SANTA CLARITA VALLEY FAMILY YMCA 26147 McBean Parkway, Valencia, CA 91355 661-253-3593

Santa Clarita Valley Family YMCA 2014 Licensed Summer Camp Program Registration CHILD’S NAME PARENTS’ NAME_ SCHOOL GRADE IN FALL PHONE NUMBER ______________________

DAY CAMP WEEKS TRADITIONAL DAY CAMP

SPECIALTY DAY CAMPS

Locations (Check one)

Castaic Valley View Meadows Wiley Canyon

Old Orchard

Discovery: Entering Kinder – 2nd grade Adventure: Entering 3rd – 6th grade

Week 1 June 2 – 6 Discovery ($162) Adventure ($162) (Castaic ONLY)

Week 2 June 9 – 13 Discovery ($162) Adventure ($162) (Castaic ONLY)

Week 3 June 14 – 20 Discovery ($162) Adventure ($162)

Glee ($182) Splash ($197)

Week 4 June 23 – 27 Discovery ($162) Adventure ($162)

Great Summer Bake Off ($197) STEM-Tastic ($182)

Week 5 June 30 – July 3 (Program closed July 4th)

Discovery ($142) Adventure ($142)

Cheer ($162) Harry Potter Science ($162)

Week 6 July 7 – 11 Discovery ($162) Adventure ($162)

Space School Musical ($182) Sports Spectacular ($182)

Week 7 July 14 – 18 Discovery ($162) Adventure ($162)

Duct Tape Creation ($182) Music & Movement ($182)

Week 8 July 21 – 25 Discovery ($162) Adventure ($162)

Master Chef Jr. ($197) Splash ($197)

Week 9 July 28 – Aug. 1 Discovery ($162) Adventure ($162)

Art-Tastic ($182) Contemporary Dance ($182)

Week 10 August 3 – 8 Discovery ($162) Adventure ($162)

Bowl-Arama ($197) Build-It ($182)

Child’s T-Shirt Size: Child 6-8 Child 10-12 Child 14-16 Adult Sm. Adult Med. Adult Lrg. Adult XL I have received a copy of the Santa Clarita Valley Family YMCA's Camp Parent Handbook regarding policies,

procedures and the financial policy. I have read and understand these policies and receipt acknowledge of Personal Rights, Parents Rights and Earthquake Kit form. I have read, understand and agree to these policies.

Initials

Parent Signature Date

For Office Use Only Account #: ___________________ Staff Initials: _______________

SANTA CLARITA VALLEY FAMILY YMCA 26147 McBean Parkway, Valencia, CA 91355 661-253-3593

2014 CAMP GENERAL INFORMATION, POLICIES, & PROCEDURES PAYMENT OPTIONS :

Deposit/Payment - The first week of camp must be paid in full at the time of registration. A $25 camp deposit per week per child is due for all subsequent weeks. Parent/Guardian will pay by cash, check, credit card, or online by due dates unless cancelled in writing to the YMCA 7days prior to the due date. Payment in Full – Cash, check, or credit card is for full payment of all camps requested and available.

CAMP PAYMENT AND CANCELLATION/TRANSFER POLICY I understand that camp deposits are non-refundable. The deposits for programs are as follows: $25 per week. Weekly payment in full are due one week prior to the start of the camp week. I understand my registration may be cancelled if the balance is not paid one week prior to the start of the camp week. If the weekly summer camp fee has not been paid in full, then the child may not participate in our program. If there is an outstanding balance from the school year or a previous week of camp, you child will not be allowed to attend until the outstanding balance is paid in full. Cancellations may be made in writing up 10 days prior to the final payment due date to receive a refund less deposit. Any returned items, such as nonsufficient checks or automatic transfers, will be subject to a $25 service fee.

General Information, Policies & Procedures

Initial enrollment must be done in person at our Main Facility in Santa Clarita, only the payment of balances can be made over the phone or online. If you wish to add additional weeks, it can be done in person or over the phone. We cannot take camp registration forms at the program sites. Payments to balances will not be accepted at the childcare sites. Payments can be made in person at our Main Facility

in Santa Clarita, over the phone using a credit card, or online at www.ymcala.org. Camp site hours are from 6:30am to 6:30pm. There is a $1 per minute late fee charge for every minute you pick your child up after 6:30pm. All field trips and trip days are subject to change. Field trip information will be posted and updated weekly with both departure and expected arrival times. It is the parents responsibility to have their child at the site prior to the departure time. We provide an am and pm snack. It is the parent/guardian’s responsibility to pack a lunch for your child. Refrigeration and/or microwaves are not available for lunches. We do not allow children to purchase lunch on field trips.

