously. Parents may secure information about child abuse and neglect by contacting: DCF, Office of Communications and Legislation at (609) 292-0422 or go to www.state.nj.us/dcf/.

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2018-2019 Cumberland Cape Atlantic YMCA

Before & After School Payment Authorization

Form (OPTIONAL PAYMENT METHOD)

Child’s Name: ____________________________________

Additional Child Name: _____________________________

School Name: ____________________________________

Before After Both

Automatic Payment Plan: The Cumberland Cape Atlantic YMCA (CCA YMCA) or YMCA of Vineland offers an automatic payment plan via our accounting software company called DAXKO. Monthly fees are automatically charged to a Bank, Credit Union, or Credit Card Company. There’s no additional cost for this program.

Bank/Credit/Debit Draft Agreement:

1. I understand that Daxko has been authorized as an agent on behalf of the CCA YMCA to initiate debit entries against my Checking/Savings Account or Credit/Debit Card. Also, I acknowledge that the origination of ACH (Automatic Clearing House) transactions to my account must comply with the provisions of United States Law.

2. I understand that Daxko, a U.S. corporation, will be processing electronic funds transfers. Debit to your account will be presented in your bank statements as “Cumberland Cape,” and these funds will be electronically transferred to CCA YMCA and posted to your child-care account monthly.

3. The CCA YMCA, Board of Directors and/or management may, at their discretion, adjust the rate plan applicable to childcare programs at any time. I understand that I will receive at least a 30 day notification prior to any such change.

4. All Before and After Care payments will be debited on the 20th of each month (October-June)

Option 2: Bank Draft/EFT: *Please include a voided check with this form*

When using the bank draft/EFT method: Should any debit not honored by my bank/EFT account for any reason, I understand that I am still responsible for the payment, plus a $30.00 service charge applied by the YMCA. This is in addition to may service fee my bank com-pany may require.

Print Name of Account Holder: _______________________________________ Name of Bank: _______________________

Bank Routing/Transit Number: Bank Account Number:

Authorization: I hereby authorize the CCA YMCA to debit the above credit card/ bank draft/ EFT on the dates

indicated for my 2018-2019 Before & After Care monthly payments. I understand that I am being enrolled in the

automatic payment plan as described above and agree to any and all fees that may incur use of this service.

X _________________________________________________ X _______________________________ Signature of Parent/Guardian Date

Option 1: Credit/Debit Card: Print Name of Account Holder: __________________________________________

When using the credit/debit card payment method: Should any debit not be honored by my credit card company for any reason, I understand that I am still responsible for the payment plus a $20.00 service charge applied by the YMCA. This is in addition to any service fee my credit card company may require.

Expiration Date: ______________ Security Code: _____________ Card: AMEX Discover Mastercard Visa Credit Card Billing Address: __________________________________________________________________________

Is

this the primary contact for all billing concerns/questions? Circle: YES NO