BUILDING BRIGHT FUTURES - Greater Valley YMCA
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BUILDING
BRIGHT
FUTURES
2019-2020 CHILD CARE, PRE-K COUNTS AND SCHOOL-AGE
EDUCATIONAL PROGRAMS
REGISTRATION PACKET
HIGHLIGHTS
• Licensed by the Department of Human Services
• Keystone Stars Accredited
• Healthy meals and snacks provided
• Website: www.gv-ymca.org
• Facebook: www.facebook.com/allentownymca
OFFICE USE ONLY:
GREATER VALLEY YMCA Date Received: ______________ By: ______________
ALLENTOWN BRANCH MEMBER OR NON-MEMBER
425 S. 15th Street
Allentown, PA 18102 Enrollment Fee Received: YES or NO (CK #____________)
T 610-351-YMCA
W www.gv-ymca.org
5.3.2019
2019-2020 GREATER VALLEY YMCA, ALLENTOWN BRANCH
CHILD CARE, PRE-K COUNTS AND SCHOOL-AGE EDUCATIONAL PROGRAMS
HOW TO REGISTER ENROLLMENT CHECKLIST CLASSROOM ASSIGNMENT
To register, simply complete the attached
Congratulations - Your child has
registration packet and return it to the
Greater Valley YMCA, Allentown Branch, NAME: ___________________ been accepted to participate in the
425 South 15th Street, Allentown, PA Allentown YMCA Child Care Program.
PARENTS: (HIGHLIGHTED SECTIONS ARE
18102. INCOMPLETE. PLEASE UPDATE AND
RESUBMIT DOCUMENTS TO COMPLETE
Registration deadline is the Monday prior EARLY CHILDHOOD PROGRAM
YOUR REGISTRATION PACKET.)
for your child to start the following week.
Late registration is subject to Director’s
approval and a $25 late registration fee. ❑ Infants
❑ Child Getting to Know You Form: ❑ Younger Toddler
Signature and date required
CONFIRMATIONS ❑ Older Toddler
❑ Agreement Form: ❑ Preschool/Pre-K
▪ The Administrative Office will send a Signature & date required ❑ Pre-K Counts 3
welcome packet to the email address ❑ Pre-K Counts 4
provided once your registration is ❑ Emergency Contact Form:
accepted. Incomplete paperwork will Signature & date required
delay the registration process. Waiting List
▪ Waiting List Status will be notified by
phone.
❑ Authorization and Permission for
Medical Treatment Form ❑ Infants
❑ Younger Toddler
PAYMENT INFORMATION
❑ Health Appraisal: Must be received 30 ❑ Older Toddler
days from start date. Due as follows: ❑ Preschool/Pre-K
▪ Registration Fee, $50 annually per • Birth thru 23 months –Twice
family (waived for Allentown YMCA
❑ Pre-K Counts 3
Annually ❑ Pre-K Counts 4
Members). Registration fee is paid at • Age 2 thru 5 – Annually
initial enrollment. If a child disenrolls • Age 6 and older - Every other year
for a period of 90 days, a new SCHOOL-AGE PROGRAM
registration fee must be paid. ❑ Tuberculosis Assessment Report
▪ The first week’s tuition payment and ❑ Before School
registration fee is due at the time of
❑ Copy of your child’s Medical Insurance ❑ After School
registration. ❑ Before & After School
Card (Pre-K Counts Only)
▪ Tuition payments are Monday, the
week before the service period; as per Allentown School District
Parent Agreement Form Payment
❑ Copy of your child’s Birth Certificate
(Pre-K Counts Only) ❑ Jackson Early Education
Option selected. Payments not ❑ Lehigh Parkway
received on time will result in a $10.00
❑ Child Care and Adult Food Program ❑ Ramos
late fee.
▪ Electronic Credit Card Payment: Child Enrollment Form ❑ Union Terrace
Credit Card Payments will automatically
❑ Child Care and Adult Food Meal Benefit East Penn School District
be processed on scheduled due dates
as per your parent agreement. Income Eligibility Form ❑ Macungie (at Shoemaker)
▪ Electronic Bank Draft Transfer: ❑ Shoemaker
Bank Accounts will be drafted on ❑ Registration Fee ($50 non-refundable) ❑ Willow Lane
scheduled due dates as per your parent and first week’s tuition payment (non-
agreement. refundable). Registration fee waived Parkland School District
▪ On-Line Payments: On-line parent for Allentown YMCA Members.) ❑ Cetronia ❑ Fogelsville
access is available at ❑ PELICAN Form ❑ Ironton ❑ Jaindl
https://www.myprocare.com/ . ❑ Kratzer ❑ Kernsville
Subject to payment terms. ❑ Tuition Express Enrollment Form ❑ Parkway Manor ❑ Schnecksville
▪ Transactions completed in person
or by phone: For families who do not Paperwork must be updated every six
have a checking account and/or credit months and/or when changes have WELCOME PACKET CHECKLIST
card, cash payments will be accepted. occurred, as per DHS regulations.
Approval must be obtained by the ❑ Staff Bio
Director, prior to picking the CASH ❑ Classroom Schedule
CONTACTS ❑ Menu (2 copies) one signed and
option. A $5.00 fee will apply to each
Angela Kukitz
cash payment. Additionally, a $5.00 fee returned by parent, one for parent to
Early Childhood Education Director
may apply to credit card transactions angelakukitz@gv-ymca.org keep
processed in person or by phone. 610-351-9622 x812 ❑ Parent Handbook
❑ Program Calendar
ACCOUNT STATEMENTS Tami Unger ❑ Original Agreement
CAMP TIIKERI,
Statements CAMP as
will be e-mailed MACUNGIE
per and SUMMER SPROUTS CAMPER INTAKE
Child Care Director
tamiunger@gv-ymca.org
parent’s request.