I HAVE READ THE ABOVE CAMP GENERAL INFORMATION, POLICIES, & PROCEDURES AGREEMENT AND AGREE TO THE TERMS OUTLINED. Parent Signature Date

SANTA CLARITA VALLEY FAMILY YMCA 26147 McBean Parkway, Valencia, CA 91355 661-253-3593

FINANCIAL POLICY THIRD PARTY BILLING: The Santa Clarita Valley Family YMCA is happy to accept 3rd party payments on your behalf from a recognized state or county agency. Please understand that this contract is between you and the funding provider. It is your responsibility to keep your YMCA childcare account current. Receiving funding from another agency requires additional paperwork from that provider. This paperwork may include:

• Sign in and out forms • Application • Verification of income

At the end of the month, forms are turned in to our billing office by your Center Director. It is checked for accuracy and mailed to the participating agency. It is imperative that this form be received by the billing office by the 2nd of the month, so that it will be received by the agency no later than the 5th of the month. If this form is late to our office for any reason, causing payment to be delayed, you will be responsible for such payment. We understand that the 3rd party billing system runs 30 days behind. Any balance over 30 days becomes the responsibility of the participant. Please understand the YMCA will not and cannot act on your behalf with the funding provider. However, the YMCA can assist with coordination of your efforts to complete the required documentation. Failure to meet the provider’s deadlines will result in your account being delinquent and will jeopardize your childcare service. Please communicate, with your Center Director, any problems or concerns about your account. Please also understand that the YMCA is not connected with these agencies and can only collect fees based on your cooperation. The YMCA does not and cannot negotiate on your behalf. We ask that you work directly with the funding provider. The YMCA will only accept the contract on the date it is received as the start date by the funding provider. We do not back date enrollment and attendance. Parents who would like to begin care prior to being accepted by the funding provider are responsible for all fees associated with the program. We’d like to remind you that you must give us 30 days written notice for program changes. All fees not paid by 3rd party billing become the responsibility of the participant. I HAVE READ THE ABOVE FINANCIAL POLICY AGREEMENT AND AGREE TO THE TERMS OUTLINED. Parent Signature Date

SANTA CLARITA VALLEY FAMILY YMCA 26147 McBean Parkway, Valencia, CA 91355 661-253-3593

AUTHORIZATION FOR PICK-UP

CHILD ENROLLED: ____________________________________________________________________________________________________________________ Last First Middle ADDRESS:_______________________________________________________________________________________________________________________________ Street City Zip BIRTHDATE __________ GENDER_____ HOME PHONE (____)_____________ SCHOOL________________________ GRADE__________

PARENT/GUARDIAN________________________________________________________________ CELL PHONE (______)___________________________

HOME ADDRESS___________________________________________________________________________________________________

PLACE OF EMPLOYMENT & CITY___________________________________________________ WORK PHONE (_____)_______________________

EMERGENCY CONTACT NAME_________________________ PHONE (____)__________ RELATIONSHIP______________________

NAME OF OUT-OF-STATE CONTACT____________________ PHONE (____)__________ RELATIONSHIP______________________

THE FOLLOWING INDIVIDUALS HAVE MY UNRESTRICTED PERMISSION TO PICK-UP AND SIGN-OUT THE ABOVE CHILD FROM THE YMCA PROGRAM WITHOUT ANY FURTHER CONFIRMATION FROM ME. NAME HOME PHONE WORK PHONE PAGER/CELL PHONE RELATIONSHIP

