P 562.925.1292 F 562.925.2192

Dear Y Family,

Thank you for your interest in the Los Cerritos YMCA Before & After School Academic Enrichment Program. At the Y, our Areas of Focus are Youth Development, Healthy Living and Social Responsibility and we look forward to working together with you to ensure that each child has a safe, nurturing environment where they can learn, grow and thrive. When filling out this registration packet, it is important that you:

• Use blue or black ink (no pencil or white-out/correction tape)

• Complete one application for each child being enrolled in the program

• Fill out each section thoroughly

• Sign all documents (where required)

In addition to the completed application, you will also need to provide the following documents listed below at the time of registration:

• 2 current photos of your child (alone)

• Supplemental documentation, if applicable (Court documents, medical forms, etc.)

Once you have completed the packet and gathered the required additional documentation, please contact our Administrative Office at 562.925.1292 to schedule a registration appointment. Appointments are offered during our business hours, Monday through Friday between 9:00 am and 6:00 pm.

Once again, we would like to thank you for your interest in the Los Cerritos YMCA Before & After School Academic Enrichment Program and look forward to partnering with you for a successful 2018/2019 school year!

Your scheduled appointment is on: Date______________________ at _______________a.m./p.m. Rev. 4/18

LOS CERRITOS YMCA 15530 Woodruff Avenue, Bellflower CA 90706

2018/2019 BEFORE & AFTER SCHOOL ACADEMIC ENRICHMENT PROGRAM

PARTICIPANT INFORMATION

Participant’s First Name: Participant’s Last Name: YMCA Program Site Location:

Date Of Birth: Age: Sex:

M F

Grade in Fall 2018: School Enrolled: Teacher’s Name: Class Room #:

Home Address: City: State: Zip Code: School Start Time:

School Dismissal Time:

Emergency Contact Name: Phone Number:

Please List Any Disabilities Or Illnesses: Please List Any Known Allergies:

Child Lives With (circle one): Mother Father Both 50/50 Other (Explain):

PARENT OR GUARDIAN INFORMATION (The “Responsible Party” is the parent/guardian enrolling the child and is responsible for payment of fees, signing releases, authorizing

individuals to sign out the child and making any changes to the child’s participation in the program.)

Responsible Party First and Last Name: Date of Birth: Relationship to Child:

Home Address (if different from the child): City: State: Zip Code: Best Contact Number:

Employer Name: Work Phone: Email Address:

2nd Parent/Guardian Parent’s First and Last Name: Date of Birth: Relationship to Child:

Home Address (if different from the child): City: State: Zip Code: Best Contact Number:

Employer Name: Work Phone: Email Address:

In order to help ensure the safety of your child, please indicate those individuals whom you grant permission for your child to be released to. If you need to remove or add additional individuals after registration, you must come in and personally make any modifications. Should your child need to be released to an individual who is not listed below in the event of an emergency, you may fax or email written approval which must include your name, your child’s name, the name of the person picking up your child, the date and your signature. This type of authorization is only valid as a one day exception; you must come in to the Los Cerritos YMCA Administrative Office and add them to the original form if they are to continue to pick up your child. (Minimum of two required.)

Name Phone #1 Phone #2 Relationship to child Pick-Up Emergency

□

□

□

□

□

□

The following individuals are restricted from signing out my child due to a court-issued restraining order (a certified copy of the official court documentation must be submitted and on file with the Los Cerritos YMCA):

2018/2019 BEFORE & AFTER SCHOOL ACADEMIC ENRICHMENT PROGRAM Child’s Name: Child’s Date of Birth:

Parental Consent to Treat I hereby certify that the individual on this application is in good health and capable of participating in and using the camp program, equipment and facilities. I understand that my child must comply with the camp's rules and standards for participant behavior. I agree that the YMCA of Greater Long Beach has the right to enforce appropriate standards of conduct and that the organization may terminate my child's participation in the camp program if he/she does not maintain these standards. Further I give my consent for the use of my son/daughter's comments and photographs to be used in promotional materials for the YMCA of Greater Long Beach. This Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities, except as noted on this health form. The undersigned, as parent or legal guardian of the child registered on this form, hereby authorizes the YMCA and its delegated leaders and directors to consent to any medical and hospital care, (which may include but not be limited to X-rays, anesthesia, surgery, hospital care and dental work), to be rendered to said minor upon the advice of a licensed physician or dentist. This authorization is given pursuant to the provisions of the California Medical Practice Act. It is understood that if time and circumstances reasonably permit, the YMCA will endeavor, but is not required, to communicate with me prior to such treatment. The undersigned further agrees that the YMCA and its designated leaders and directors are not responsible for costs incurred for medical care or for any claim arising from any consent given in good faith in connection with such diagnosis or advised treatment. This authorization and consent to treatment is given to the YMCA in conjunction with any authorized event.

Parent’s Signature Date

Insurance Information I understand that I am responsible for the medical fees of my child, if he/she should be injured or is ill at the YMCA of Greater Long Beach, or during YMCA of Greater Long Beach activities or field trips.

Insurance Carrier:

Policy Number:

Name of Family Physician: Phone Number: Name of Dentist: Phone Number:

Department of Children’s Services (if applicable) Case Worker’s Name: Phone #: Case #:

Health History Include Past and Present Conditions

Asthma □ Yes □ No Heart Defects/Disease □ Yes □ No Recent Hospitalizations □ Yes □ No Currently Under Doctor’s Care □ Yes □ No Seizures □ Yes □ No Diabetes □ Yes □ No

ADD/ADHD □ Yes □ No Head Lice (recent) □ Yes □ No Bedwetting □ Yes □ No Sleepwalking □ Yes □ No Tuberculosis □ Yes □ No Chicken Pox □ Yes □ No Measles □ Yes □ No German Measles □ Yes □ No Ear Infection □ Yes □ No

Other Diseases or Conditions:

Operations or Serious Injuries:

If yes to any, please explain:

Immunization Dates MMR (Measles, Mumps, Rubella): DPT: Tetanus: Polio OPV (Sabin ): Other:

Allergies: Hay Fever □ Yes □ No Bee Stings □ Yes □ No Penicillin □ Yes □ No Oak/Ivy Poisoning □ Yes □ No Bee Sting Kit? □ Yes □ No Other Drugs □ Yes □ No Foods □ Yes □ No Other insects □ Yes □ No Other animals □ Yes □ No Any other allergies □ Yes □ No

If yes, please explain:

Female Participants Only Has your child started her menstruation cycle? □ Yes □ No If no, has she been talk to about it? □ Yes □ No

Please List Any Dietary Restrictions: Please List Any Activity Restrictions:

My child takes medication: □ Yes □ No *Please see your site director if the YMCA needs to administer medication Medication: Dosage: Time:

Medication: Dosage: Time:

Medication: Dosage: Time:

PROGRAM PARTICIPATION PLAN

Please Select From One of the Following Program Plans:

□ AM Only Care - $174 □ PM Only Care - $302 □ AM & PM Care - $477 □ PM Care with Breaks (August Start Only) - $374 □ AM & PM Care with Breaks (August Start Only) -$549

Paramount Kindergarten □ PM Kinder (Paramount) - $377 □ AM & PM Kinder (Paramount) - $554 □ PM Kinder with Breaks (August Start Only) - $449 □ AM & PM Kinder with Breaks (August Start Only) - $626

Payment Method: □ Monthly Automatic Debit - ATS Form Require

□ Monthly over the counter payment by cash, check, debit or credit card

□ Current Agency Certificate-CHS or HRC

I authorize the verification of the information provided on this form. I acknowledge that I have received a copy of the parent handbook and are responsible for the information it contains, including but not limited to program policies, procedures and financial obligations.

Parent/Legal Guardian Name (Please Print): Parent/Legal Guardian Signature: Date:

Date:

YMCA OF GREATER LONG BEACH PHOTO

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

For my participation in activities to be conducted by YMCA of Greater Long Beach, I hereby give my permission and consent, now and for all time, to YMCA of Greater Long Beach, the National Council of Young Men’s Christian Associations of the United States of America (YMCA of the USA) and third parties collaborating with YMCA of Greater Long Beach and/or YMCA of the USA to make, reproduce, edit, broadcast or rebroadcast any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Greater Long Beach for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any compensation to, and/or claim, by me. I may, or may not be, identified in such reproductions; however, I shall not be stated by name to have endorsed any particular commercial products or commercial services.