610-351-9622 x813
GREATER
Account VALLEY
statements YMCA, online
are available ALLENTOWN BRANCH
at https://www.myprocare.com/. or
EARLY
upon CHILDHOOD
written EDUCATION
request. Please e-mail to AND SCHOOL-AGE
2017-2018
request GETTING
an account statement. TO KNOW YOU FORMGREATER VALLEY YMCA, ALLENTOWN BRANCH
EARLY CHILDHOOD EDUCATION, PRE-K COUNTS AND SCHOOL-AGE
2019-2020 GETTING TO KNOW YOU FORM
Thank you for choosing the Greater Valley YMCA, Allentown Branch for your child’s care needs. We are happy to
have you and your child with us! For us to serve your, we ask that you please complete the following form with
information regarding your child’s preferences.
Child’s Name Nickname
Date of Birth Age Male Female
Grade (School Age)
Has your child ever been in child care before? If
yes, where? Yes No
Are there any needs, fears or concerns you would
like to let us know about? Yes No
What is your child’s preference for social
interactions?
Does your child prefer to work:
With others Independently
Child’s interaction with peers:
Excellent Good Fair Poor
Would you like a meeting with your child’s
teacher prior to him/her starting Yes Not at this time.
Do you have an IEP, IFSP, Special Needs
Assessment, or other documentation? If so,
please attach it for our records Yes No
Are there any behaviors you are aware of that
your child may need assistance or support from Yes No
our staff? If yes, please list.
Is there anything else that you would like us to
know about your child?
Are there people who you would like us to
contact who have worked with your child? Name/Phone
Name/Phone
This paper is provided for general information purposes and is not intended to substitute for legal advice on specific issues.
STAFF USE ONLY
3[THIS PAGE INTENTIONALLY LEFT BLANK]
2019-2020 GREATER VALLEY YMCA, ALLENTOWN BRANCH CHILD CARE AGREEMENT FORM
❑ NEW ❑ CHANGE OF ENROLLMENT (subject to $15 processing fee)
Child’s Name: ______________________________________________ Date of Birth: ____________Age_______ Grade in 2019-20: _______
Arrival Time: ______ Departure Time:_______ Anticipated Start Date: ______ School:_________________ Allentown SD East Penn Parkland
EARLY ON-SITE ON-SITE ON-SITE ON-SITE ON-SITE ON-SITE OFF-SITE WEEKLY
INFANT YOUNG OLDER PRESCHOOL/ PRE-K GRADES K-5 GRADES K-5 TUITION
CHILDHOOD
TODDLER TODDLER PRE-K COUNTS ASD EPSD/PSD
EDUCATION
Circle days Circle days Circle days Circle days Circle days Circle days
attending attending attending attending attending attending
M, T, W, TH, F M, T, W, TH, F M, T, W, TH, F M, T, W, TH, F M, T, W, TH, F M, T, W, TH, F
Full Time ❑ $206 ❑ $192 ❑ $181 ❑ $171 $
5 days, (cannot exceed
10hrs/day)
3 Days ❑ $150 ❑ $140 ❑ $130 ❑ $120 $
3 days, (cannot exceed
10hrs/day)
PRE-K COUNTS Program Hours
8:30am-3:30pm
3 Year Old Program $0 $
Must be three by
September 1, 2019.
4 Year Old Program $0 $
Must be four by
September 1, 2019.
AM Extended Care TBD $
6:00am-8:30am
PM Extended Care TBD $
3:30pm-6:00pm
Holiday Care TBD $
cannot exceed 10hrs/day
SCHOOL-AGE HOURS OF CARE HOURS OF CARE
6AM until school begins 7AM until school begins
PROGRAM After school until 6PM After school until 6PM
Before School ❑ $72 – 5 days ❑ $59 – 5 days $
❑ $43 - 3 days ❑ $36 - 3 days
❑ $35 – 2 days ❑ $28 – 2 days
After School ❑ $96 – 5 days ❑ $87 – 5 days $
❑ $58 - 3 days ❑ $53 - 3 days
❑ $46 – 2 days ❑ $42 – 2 days
Before & After ❑ $126 – 5 days ❑ $113 – 5 days $
School ❑ $108 - 3 days ❑ $87 - 3 days
❑ $ 72 – 2 days ❑ $55 – 2 days
Fun Days $25/Per Day $27/Per Day $
Care is provided at the Included with 5 Day Included with 5 Day
Allentown YMCA for “Before & After” tuition. “Before & After” tuition.
participants enrolled in our
school-age programs.Financial Policy & Procedure – AGREEMENT FORM HOLIDAY/IN-SERVICE DATES
Enrollment Fee: An enrollment fee of $50 will be assessed to families annually. The enrollment fee is waived for Greater Valley YMCA members. (Child care services are NOT available.)
Tuition includes: Instruction, meals, transportation, swimming and transportation (if applicable) are included with tuition. September 2, 2019
Payment Due Date/Late Registration Fee: First week of tuition is due at the time of registration for all programs. All payments are due each Monday, THE WEEK October 14, 2019
BEFORE THE SERVICES ARE PROVIDED; as per the parent Agreement Form Payment Option selected. Children will be unable to attend and placed on a waiting list in the November 28, 2019
event that payment is not received and/or late. Registration for programs must be completed by Monday at 5PM, the week before the start of the service period.
December 25, 2019
Late Payment Fee: Any payment made after the date due will be assessed a $25.00 late fee. All payments are due Monday, THE WEEK BEFORE THE REGISTERED WEEK;
January 1, 2020
as per Parent Agreement Form.