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________

Pick-up Child from Childcare Center I, _______________________, understand and agree that in the event my child is not called for by closing, the Center will immediately make every attempt to contact me, or other persons authorized by me to take my child from the center. If I or these people cannot be located, or if satisfactory arrangement for calling for the child cannot be made, that the office will continue to try to locate me or other designated persons; but if those efforts are unsuccessful within a reasonable period of time (e.g., day time, one hour), the appropriate local law enforcement and welfare authorities will be contacted, and my child may be released to the custody of those welfare authorities as a possible ward of Juvenile Court. I hereby release the YMCA, its employees and agents from all liability for any damage sustained by my child or by me which results directly or indirectly from the procedure outlined above. I further agree that if this procedure must be utilized because I fail to pick-up my child on time from the Center, or because any person designated by me fails to pick up my child on time from the Center, I will indemnify and hold the YMCA Childcare Center harmless for any damage sustained by my child. SIGNED_____________________________________________________ DATE________________________________________________ SIGNED_____________________________________________________ DATE________________________________________________

SANTA CLARITA VALLEY FAMILY YMCA 26147 McBean Parkway, Valencia, CA 91355 661-253-3593

Santa Clarita Valley Family YMCA Participant Transportation Policy

All children will take part in field trips during the year. All transportation rules and policies apply for both situations.

The following section from REGULATIONS AND LAWS RELATING TO PUPIL TRANSPORTATION IN CALIFORNIA is quoted to point out to you the authority and responsibility of the driver of our vans: “Section 1089. AUTHORITY OF DRIVER. Pupils transported in a school bus shall be under the authority of, and responsible directly to, the driver of the bus, and the driver shall be held responsible for the orderly conduct of the pupils while they are on the bus or being escorted across a street, highway or road. Continued disorderly conduct or persistent refusal to submit to the authority of the driver shall be sufficient reason for a pupil to be denied transportation…” At the Santa Clarita Valley Family YMCA, it is our goal while transporting children to keep them safe at all times. In order for us to do this, the basic safety rules listed below must be followed:

1. Stay seated at all times while in the vehicle 2. Properly wear seat belt at all times when equipped 3. Refrain from eating and or drinking while in the vehicle 4. Use a low voice while in the vehicle 5. Keep all body parts inside the vehicle at all times 6. Adhere to driver’s directions

In the event that a child endangers himself or others by not adhering tone or more of the above stated rules, the following consequences will result, determined by the Center Director and the Transportation Coordinator: 1. Parent conference

2. Suspension from transportation the following day 3. Suspension from transportation for one (1) week 4. Transportation privilege terminated

Your signature below indicates that you and your child have read, understand and agree to the Participant Transportation Policy. Thank you for your cooperation. ______________________________ ______________________ Child’s Name Date ______________________________ ______________________ Parent Signature Date

SANTA CLARITA VALLEY FAMILY YMCA 26147 McBean Parkway, Valencia, CA 91355 661-253-3593

Activity Release and Permission My child, ______________________, has my permission to participate in all activities which are part of the YMCA Childcare Program. These activities include water play, use of play ground and tumbling apparatus, woodworking, cooking, animal care, messy craft activities, adult supervised walks in the immediate neighborhood of the YMCA, field trips and other active play experiences typical in a Childcare Program. I, the undersigned, hereby release and discharge the YMCA, officers, employees, agents and servants (Herin collectively reffered to as YMCA). For the purpose of this agreement, liability means all claims, demands, losses, courses of action, suits or judgments of any kind that I, my heir, executors, administrators or assignees may have against the YMCA because of any loss or damage to property that results from any cause other than the negligence of the YMCA. I have no objection to my child being included in photographs, slides, or movies taken in the YMCA which might be used for purposes of interpreting the Childcare Program. I understand that college students may be making observations at the YMCA as part of class assignments and that any photography or observations will be done only under the supervision of the director. I understand that the discipline methods used with my child shall include warnings, time outs, denial of privileges and logical consequences. I have read, understand, and agree to the stipulations and policies in the Childcare registration packet and policy handbook and realize that abuse of the policies may lead to the termination of my child’s enrollment. I have read and agree to all the statements in this document Parent Signature Date

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTS Child Care Centers

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers. (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are

not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her

needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,

threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing

agency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

COMMUNITY CARE LICENSING DIVISION – LOS ANGELES NORTHWEST REGIONAL OFFICE

NAME REGIONAL MANAGER

ADDRESS 6167 BRISTOL PARKWAY, SUITE 400 ms:29-13

CITY ZIP CODE AREA CODE/TELEPHONE NUMBER CULVER CITY 90230 310-337-4333

DETACH HERE TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to:

(PRINT THE NAME OF THE FACILITY)

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

(PRINT THE ADDRESS OF THE FACILITY)

(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)

LIC 613A (8/08)

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENT- Child Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

. THIS CARE MAY BE GIVEN UNDER

NAME

WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD

NAMED ABOVE.