I further agree to the following: - Any video film, footage, sound track recordings, and photo reproductions of me and/or my narrative

account of my experience at YMCA of Greater Long Beach, I authorize, according to this Release, shall belong to YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long Beach and/or YMCA of the USA. Therefore, they will have full right of disposition of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Greater Long Beach;

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

account of my experience YMCA of Greater Long Beach will not be subject to any obligation of confidentiality and may be shared with and used by YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long Beach and/or YMCA of the USA;

- YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long

Beach and/or YMCA of the USA shall not be liable for any use or disclosure to a third party of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Greater Long Beach; and

- YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long

Beach and/or YMCA of the USA shall exclusively own all known or later existing rights to worldwide and shall be entitled to the unrestricted use any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience at YMCA of Greater Long Beach for any purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge YMCA of Greater Long Beach, YMCA of the USA and third parties collaborating with YMCA of Greater Long Beach and/or YMCA of the USA from any and all claims in connection with the uses and reproductions of any video film, footage, sound track recordings and photo reproductions of me and/or my narrative account of my experience YMCA of Greater Long Beach as described herein.

Signature: Printed Name:

Age: Address:

I am the Mother/Father/Legal Guardian of (child’s name). For the consideration contained herein, I hereby consent to the foregoing on behalf of my minor child.

Signature of Mother/Father/Legal Guardian:

YMCA OF GREATER LONG BEACH RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

IN CONSlOERATlON of being pennitted 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,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 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 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, HERBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the YMCA, its directors, officers, employees, and agents (hereinafter referred to as "releasees') from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefor on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence 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, damage or cost they may incur due to the presence of the undersigned of such children in, upon or about the YMCA premises or in any way observing or using any facilities or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by negligence of the releasees or otherwise.

3. THE UNDERSIGNED HERBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence of releasee 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,WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is pennitted 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 of inducement apart from the foregoing written agreement have been made.

IHAVE READ AND UNDERSTAND THIS RELEASE

Printed Name of Parent/Guardian Signature of Applicant/Parent Date

Name of Child in Program

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENC Y CALIFORNIA DEPARTMENT OF SOCIAL SERVCI ES 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: LOS ANGELES EAST REGIONAL OFFICE

Licensing Office Address:

Licensing Office Telephone#: (323) 981-3350

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)

--------------------------------------------------------------------------------------------------------------------------- ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS

(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.

YMCA of Greater Long Beach -Los Cerritos YMCA 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 (9/00)

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:

NAME

Department of Social Services

ADDRESS

1000 Corporate Center Dr., Suite 200- B

CITY ZIP CODE AREA CODE/TELEPHONE NUMBER

Monterey Park 91754 323-981-9950

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: 1/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 ADDRESS OF THE FACILITY)

YMCA of Greater Long Beach- Los Cerritos YMCA 15530 Woodruff Ave., Bellflower, CA 90706

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

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

LIC 613A (8/08

CAUFORNIA DEPARTMENT OF EDUCATION NUTRITION SERVICES DMSION

CHILD AND ADULT CARE FOOD PROGRAM

NSD 3104, PAGE 1 (REV. 04/11)

LETTER TO PARENTS (Child Care Center- Non-Pricing Program)

Dear Parent/Guardian:

The YMCA of Greater Long Beach and its child care centers participate in the Child and Adult Care Food Program (CACFP) offered by the United States Department of Agriculture (USDA) and serves meals at no separate charge to all enrolled children. The reimbursement received from the CACFP helps with our food costs, and therefore, enables us to keep our fees for care as low as possible.

Please help us comply with the requirements of the USDA's CACFP. Please complete,sign,and return the attached Meal Benefit Form to the center as soon as possible. All children enrolled in our center receive their meals at no separate charge,but the determination of eligibility category affects the amount of funding received by our center.This information is necessary to receive the reimbursement for the meals we served to children in our program. If your first language is not English,you have a right to ask us for written or oral translation of these materials free of charge in your native language.