Late Pick Up Fee: $20.00 for the first 15 minutes past program hours selected and $1.00 each minute thereafter. This includes excess hours beyond 10 hours per day of
February 17, 2020
care. A charge of $20.00 will be applied for the first 15 minutes past 10 hours and then $1.00 each minute thereafter. April 10, 2020
Returned Check /Bank Draft: A $25.00 fee per NSF bank draft will be assessed; future payments may be required in the form of cash. May 25, 2020
Declined Credit Card: A $25.00 fee will be applied each time a credit card is declined for any reason. July 4, 2020
Absences/Vacation Days/Holidays: Parent/Guardian is responsible for paying the required tuition amount each week. No credit will be given for days registered, but We reserve the right to add additional
unattended. closed days and early dismissal dates for
Outstanding Balances: If your child has an outstanding balance your child will be declined the ability to attend, register or attend a new session, transition to a new professional development.
classroom/program, register at another YMCA, transfer records, or obtain end of year statements until the account balance is current or paid in full.
Refunds/Cancellation Policy: Enrollment and tuition are non-refundable. Cancellations must be received in writing. All refund requests must be approved by Director and Pre-K Counts classrooms will have additional
may be subject to a $10 processing fee. in-service days.
Subsidized Enrollment: Parent/Guardian is responsible for any unpaid tuition fees and/or days.
Subsidy Provider Information PAYMENT OPTION FORM (Registration application will not be processed without paid registration fee
and first week’s tuition.) For Internal Use Only
YMCA Adjustment ____________________________ Director Approval (initial)________________
Payment Plan
YMCA Financial Assistance______________ %
Weekly Tuition Payments (Cash Option Only) Bi-Weekly Tuition Payments (Credit Card/Bank Draft/On-Line) CCIS Contacted
Approved Start Date: ________________________ Monthly Tuition Payments (Credit Card/Bank Draft/On-Line) Caseworker name:_______________________
End Date: _______________________________________ Method of Payment Copay verified: __________________________
State Subsidy (Current Agreement Form Cash ($5 fee applies to weekly cash payment) Scheduled verified _____________________
and/or confirmation must be on file prior to Credit Card Draft Start date:________________________________
tuition adjustment.) EFT Draft (submit payment authorization form)
Lehigh County CCIS Parent On-Line EFT (submit voided check or statement)
Northampton County CCIS Parent Online Credit Card ProCare input complete
__________________ County CCIS Cash: (subject to $5 fee) Remit payment to Allentown YMCA $____________(Weekly) Subsidy/Financial Assistance applied
Other:__________ Bank Draft: (Please attach a Voided Check and complete Payment Authorization Form) Registration Fee applied
Caseworker: ______________________________ Electronic Bank Draft Transfer as per my Payment Option: Initial payment made
Phone Number: ___________________________ $ _________________ (Bi-weekly) $ _______________ (Monthly: 4 Mon) $_________________ (Monthly: 5 Mon) Parent called, start confirmed
CCIS Copay: $______________________________ Credit/Debit Card (Please complete Payment Authorization Form)
Electronic Credit/Debit Card Transfer as per my payment Option: Welcome packet sent
$_________________(Bi-weekly) $ ______________ (Monthly: 4 Mon) $________________ (Monthly: 5 Mon)
Person(s) designated by parents to whom their child may be released:
I, the parent/guardian have reviewed and approved this registration information. I have read, understand and agree to comply with the YMCA’s payment procedures and policies. I understand that my child will become ineligible for participation in the child
care program if payment has not been received by the YMCA prior to or on scheduled due date. I agree to update the emergency contact, parent consent form, agreement form and health appraisal forms information whenever changes occur or every six
months at a minimum (DHS Standards - 3270.124, 3280.124, 3290.124). I acknowledge that I have received the parent handbook and I understand that the YMCA will not provide care on the holiday/in-service days listed above.
Parent/Guardian Name (printed):____________________________________________________Parent/Guardian Signature: __________________________________________________________ Date:_______________ Parent Daytime Phone:________________________________________________
Parent/Guardian Name (printed):____________________________________________________Parent/Guardian Signature: __________________________________________________________ Date:_______________ (initial review)
Parent/Guardian Name (printed):____________________________________________________Parent/Guardian Signature: __________________________________________________________ Date:_______________ (6 month update)
Original Enroll Date: _______________ Enroll Date: ___________________________ Withdrawal Date:_________________
Registrar/Director’s Signature: ________________________________________________________Date: __________________________________ Confirmation Sent: ________________ Billing Date: _________________
6GREATER VALLEY YMCA, ALLENTOWN BRANCH
Child Care , Pre-K Counts & School-Age Educational Programs
EMERGENCY CONTACT / PARENTAL CONSENT FORM (ALL LINES MUST BE COMPLETED – WRITE N/A IF NOT APPLICABLE)
CHILD'S NAME BIRTH DATE GENDER
ADDRESS
NAME OF LEGAL GUARDIAN (1) BIRTHDATE
ADDRESS HOME/CELL NUMBER
BUSINESS NAME EMAIL ADDRESS
BUSINESS ADDRESS BUSINESS TELEPHONE NUMBER
NAME OF LEGAL GUARDIAN (2) BIRTHDATE
ADDRESS HOME/CELL NUMBER
BUSINESS NAME EMAIL ADDRESS
BUSINESS ADDRESS BUSINESS TELEPHONE NUMBER
EMERGENCY CONTACT PERSON NAME/ADDRESS : CHILD MAY BE RELEASED TO INDIVIDUAL DAYTIME PHONE NUMBER
EMERGENCY CONTACT PERSON NAME/ADDRESS : CHILD MAY BE RELEASED TO INDIVIDUAL DAYTIME PHONE NUMBER
EMERGENCY CONTACT PERSON NAME/ADDRESS : CHILD MAY BE RELEASED TO INDIVIDUAL DAYTIME PHONE NUMBER
EMERGENCY CONTACT PERSON NAME/ADDRESS : CHILD MAY BE RELEASED TO INDIVIDUAL DAYTIME PHONE NUMBER
EMERGENCY CONTACT PERSON NAME/ADDRESS : CHILD MAY BE RELEASED TO INDIVIDUAL DAYTIME PHONE NUMBER
EMERGENCY CONTACT PERSON NAME/ADDRESS : CHILD MAY BE RELEASED TO INDIVIDUAL DAYTIME PHONE NUMBER
NAME OF CHILD'S PHYSICIAN / MEDICAL CARE PROVIDER TELEPHONE NUMBER
ADDRESS
SPECIAL DISABILITIES (IF ANY) ALLERGIES INCLUDING MEDICATION REACTION
MEDICAL OR DIETARY INFORMATION NEEDED IN AN EMERGENCY MEDICATION, SPECIAL CONDITIONS
ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD - DOES YOUR CHILD HAVE AN IFSP/IEP? YES NO (IF YES, PLEASE PROVIDE)
HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS POLICY NUMBER (REQUIRED)
PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT
OBTAINING EMERGENCY MEDICAL CARE ADMINISTRATION OF MINOR FIRST - AID PROCEDURES
WALKS AND TRIPS SWIMMING
TRANSPORTATION BY THE FACILITY WADING
_______
SIGNATURE OF PARENT OR GUARDIAN DATE
_______
SIGNATURE OF PARENT OR GUARDIAN (INITIAL REVIEW) DATE
_______
SIGNATURE OF PARENT OR GUARDIAN (6 MONTH REVIEW) DATE 7GREATER VALLEY YMCA, ALLENTOWN BRANCH CHILD CARE AND SCHOOL-AGE PROGRAM
2019-2020 Authorization for Medical Treatment and Permissions Form
CHILD’S NAME: BIRTH DATE:
I give I do not
permission give Parent Signature
Action Item
permission (MUST SIGN EACH LINE)
(✓) (✓)
Sunscreen/Lotion: Permission for the staff to assist with the application of
Parent Signature
sunscreen/lotion to my son/daughter, which I will provide.