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

HOME ADDRESS

HOME PHONE

( ) WORK PHONE

( )

LIC 627 (9/08) (CONFIDENTIAL)

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative

CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE

( ) ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE

FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE

( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE

( ) MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE

( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE

( ) PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST HOME TELEPHONE

( ) BUSINESS TELEPHONE

( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

NAME

ADDRESS

TELEPHONE

RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER

DENTIST ADDRESS MEDICAL PLAN AND NUMBER

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

TELEPHONE

( ) TELEPHONE

( )

■ CALL EMERGENCY HOSPITAL ■ OTHER EXPLAIN:

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

NAME RELATIONSHIP

TIME CHILD WILL BE CALLED FOR

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE

DATE OF ADMISSION

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE DATE LEFT

LIC 700 (8/08)(CONFIDENTIAL)

WHAT TIME DOES CHILD GET UP?* WHAT TIME DOES CHILD GO TO BED?* DOES CHILD SLEEP WELL?*

DOES CHILD SLEEP DURING THE DAY?* WHEN?* HOW LONG?*

BREAKFAST WHAT ARE USUAL EATING HOURS? BREAKFAST LUNCH DINNER

LUNCH

STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT

CHILD’S NAME SEX BIRTH DATE

FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN? DATE OF LAST PHYSICAL/MEDICAL EXAMINATION

DEVELOPMENTAL HISTORY (*For infants and preschool-age children only) WALKED AT*

MONTHS BEGAN TALKING AT*

MONTHS TOILET TRAINING STARTED AT*

MONTHS

PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:

■ Chicken Pox

■ Asthma

■ Rheumatic Fever

■ Hay Fever

DATES ■ Diabetes

■ Epilepsy

■ Whooping cough

■ Mumps

DATES ■ Poliomyelitis

■ Ten-Day Measles (Rubeola)

■ Three-Day Measles (Rubella)

DATES

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

DOES CHILD HAVE FREQUENT COLDS? ■ YES ■ NO HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF

DAILY ROUTINES (*For infants and preschool-age children only)

DIET PATTERN: (What does child usually eat for these meals?)

DINNER

ANY FOOD DISLIKES? ANY EATING PROBLEMS?

IS CHILD TOILET TRAINED?* ■ YES ■ NO

IF YES, AT WHAT STAGE:* ARE BOWEL MOVEMENTS REGULAR?* ■ YES ■ NO

WHAT IS USUAL TIME?*

WORD USED FOR “BOWEL MOVEMENT”* WORD USED FOR URINATION*

PARENT’S EVALUATION OF CHILD’S HEALTH

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

■ YES ■ NO

IF YES, NAME OF DOCTOR: DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

■ YES ■ NO

IF YES, WHAT KIND AND ANY SIDE EFFECTS:

DOES CHILD USE ANY SPECIAL DEVICE(S):

■ YES ■ NO

IF YES, WHAT KIND: DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

■ YES ■ NO

IF YES, WHAT KIND:

PARENT’S EVALUATION OF CHILD’S PERSONALITY

HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?

DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?

REASON FOR REQUESTING DAY CARE PLACEMENT

PARENT’S SIGNATURE DATE

LIC 702 (8/08) (CONFIDENTIAL)

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS

PARENTS’ RIGHTS As a Parent/Authorized Representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care.

2. File a complaint against the licensee with the licensing office and review the licensee’s public file

kept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years.

4. Complain to the licensing office and inspect the child care center without discrimination or retaliation

against you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: Community Care Licensing Division-Los Angeles Northwest Division Office

Licensing Office Address: 6167 Bristol Parkway, Suite 400, MS:29-13, Culver City 90230

Licensing Office Telephone #: 310-337-4333

7. Be informed by the licensee, upon request, of the name and type of association to the child care

center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A

PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE. For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov

LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)

A C K N O W L E D G E M E N T O F N O T I F I C A T I O N O F PA R E N T S ’ R I G H T S

(Parent/Authorized Representative Signature Required)

I, the parent/authorized representative of , have received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

Name of Child Care Center

Signature (Parent/Authorized Representative) Date

NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to

parent/authorized representative.

For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

LIC 995 (9/08)

MULTIJURISDICTIONAL AUTHORIZATION AND RELEASE FOR MEDICAL AND DENTAL TREATMENT

(IMPORTANT- This Form Must be Completed Prior to Attendance)

Rev. 5/2013

CHILD'S NAME: _____________________________________________________________

DOCTOR: ___________________________________________ PHONE #: _______________________

Please specify any medical problems, allergies, past operations, or treatment of serious illness _______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Specify allergic reactions to medication and/or food: ___________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the YMCA Program. I hereby grant permission for my child to leave the YMCA Program premises under the supervision of a staff member for neighborhood walks or field trips in an authorized vehicle. I hereby grant permission for my child to be included in evaluation and pictures connected with YMCA Programs.

The undersigned, as the parent(s) or legal guardian(s) of the above named person (the minor) authorizes the YMCA of Metropolitan Los Angeles and its Employees, Directors, and Adult Volunteers (collectively “YMCA”) to consent to an x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively “dental care”) to be rendered to the minor by a dentist licensed under the law of the State or other jurisdiction in which dental care is sought. For the purpose of medical care or dental care obtained outside of California, this authorization is given with the intent that any consent given pursuant to this authorization shall be the consent of each of the undersigned.

The undersigned understand and agree that the YMCA shall not be legally or financially liable for any bills or medical expenses incurred, or for any cause of action or claim arising from any medical care or dental care provided, or the lack of medical care or dental care. The undersigned hereby agree to this indemnity defined and hold YMCA harmless from any claim made by or on behalf of the minor’s heirs or parents or guardian arising out of any medical care or dental care provided.

SIGNED: _______________________________________________ DATE: ______________________________________

SIGNED: _______________________________________________ DATE: _______________________________________

MEDICAL INSURANCE COMPANY: __________________________________________________________________

POLICY NUMBER: ____________________________________ EXPIRATION DATE: ______________________

Note: The YMCA requests that if the minor is in the custody of two parents, or more than one legal guardian, both or all sign this authorization. The YMCA understands that the minor is in custody only of the person(s) who have signed this authorization. If for religious reasons you cannot sign this form the Branch must be contacted for a legal waiver, which must be signed for attendance.

AUTORIZACIÓN MULTIJURISDICCIONAL PARA TRATAMIENTO MÉDICO Y DENTAL

(IMPORTANTE – Este formulario debe ser completado previo a la asistencia del menor)

Rev. 5/2013

NOMBRE DEL MENOR: ________________________________________________________

DOCTOR: ___________________________________________ TELÉFONO: ______________________

Favor de especificar cualquier problema médico, alergia, operaciones previas o tratamiento para enfermedad grave __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________

Favor de especificar cualquier reacción alérgica a medicamento y/o comida: ________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Por la presente otorgo permiso para que mi hijo/a use todo el equipo de juego y participe en todas las actividades del Programa de la YMCA. Por la presente otorgo permiso para que mi hijo/a salga de las instalaciones del Programa de la YMCA bajo la supervisión de un miembro del personal en las caminatas por el vecindario o en las excursiones en un vehículo autorizado. Por la presente otorgo permiso para que mi hijo/a sea incluido/a en las evaluaciones y fotografías en relación a los Programas de la YMCA.

Los suscritos, como padre/madre o ambos, o tutor(es) legal(es) del menor (el menor) arriba mencionado, por la presente autorizan a la YMCA de Los Ángeles Metropolitano y a sus empleados, directores y voluntarios adultos (colectivamente la “YMCA”) a acceder a cualquier examen de radiografía, anestésico, diagnóstico o tratamiento médico o quirúrgico y cuidado hospitalario (colectivamente “cuidado dental”) para el menor por un dentista autorizado bajo las leyes del estado o cualquier otra jurisdicción en la que se solicite cuidado dental. Para el propósito del cuidado médico o dental recibido fuera de California, se presenta esta autorización con la intención de que cualquier consentimiento dado en cumplimiento de esta autorización será el consentimiento de cada uno de los suscritos.