Picture: Permission to use my child’s photograph in any official publicity
pieces, including, but not limited to; news releases, social media, publications Parent Signature
and web use.
Picture: Permission to use photographs of my child taken during the program
Parent Signature
or YMCA events, ONLY within the YMCA or Child Care Center.
Allergy: Permission to post my child’s allergies in their classroom or binders. Parent Signature
Hand Sanitizer: To use hand sanitizer to supplement hand washing.
(Regulations from the PA Department of Child Development and Early
Parent Signature
Learning – see 55PA Code 3720.132, 3280.134 and 3290.134, relating to
child hygiene.)
Pelican: Permission for my son/daughter’s information to be used in the
Pennsylvania Enterprise to link information for Children Across Networks Parent Signature
(PELICAN).
Permission For Release Of Information: The Y has my permission to obtain
records and discuss information pertaining to my child with agencies involved Parent Signature
in the care and development of my child.
Permission to View Movies: The Y has my permission to allow my children
Parent Signature
to participate in viewing age-appropriate PG movies.
2019-2020 Child Care Handbook/Statement of Understanding: I have
received, read and will abide by the Statement of Understanding and the Parent Signature
Allentown YMCA Parent Handbook.
Emergency Operations Plan: I have received, read and understand the
information on the Emergency Operations Plan for the Allentown YMCA
Parent Signature
Programs. I understand that the persons listed on the Emergency Contact
Sheet will be designated custodians for release of my child.
In case of an emergency due to illness or accident, when it is thought
advisable to have immediate medical attention for my child, I hereby authorize
the Allentown YMCA to send my child to the following hospital:
_________________________________________________. (Lehigh Valley Hospital will be used if Parent Signature
no location is designated.) I agree to meet the YMCA Staff person at the
hospital as soon as possible after being notified. I understand that I must
bear all expenses, including those incurred to transport my child to the
hospital.
Permissions below are for all Allentown YMCA program participants and East Penn/Parkland
program participants who attend FUN DAYS at the Allentown YMCA.
I give my consent for the above named child to attend the field trip(s) listed below. In giving my permission, I understand that
the Allentown YMCA will be providing transportation to and from all field trips. I accept full responsibility and release the
Allentown YMCA of all liability.
Sept 3, 2019 – June 19, 2020
Daily/Weekly Walking trips to Cherry Hill, Allentown.
Sept 3, 2019 – June 19, 2020
Daily/Weekly Walking trip to Allentown YMCA Picnic Grove (located at Allentown YMCA).
Sept 3, 2019 – June 19, 2020
Daily/Weekly Walking trips to Fountain Park, Allentown.
Parent Signature Date
8GREATER VALLEY YMCA, ALLENTOWN BRANCH
STATEMENT OF UNDERSTANDING/YMCA CHILD ABUSE POLICY
The following information is important for the safety and protection of your child. Please read the information, and sign the
permission form indicating your understanding. A copy will be placed in your child’s records.
• I understand that my child will not be allowed to leave with any unauthorized person. All persons authorized to pick up my
child, including older siblings or other relatives, must be listed with the Y and must be of the age required by this Y. Any
other arrangements must be made by calling the Child Care office at
610-351-9622.
• I understand that should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for
the child’s safety, staff may have no recourse but to contact the police. Please do not put staff in a position where they have
to make this judgment call.
• I understand that the Y is mandated by state law to report any suspected cases of child abuse or neglect to the appropriate
authorities for investigation.
• I understand that Y staff and volunteers are not allowed to babysit or transport children at any time outside the Y program.
Immediate disciplinary action will be taken by the Y toward staff and volunteers if a violation is discovered.
• I understand that I am not to leave children unattended. I will wait for Y staff or volunteer to receive and supervise the child.
• I understand that children should not receive excessive gifts (e.g., TV, video games, jewelry) from Y staff or volunteers, and
that I should report this to a supervisor if they do.
I understand that I can help ensure my child’s safety by taking an active interest in his or her Y 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.
EMERGENCY OPERATIONS PLAN
Dear Parent (s)/Guardian,
The YMCA recoginizes safety as our first priority for all children attending Y programs. With this in mind The YMCA has
developed a comprehensive Emergency Operations Plan (EOP) that provides for response to all types of emergencies. The
specifics of the plan is located at each child care facility and can be viewed at anytime.
Depending on the circumstance of the emergency, the children may be relocated to a different part of the facility and/or offsite at
a tempory shelter. Children will remain there until all is clear and/or accomodations for parent pick up has been established. Once
the children are in a safe location and/or emergency has been cleared parents will be contacted.
Early Childhood and School-age located at the Allentown Branch
Immediate evacuation
• Greater Valley YMCA, Allentown Branch
• Emergency in the Main Building, children will be evacuated to the exterior of the building, front or back parking lots.
In-place sheltering - Sudden occurrences, weather or hazardous materials related, may dictate that taking cover inside the
building is the best immediate response.
• Greater Valley YMCA, Allentown Branch – Each classroom has a specific area within the building as referenced in the EOP.
School-age at Parkland & East Penn
Immediate evacuation
• Emergency in the Main Building, children will be evacuated to the exterior of the building, front or back parking lots.
In-place sheltering - Sudden occurrences, weather or hazardous materials related, may dictate that taking cover inside the
building is the best immediate response.School Primary Evacuation Site Secondary Evacuation Site
3501 Grille Allentown YMCA
Cetronia
3501 Broadway 425 S. 15th St.,
Allentown, PA 18104 Allentown, PA 18102
Ocean Spray Allentown YMCA
Fogelsville
151 Boulder Dr 425 S. 15th St.,
Breinigsville, PA 18031 Allentown, PA 18102
East Penn Trucking Allentown YMCA
Kernsville
4822 Kernsville Rd., 425 S. 15th St.,
Orefield, PA 18069 Allentown, PA 18102
Hops at the Paddock Allentown YMCA
Kratzer
1945 W. Columbia St. 425 S. 15th St.,
Allentown, PA 18104 Allentown, PA 18102
St. Paul's Lutheran Church Allentown YMCA
Jaindl
8227 Hamilton Blvd. 425 S. 15th St.,
Trexlertown, PA 18087 Allentown, PA 18102
Nativity Lutheran Church Allentown YMCA
Parkway Manor
4004 W. Tilghman St., 425 S. 15th St.,
Allentown, PA 18104 Allentown, PA 18102
Macungie Elementary Allentown YMCA
Shoemaker
4062 Brookside Rd., 425 S. 15th St.,
Macungie, PA 18062 Allentown, PA 18102
Brookside Country Club Allentown YMCA
Willow Lane 901 Willow Ln. 425 S. 15th St.,
Macungie, PA 18062 Allentown, PA 18102
LCCC Main Campus Allentown YMCA
Schnecksville 4525 Education Park Dr., 425 S. 15th St.,
Schnecksville, PA 18018 Allentown, PA 18102
North Whitehall Township Allentown YMCA
Ironton 3256 Levans Rd. 425 S. 15th St.,
Coplay, PA 18037 Allentown, PA 18102
Evacuation - Total evacuation of the facility may become necessary if there is a danger in the area.
• In-Place Shelter Location – Greater Valley YMCA, Allentown Branch, 425 South 15th Street, Allentown, PA, 18102,
610-351-9622
• Primary Location – Lehigh Valley Active Life, 1633 West Elm Street, Allentown, PA 18102, 610-437-3700
• Secondary Location – First Presbyterian Church, 3231 West Tilghman Street, Allentown, PA 18102, 610-395-3781
Modified Operation - May include cancellation/postponement or rescheduling of normal activities. These actions are normally
taken in case of a winter storm or building problems (such as utility disruptions) that make it unsafe for students but may be
necessary in a variety of situations.
Please visit us online at www.gv-ymca.org or Channel 69 News WFMZ for announcements relating any of the emergency actions
listed above. Additionally, we will be utilizing Remind.com for text message alerts.
We ask that you not call during the emergency. This will keep the main line telephone free to make emergency calls and relay
information. We will call you to let you know that we have taken one of these protective actions. We will also call you when we
have resolved the situation and it is safe for you to pick up your child either at the YMCA or at our relocation facility.
If an emergency forces school to close, please do not attempt to take your child to the YMCA. The designated persons to pick up
your child during an emergency are listed on the Emergency Contact Form included with the Registration Packet.
We urge all families to have their own emergency plan in place. Your plan should include a predetermined meeting spot for all
family members along with designated family and friends who are able and available to pick up your child in the event you are
unavailable.
In order to assure the safety of your children and our staff, I ask for your understanding and cooperation. Should you have
additional questions regarding our emergency operating procedures, contact your Child Care Director.
[Receipt of this document acknowledged on page 8]
10For Allentown YMCA SACC, Early Childhood and ALL FUN DAY participants only.