Los suscritos entienden y acuerdan que la YMCA no será ni legal ni económicamente responsable de ningún gasto médico

incurrido, o de ninguna demanda que resulte del cuidado médico o dental proporcionado, o de la falta de cuidado médico o

dental. Los suscritos, por la presente aceptan esta indemnidad y consideran a la YMCA inocua de cualquier demanda hecha

por o de parte de los padres o tutores del menor que surja de algún cuidado médico o dental proporcionado.

FIRMA: _______________________________________________ FECHA: ______________________________________

FIRMA: _______________________________________________ FECHA: _______________________________________

COMPAÑÍA DE SEGURO MÉDICO: __________________________________________________________________

NÚMERO DE SEGURO: ____________________________________ CADUCA: ______________________

AVISO: La YMCA solita que si el menor está bajo el cuidado de ambos padres o de más de un tutor legal, que ambos o todos

firmen esta autorización. La YMCA sobreentiende que el menor está bajo el cuidado solamente de la persona o las personas

que han firmado esta autorización.

Si por motivos religiosos no puede firmar esta autorización, se deberá contactar a la división para obtener una renuncia legal

que deberá ser firmada para permitir asistencia.

YMCA OF METROPOLITAN LOS ANGELES RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

IN CONSIDERATION for being permitted to utilize the facilities, services, and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as “the undersigned”) hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities and/or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, volunteers and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all personal representatives, assigns, heirs, and next of kin of the undersigned for any loss or damage, and any claim or demands on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR, AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence, active or passive, of releasees or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

THIS AGREEMENT DOES NOT APPLY TO LICENSED CHILD CARE SERVICES.

I HAVE READ THIS RELEASE

___________________________________________________________________ ___________________________________________________________________ Date Printed Name

____________________________________________________________________ Signature of Applicant/Guardian

____________________________________________________________________________________________________________________________________________________ Name(s) of Child(ren) in Program and/or YMCA Facility

Revised 4/2013

YMCA DEL AREA METROPOLITANA DE LOS ANGELES ACUERDO DE EXONERACIÓN Y CESIÓN

DE RESPONSABILIDAD CIVIL E INDEMNIZACIÓN EN CONSIDERACION de haber sido otorgado permiso del uso de las instalaciones, servicios y programas del YMCA (o para que un menor participle en ellos) por cualquier propósito, incluyendo, pero sin limitarse, a la observación o uso de los equipos de las instalaciones, o participación en cualquier programa en otro sitio pero afiliado al YMCA el que firma, por si mismo y en nombre de cualquier menor participante, representante, heredero y pariente, reconoce, acuerda y asevera que ha inspecciónado cuidadosamente las premisas e instalaciones del programa afiliado. Además, queda muy bien entendido que tal ingreso al YMCA para observación o uso de cualquiera de los equipos de las instalaciones o la participación en tales programas afiliados, constituye un reconocimiento de que tales premisas, toda instalación, los equipos de las mismas y tales programas afiliados han sido inspecciónados cuidadosamente y que el que firma los encuentra y los acepta como seguros y razonablemente adecuados para los propósitos de tales observaciones, uso o participación por su parte o por parte del menor. ADEMAS DE CONSIDERAR EL HABER SIDO OTORGADO PERMISO PARA INGRESAR AL YMCA PARA CUALQUIER PROPOSITO INCLUYENDO, PERO NO LIMITANDOSE, A LA OBSERVACION O USO DE LAS INSTALACIONES Y EQUIPOS, O LA PARTICIPACIÓN EN CUALQUIER PROGRAMA AFILIADO AL YMCA, EL QUE FIRMA ACUERDA A LO SIGUIENTE: 1. EL QUE FIRMA, POR SU PARTE Y LA DEL MENOR, EXIME, CEDE, LIBERA Y GARANTIZA NO DEMANDAR AL YMCA, sus directores, oficiales, empleados y agentes (de aquí en adelante se refiere a estos como los “eximidos”) por cualquier responsabilidad hacia el que firma, o el menor, sus representantes, herederos y parientes, por cualquier pérdida o daño y cualquier reclamo o demanda por los mismos, con relación a lesiones a la persona o a la propiedad o que causarán la muerte a el que firma o al menor, haya sido a causa de negligencía del eximido o no, mientras el que firma o el menor esté, dentro o en los alrededores de las premisas o cualquiera de los equipos de las instalaciones o participando en cualquier programa afiliado al YMCA. 2. EL QUE FIRMA ACUERDA INDEMNIFICAR, SALVAGUARDAR Y NO PERJUDICAR a ninguno de los eximidos por cualquier pérdida, responsabilidad, daño o costo que pudiera tener, debido a la presencia de el que firma o del menor dentro o en los alrededores de las premisas del YMCA, o en cualquier forma observando o usando los equipos de las instalaciones del YMCA, o participando en cualquier programa afiliado al YMCA. 3. EL QUE FIRMA ASUME COMPLETA RESPONSABILIDAD Y LOS RIESGOS DE LESIONES CORPORALES, MUERTE O DAÑO A LA PROPIEDAD a el que firma o al menor debido a la negligencía del eximido o no, mientras esté, dentro o en los alrededores de las premisas del YMCA, y mientras esté usando las premisas o cualquiera de los equipos de las instalaciones, o participando en cualquier programa afiliado al YMCA. EL QUE FIRMA además acuerda expresamente que este ACUERDO DE EXONERACIÓN, CESIÓN E INDEMNIZACIÓN ha de ser tan amplio e inclusivo como lo permita la ley del estado de California y que si cualquier parte del mismo fuera invalido, se acuerda que el saldo, no obstante, continuará en plena fuerza y efecto. EL QUE FIRMA HA LEÍDO Y VOLUNTARIAMENTE FIRMA EL ACUERDO DE EXONERACIÓN Y CESIÓN DE RESPONSABILIDAD CIVIL E INDEMNIZACIÓN y además asegura que no se le ha hecho ninguna aserveración oral, declaración o inducción, aparte del presente acuerdo por escrito.