Greater Valley YMCA, Allentown Branch Child Care and School-Age Educational Program Dear Parent/Guardian: This letter is intended for parents or guardians of children enrolled in a child care center. Greater Valley YMCA, Allentown Branch Child Care and School-Age Educational Program offers healthy meals to all enrolled children as part of our participation in the U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP). The CACFP provides reimbursements for healthy meals and snacks served to children enrolled in child care. Please help us comply with the requirements of the CACFP by completing the attached Meal Benefit Income Eligibility Form. In addition, by filling out this form, we will be able to determine if your child(ren) qualifies for free or reduced price meals. 1. Do I need to fill out a Meal Benefit Form for each of my children in day care? You may complete and submit one CACFP Meal Benefit Income Eligibility Form for all children enrolled in child care in your household only if the children in child care are enrolled in the same center. We cannot approve a form that is not complete, so be sure to read the instructions carefully and fill out all required information. We request that ALL families complete the forms. Return the completed form to: Greater Valley YMCA, Allentown Branch, 425 South 15th Street, Allentown, PA 18102. 2. Who can get free meals without providing income information? Children in households getting Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps), Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian Reservations (FDPIR) benefits can get free meals. Foster children and children enrolled in Head Start are also eligible for free meals. Children in households participating in WIC may be eligible for free meals. 3. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Chart, shown on this application. Children in households participating in WIC may be eligible for reduced price meals. 4. May I fill out a form if someone in my household is not a U.S. citizen? Yes. You or your children do not have to be U.S. citizens to qualify for meal benefits offered at the child care center. 5. Who should I include as members of my household? You must include everyone in your household (such as grandparents, other relatives, or friends who live with you) who shares income and expenses. You must include yourself and all children who live with you. You also may include foster children who live with you. 6. How do I report income information and changes in employment status? The income you report must be the total gross income listed, by source, each household member received last month. If last month’s income does not accurately reflect your circumstances, you may provide a projection of your monthly income. If no significant change has occurred, you may use last month’s income as a basis to make this projection. If your household’s income is equal to or less than the amounts indicated for your household’s size on the attached Income Chart, the center will receive a higher level of reimbursement. Once properly approved for free or reduced price benefits, whether through income or by providing a current SNAP, TANF, or FDPIR case number, you will remain eligible for those benefits for 12 months. You should notify us, however, if you or someone in your household becomes unemployed and the loss of income causes your household income to be within the eligibility standards. 7. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime, include it, but not if you only get it sometimes. 8. What if I have foster children? Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. Households may include foster children on the Meal Benefit Form, but are not required to include payments received for the foster child as income. Households wishing to apply for such benefits for foster children should contact Greater Valley YMCA, Allentown Branch, 425 South 15th Street, Allentown, PA 18102, 610-351-9622. 9. We are in the military; do we include our housing and supplemental allowances as income? If your housing is part of the Military Housing Privatization Initiative and you receive the Family Subsistence Supplemental Allowance, do not include these allowances as income. Also, in regard to deployed service members, only that portion of a deployed service member’s income made available by them or on their behalf to the household will be counted as income to the household. Combat Pay, including Deployment Extension Incentive Pay (DEIP) is also excluded and will not be counted as income to the household. All other allowances must be included in your gross income. In the operation of child feeding programs, no person will be discriminated against because of race, color, national origin, sex, age or disability. If you have other questions or need help, call 610-351-9622. Sincerely, Tami S. Unger Tami S. Unger Child Care Director
Instructions for Completing the CACFP
Child Care Center Meal Benefit Income Eligibility Form
Follow these instructions, if your household gets SNAP, TANF or FDPIR:
Part 1: List all enrolled children and household members.
Part 2: List the case number for any household members (including adults) receiving State SNAP or State
TANF or FDPIR benefits.
Part 3: Skip this part.
Part 4: Skip this part.
Part 5: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 6: Answer this question if you choose.
FOSTER CHILDREN HOUSEHOLDS, will follow these instructions:
A Meal Benefit Form is not required to be completed. Contact the center at 610-250-7193; OR
If some of the children in the household are foster children:
Part 1: List all enrolled children and household members. For any people, including children, with no income, you must
check the “No Income Box.” Check the box if the child is a foster child.
Part 2: If the household does not have a case number, skip this part.
Part 3: If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call [your
school, homeless liaison, migrant coordinator]. If not, skip this part.
Part 4: Follow these instructions to report total household income for this month or last month.
Column A – Name: List only the first and last name of each person living in your household who share income and
expenses, related or not (such as grandparents, other relatives, or friends who live with you) with income. Include
yourself and all children living with you. Attach another sheet of paper if you need to.
Column B – Gross Income and How Often it was Received: For each household member, list each type of income
received for the month. You must tell us how often the money is received – weekly, every other week, twice a month, or
monthly.
Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other
deductions. You should be able to find it on your stub or your boss can tell you.
Box 2: List the amount each person got for the month from welfare, child support, alimony.
Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s (VA) benefits, disability
benefits.
Box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,
regular contributions from people who do not live in your household, and any other income. For ONLY the self-
employed, report income after expenses in Box 1. Box 4 is for your business, farm or rental property. Do not include
income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Housing Privatization
Initiative or get combat pay, do not include this housing allowance as income.
Part 5: Adult household member must sign the form and list the last four digits of the Social Security Number
or mark the box if she/he doesn’t have one.
Part 6: Answer this question if you choose.ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:
Part 1: List all enrolled children and household members. For any people, including children, with no income,
you must check the “No Income Box.”
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Follow these instructions to report total household income for this month or last month.
Column A – Name: List only the first and last name of each person living in your household who share income and
expenses, related or not (such as grandparents, other relatives, or friends who live with you) with income. Include
yourself and all children living with you. Attach another sheet of paper if you need to.
Column B – Gross Income and How Often it was Received: For each household member, list each type of income
received for the month. You must tell us how often the money is received – weekly, every other week, twice a month, or
monthly.
Box 1: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other
deductions. You should be able to find it on your stub or your boss can tell you.
Box 2: List the amount each person got for the month from welfare, child support, alimony.
Box 3: List retirement, Social Security, Supplemental Security Income (SSI), Veteran’s (VA) benefits, disability
benefits.
Box 4: List ALL OTHER INCOME SOURCES including Worker’s Compensation, unemployment, strike benefits,
regular contributions from people who do not live in your household, and any other income. For ONLY the self-
employed, report income after expenses in Box 1. Box 4 is for your business, farm or rental property. Do not include
income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Housing Privatization
Initiative or get combat pay, do not include this housing allowance as income.
Part 5: Adult household member must sign the form and list the last four digits of the Social Security Number
or mark the box if she/he doesn’t have one.
Part 6: Answer this question if you choose.
Privacy Act Statement: This explains how we will use the information you give us.
Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly.Child and Adult Care Food Program Center: Allentown YMCA
Child Enrollment Form
PARENTS: This institution participates in the Child and Adult Care Food Program (CACFP) and receives reimbursement to provide more nutritious meals for your
child(ren). Federal CACFP regulations require all parents and guardians to complete a CACFP Annual Enrollment Form when enrolling their child(ren) and again every
year thereafter. This information will help ensure all children receive appropriate meals during their care. Please complete all areas to include signing and dating
same. This document does not have to be completed for children in Emergency Shelters, Outside School Hours, and/or At-Risk programs.
TIMES CHILD NORMALLY ATTENDS DURING WEEK
TIME-IN TIME OUT TIME CHILD ATTENDS
FULL NAME OF ENROLLED CHILD DAYS OF WEEK IN
(Include Birth Date/Age ATTENDANCE SCHOOL MEALS RECEIVED
AM PM TIME AM PM TIME LEAVES RETURNS
CENTER TO CENTER
FIRST CHILD MONDAY
TUESDAY
NAME WEDNESDAY Yes No I work multiple shifts and child(ren) may be in care different days/hours
THURSDAY Other:
BIRTH DATE FRIDAY BREAKFAST
LUNCH
AGE PM SNACK
Enrollment Date: Withdrawal Date: DINNER
TIMES CHILD NORMALLY ATTENDS DURING WEEK
TIME-IN TIME OUT TIME CHILD ATTENDS
FULL NAME OF ENROLLED CHILD DAYS OF WEEK IN SCHOOL MEALS RECEIVED
(Include Birth Date/Age ATTENDANCE Same Times as Above
AM PM TIME AM PM TIME LEAVES RETURNS
CENTER TO CENTER
SECOND CHILD Same as Above Same Meals as Above
MONDAY
NAME TUESDAY Yes No I work multiple shifts and child(ren) may be in care different days/hours
WEDNESDAY Other:
BIRTH DATE THURSDAY BREAKFAST
FRIDAY LUNCH
AGE PM SNACK
Enrollment Date: Withdrawal Date: DINNER
TIMES CHILD NORMALLY ATTENDS DURING WEEK
TIME-IN TIME OUT TIME CHILD ATTENDS
FULL NAME OF ENROLLED CHILD DAYS OF WEEK IN SCHOOL MEALS RECEIVED
(Include Birth Date/Age ATTENDANCE Same Times as Above
AM PM TIME AM PM TIME LEAVES RETURNS
CENTER TO CENTER
THIRD CHILD Same as Above Same Meals as Above
MONDAY
NAME TUESDAY Yes No I work multiple shifts and child(ren) may be in care different days/hours
WEDNESDAY Other: BREAKFAST
BIRTH DATE THURSDAY LUNCH
FRIDAY PM SNACK
AGE Enrollment Date: Withdrawal Date: DINNER
TIMES CHILD NORMALLY ATTENDS DURING WEEK
TIME-IN TIME OUT TIME CHILD ATTENDS
FULL NAME OF ENROLLED CHILD DAYS OF WEEK IN SCHOOL MEALS RECEIVED
(Include Birth Date/Age ATTENDANCE Same Times as Above
AM PM TIME AM PM TIME LEAVES RETURNS
CENTER TO CENTER
FOURTH CHILD Same as Above Same Meals as Above
MONDAY
NAME TUESDAY Yes No I work multiple shifts and child(ren) may be in care different days/hours
WEDNESDAY BREAKFAST
BIRTH DATE THURSDAY
Other: LUNCH
FRIDAY PM SNACK
AGE DINNER
Enrollment Date: Withdrawal Date:
Signature
Signature of Parent or Guardian Date Telephone Number of Parent or Guardian
CHILD CARE REPRESENTATIVE USE ONLY:
Name of Representative/Signature Date
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: (1) mail: U.S. Department of
Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
program.intake@usda.gov . This institution is an equal opportunity provider.Child and Adult Care Food Program
Child Care Center Meal Benefit Income Eligibility Form
Part 1. All Household Members
Name of Enrolled Child(ren):
CHECK IF A FOSTER CHILD (THE LEGAL
RESPONSIBILITY OF A WELFARE AGENCY
OR COURT)
Names of all household members * IF ALL CHILDREN LISTED BELOW ARE CHECK
(First, Middle Initial, Last) FOSTER CHILDREN, SKIP TO PART 5 TO IF NO INCOME
SIGN THIS FORM.
Part 2. Benefits: If any member of your household received [State SNAP], [FDPIR], or [State TANF cash assistance],
provide the name and case number for the person who receives benefits. If no one receives these benefits, skip to part 3.
NAME:_________________________________________________ CASE NUMBER: ___ ___ - ___ ___ ___ ___ ___ ___ ___
Part 3. If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call [Your center
director, Homeless Liaison, Migrant Coordinator at Phone #] Homeless ❑ Migrant ❑ Runaway❑
Part 4. Total Household Gross Income—You must tell us how much and how often
A. Name B. Gross income and how often it was received
(List only household members with
income) 1. Earnings from work 2. Welfare, child support, 3. Pensions, retirement, 4. All Other Income
before deductions alimony Social Security, SSI, VA
benefits
(Example)
Jane Smith
$200/weekly_____ $150/twice a month_ $100/monthly_____ $______/________
$______/________ $______/________ $______/________ $______/_______
$______/________ $______/________ $______/________ $______/_______
$______/________ $______/________ $______/________ $______/_______
$______/________ $______/________ $______/________ $______/_______
$______/________ $______/________ $______/________ $______/_______
Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last four digits
of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the
back of this 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 purposely give false information, the participant
receiving meals may lose the meal benefits, and I may be prosecuted.
Sign Here: _________________________________________ Print Name: ________________________________________
Date: ____________________________
Address: ___________________________________________ Phone Number: _______________________
City:_______________________________________________ State: ________________ Zip Code: ________________
Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __ ❑ I do not have a Social Security NumberPart 6. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity: Mark one or more racial identities:
❑ Hispanic or Latino ❑ Asian ❑ American Indian or Alaska Native
❑ White ❑ Native Hawaiian or Other Pacific Islander
❑ Not Hispanic or Latino ❑ Black or African American
Don’t fill out this part. This is for official use only.