ESTE ACUERDO NO ES APLICABLE A SERVICIOS DE GUARDERIAS CON LICENCIA. Fecha: ____________________________________ YO HE LEÍDO ESTE ACUERDO _________________________________________________________________________ ________________________________________________________________ Nombre de el Solicitante/Padre en Letra de Molde: Firma de el Solicitante/Padre: Nombre del/los Menor(es) Matriculado(s) en el Programa: _________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

Rev. 4/2013

Rev. 2014

PHOTO & VIDEO/AUDIO RECORDING RELEASE

YMCA OF METROPOLITAN LOS ANGELES

PLEASE PRINT

I ______________________________________________________ am eighteen years of age or older, and if not,

then my Mother/Father/Legal Guardian has also signed below under my signature.

With regard to my participation in activities sponsored by or related to any activity in which I participate in any way

sponsored by the National Council of Young Men’s Christian Associations of the United States of America, and to any

YMCA of the USA Association, including the Young Men’s Christian Association of Metropolitan Los Angeles (collectively,

“YMCA”), I hereby give my permission and consent, now and for all time (without any further compensation, claim or

demand by me) to the YMCA, and to advertising agencies, agents, entities and third parties collaborating with the YMCA

and their representatives, if any, (the “Organizations”) to make, reproduce, edit, broadcast or rebroadcast any video,

film, or digital footage and other sound track recordings, or photo reproductions of my image or voice in any form, and

my narrative account of my experience with YMCA activities (“Materials”) for publication, display, sale or exhibition

thereof in promotions, advertising and legitimate business uses without any further compensation to me. I may or may

not be identified by name in such reproductions. However, I shall not be stated by name to have endorsed any particular

commercial products or commercial services without my express written permission.

I further agree to the following:

• Any Materials created subject to this Release shall belong to the YMCA as its property, with full right of disposition of

them without my oral or written permission.

• The Materials will not be subject to any obligation of confidentiality and may be shared with and used by the

Organizations, as well as with any third parties as the YMCA may elect.

• The YMCA shall not be liable for any claim arising from the use or disclosure to a third party of any of the Materials.

• The YMCA shall exclusively own all known or later existing rights to the Materials worldwide and shall be entitled to the

unrestricted use of the Materials for any purpose without compensation to me or the provider of the Materials.

AGREEMENT AND CONSENT

I have read and understood the contents of this Release. I agree that my consent to this Release is irrevocable. I hereby

voluntarily release and discharge the YMCA and the Organizations and their representatives from any and all claims

arising out of or relating to or in connection with the uses and reproductions of my image and voice and my narrative

account as described herein. I understand that the term “YMCA” in this Release specifically includes the YMCA of

Metropolitan Los Angeles.