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: _____ Eligibility: Free_____ Reduced_____ Denied (Paid)_____ Date Withdrawn: ___________________
Reason for Denied:___ __________________________________________________________________________________________
Temporary: Free_____ Reduced_____ Time Period: ______________________________(expires after _____ days)
Determining Official’s Signature: _______________________________________________________________ Date: ______________
Confirming Official’s Signature: ________________________________________________________________ Date: ______________
Follow-up Official’s Signature: _________________________________________________________________ Date:______________
Household size Yearly
1 $22,459
2 $30,451
3 $38,443
4 $46,435
5 $54,427
6 $62,419
7 $70,411
8 $78,403
Each additional person: +$7,992
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: 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 the participant for free or reduced price meals. You must include
the last four digits of the Social Security Number 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 Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for
Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for the participant 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 the participant is eligible for free or reduced price meals, and for administration and enforcement of the
Program.
Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. “In accordance with Federal
Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national
origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence
Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have
speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is
an equal opportunity provider and employer.”Dear Families,
At the Allentown YMCA Childcare Center, we are constantly looking at ways to improve on the service we provide to you
and your children.
Tuition Express, part of our ProCare Software management system, allows us to process tuition and fee payments safely,
quickly and efficiently. In a matter of minutes we will accomplish what has taken us hours to complete -- leaving us more
time to spend with your children.
Once enrolled in Tuition Express, your tuition and fee payments will be paid automatically and on a schedule that we both
agree upon. The Allentown YMCA Childcare Center can produce a receipt for payment or you can receive instant email
notification by signing up at www.tuitionexpress.com.
Your personal account information is safe with Tuition Express – safer, in fact, then paying by check. Automated payments
have proven safer than writing checks and eliminate potential check fraud or identity theft.
Please look over the attached Frequently Asked Questions. There you will find answers to questions you may have about
Tuition Express or automated payments in general. If you have further questions don’t hesitate to ask.
Tuition Express offers various payment options that meet the needs of all families:
• Point of Service: A card swipe machine will be installed at the check in/out computer for you to manually pay on
your account with a Credit Card.
• Electronic Credit Card Transfer: Credit Card Payments will automatically be processed on scheduled due dates as
per your parent agreement.
• Electronic Bank Draft Transfer: Bank Accounts will be drafted on scheduled due dates as per your parent
agreement.
• On-Line Payments: On-line parent access to Tuition Express website to make payments.
• CASH: For families who do not have a checking account and/or credit card, cash payments will be accepted.
Approval must be obtained by the Childcare Director prior to picking the CASH option.
All NEW families will need to complete the Tuition Express Registration Form, Parent Agreement Form and applicable
Payment Enrollment Form (Credit/Bank Draft) and submit to the Accounting Office prior to enrollment at the Allentown
YMCA Childcare Center.
By completing one of the enclosed Tuition Express Payment Enrollment Forms, you will help us take a gigantic step forward
in our payment processing – a step that will allow us to focus on continuous quality improvement with the services we offer
to your family. Tuition Express is convenient for you, efficient for us, but best for your children. Welcome Aboard!
Sincerely,
Tami S. Unger
Child Care DirectorPELICAN SYSTEM
GREATER VALLEY YMCA, Allentown Branch (For Allentown site enrollment only)
As a Keystone STARS Site, state guidelines requires the Greater Valley YMCA, Allentown Branch to enter all information
included on this form into the PA PELICAN System. The PELICAN System is a state wide Early Learning Network used as a
comprehensive unified data system for assessing individual-level child outcomes across multiple programs. The data will
be used to inform state policy decisions, investments and improvement efforts for early education program from birth
through third grade.
Child Information:
LAST NAME: _________________________FIRST NAME: _______________________MI:______
ETHNICITY: _______HISPANIC _______NON-HISPANIC ______UNKNOWN
RACE: ____ American Indian/Alaskan Native ____ Black/African American ____White ____
Native Hawaiian/Pacific Islander ____Asian ____Other ____ Unknown
GENDER: ______MALE _______FEMALE DATE OF BIRTH: ___________________________
SOCIAL SECURITY NUMBER: __________-___________-______________
(All 9-digits will be kept confidential)
IS ENGLISH THE FIRST LANGUAGE OF THE CHILD: ____YES ____NO
Parent/Legal Guardian Information:
LAST NAME: _______________________FIRST NAME: ______________________MI:________
GENDER: _____MALE_____FEMALE DATE OF BIRTH: ___________________________
RELATIONSHIP TO CHILD: ___MOTHER ___FATHER ___GRANDPARENT ___LEGAL GUARDIAN
SECONDARY RELATIONSHIP TO CHILD: ___BIOLOGICAL ___FOSTER ___ADOPTIVE __STEP-PARENT
ROLE: ____PRIMARY GUARDIAN ____SECONDARY GUARDIAN ____LEGAL GUARDIAN ___CAREGIVER
____POWER OF ATTORNEY ____FISCAL GUARDIANSHIP ____SPECIALIST ____LIVING WILL ___CHILD
____PERSONAL GUARDIANSHIP ____SUBSTITUTE DECISION MAKER ____REPRESENTATIVE PAYEE____PRIMARY
CARE PHYSICIAN
ADDRESS: ______________________________CITY_____________STATE_______ZIP________
COUNTY: _________________SCHOOL DISTRICT WHERE CHILD RESIDES: _________________
PARENT EMAIL ADDRESS: ______________________________________________________________
Information to be reviewed with Program Personnel and Legal Guardian ONLY.
Enrollment Information
ENROLLMENT DATE: _____ DAYS ENROLLED/WEEK: _____ HOURS ENROLLED/WEEK: ______
SCHEDULE:___FULL-TIME ___PART-TIME (5 DAYS)___PART-TIME (AM 5 HRS)____PART-TIME (PM 5 HRS)
ENROLLMENT/CLASSROOM:
CLASSROOM NAME: _____________________START DATE: ____________ END/WITHDRAW DATE: _______
PROGRAM: _____ STARS (3-4) CHILD ENROLLED IN CHILD CARE SUBSIDY: _____ YES _____ NOYou can also read