Signature: ____________________________ Date: ____/____/________ Age: ___________________

Email Address: ________________________ Phone: _________________ Cell Phone: _______________

Address: ____________________________________________________________________________________

I am the Mother/Father/Legal Guardian of ___________________________. I have read and understand PLEASE PRINT the contents of this Release and hereby voluntarily consent to this Release on behalf of my minor child.

Signature of Mother / Father / Legal Guardian: _____________________________ Date: ___________________

Email Address: ___________________________

Phone: ________________________________ Cell Phone:_______________________________ Address: ______________________________________________________________________________________

Rev. 2014

AUTORIZACIÓN PARA LA DIVULGACIÓN

DE FOTOGRAFÍAS Y VIDEO/AUDIO YMCA OF METROPOLITAN LOS ANGELES

FAVOR DE ESCRIBIR EN LETRA MOLDE

Yo _________________________tengo diez y ocho años de edad o más, y de no ser así, mi Madre/Padre/Tutor

también ha firmado bajo mi firma.

Con respecto a mi participación en actividades patrocinadas por o relacionada a cualquier actividad en la que yo participe

que esté patrocinada de cualquier forma por el National Council of Young Men’s Christian Associations of the United

States of America, y a cualquier YMCA of the USA Association, incluyendo la Young Men’s Christian Association of

Metropolitan Los Angeles (colectivamente, “YMCA”), por la presente doy mi autorización y consentimiento, ahora y

siempre (sin compensación ni demanda adicional) a la YMCA y a las agencias de publicidad, agentes, entidades y a

tercera partes colaborando con la YMCA y sus representantes autorizados (las “Organizaciones”) para fotografiar,

imprimir, editar o emitir cualquier video, cinta, material digital o cualquier otra forma auditiva, o reproducciones

fotográficas de mi imagen o voz en cualquier forma, y la retrospectiva narrativa de mis experiencias en las actividades

(“Materiales”) de la YMCA para la publicación, exposición, venta o exhibición del mismo en promociones, publicidad y

negocios legales sin compensación adicional para mí. Puede o no que yo sea identificado por nombre en tales

reproducciones. Sin embargo, no seré señalado por nombre de haber promocionado ningún producto comercial en

particular o servicios comerciales sin mi autorización por escrito.

Acepto además lo siguiente:

• Cualquier material creado sujeto a esta Autorización será propiedad de la YMCA, con derecho total de disponer del

mismo sin mi autorización verbal o escrita.

• Los materiales no quedarán sujetos a ninguna obligación de confidencialidad y podrán ser compartidos con y usados

por las Organizaciones y cualquier tercera parte, según la elección de la YMCA.

• La YMCA no será responsable por cualquier demanda que surja del uso o la revelación a una tercera parte de

cualquiera de los Materiales.

• La YMCA poseerá exclusivamente todos los derechos conocidos, o existentes posteriormente, a los Materiales

mundialmente y tendrá el derecho de usar los Materiales sin restricciones para cualquier propósito sin compensación

para mí o el proveedor de los Materiales.

ACUERDO Y CONSENTIMIENTO

He leído y entendido los contenidos de esta Autorización. Entiendo que mi consentimiento de esta Autorización es

irrevocable. Por la presente autorizo voluntariamente y exonero a la YMCA y a las Organizaciones y sus representantes

de toda y cada una de las demandas que surjan de o en relación a o en conexión a los usos y las reproducciones de mi

imagen o voz y mi retrospectiva narrativa conforme se especificó antes. Entiendo que el término “YMCA” en esta

Autorización incluye específicamente a la YMCA of Metropolitan Los Angeles.

Firma: ____________________________ Fecha: ____/____/________ Edad: ___________________

Correo electrónico: _______________________ Teléfono: _________________ Móvil: _______________

Domicilio: ____________________________________________________________________________________

Yo soy Madre/Padre/Tutor de ___________________________. He leído y entiendo el contenido de

AVOR DE ESCRIBIR EN LETRA MOLDE

esta Autorización y por la presente doy el consentimiento voluntario de esta Autorización en nombre de mi

hijo/a menor.

Firma de la Madre/Padre/Tutor: _____________________________ Fecha: ____/____/________

Correo electrónico: ___________________________ Teléfono: ___________________________________ Móvil: ______________________ Domicilio: _________________________________________________________________________________