If your household currently receives benefits under the CalFresh Program; the California Work Opportunity and Responsibility for Kids (CaiWORKs); the Kinship Guardianship Assistance Payment Program(Kin-GAP); or the Food Distribution Program on Indian Reservations (FDPIR), you only need to list your current CaiFresh, CaiWORKs, Kin-GAP, or FDPIR case number on the Meal Benefit Form. You must also have an adult sign and date the Meal Benefit Form.

However, if your household does not receive benefits under CalFresh, CaiWORKs, Kin- GAP, or FDPIR, please complete the Meal Benefit Form and make sure you:

provide the names of all household members and their income by source; and have an adult sign, date, and provide the last four digits of his or her social security number, or check the box "Check here if no Social Security Number" if the adult does not have a social security number.

For All Households:

The USDA defines a household as a group of related or unrelated individuals (not residents of a boarding house or an institution) who are living as one economic unit (i.e., sharing living expenses). Therefore, the income reported on the Meal Benefit Form must include the gross income of all members of your household, by source.

The income you report must be the total gross income received last month, listed by

CALlFORNIA DEPARTMENT OF EDUCATION NUTRITION SERVICES DIVISION

CHILD AND ADULT CARE FOOD PROGRAM NSD 3104, PAGE 2 (REV. 04/11)

source for each household member. 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 year'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 receives a higher level of reimbursement for meals served to your child(ren).

Once properly approved for free or reduced-price benefits, whether through income or proof of benefits as supported by a current CaiFresh, CaiWORKs, Kin GAP, or FDPIR case number, your child(ren) will remain eligible for those benefits for 12 months.

Foster Children:

For households with foster children, please contact us for additional information.

Confidentiality of Information on the MealBenefit Form:

We will use the information on the form to decide the level of reimbursement our center is eligible to receive. We will place the Meal Benefit Form in our food program files and keep the information confidential. Only upon your request, will we share the information on your form with officials of other child nutrition, health, and education programs so they can use it to determine benefits for those programs.

Nondiscrimination 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 agency 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 Civil Rights, Room 326 W, Whitten Building, 1400 Independence Avenue, SW, Washington DC 20250 9410, or call202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Thank you for your cooperation. If you have any questions or need assistance in filling out the Meal Benefit Form, please contact:

CENTER REPRESENTATlVE Michele Janssen

TELEPHONE NUMBER

Sincerely,

5/21/14 Date

CAUFORNIA DEPARTMENT OF EDUCATION NUTRITION SERVICES DMSION

CHILD AND ADULT CARE FOOD PROGRAM NSD 3102, PAGE 3 (REV. 04/11)

INCOME ELIGIBILITY GUIDELINES

INCOME ELIGIBILITY SCALE

GROSS INCOME OF HOUSEHOLD

to..ISEHl.D

Sl2E*

WEEKLY EVERY TWO

WEEKS TWICE PER

MONTH

MONTHLY

ANNUAL

FREE REDUCED FREE REDUCED FREE REDUCED FREE REDUCED FREE REDUCED

1

$ 273 $ 388

$ 545 $ 775

$ 590 $ 840 $ 1,180 $ 1,679 $ 14,157 $ 20,147

2

368 524

736 1,047

797 1,134

1,594 2,268

19,123 27,214

3

464 660

927 1,319

1,004 1,429

2,008 2,857

24,089 34,281

4

559 796

1,118 1,591

1,211 1,723

2,422 3,446

29,055 41,348

5

655 932

1,309 1,863

1,418 2,018

2,836 4,035

34,021 48,415

6

750 1,067

1,500 2,134

1,625 2,312

3,249 4,624

38,987 55,482

7

846 1,203

1,691 2,406

1,832 2,607

3,663 5,213

43,953 62,549

8

941 1,339

1,882 2,678

2,039 2,901

4,077 5,802

48,919 69,616 FOR EAG-1 ADWI ONA L FAM LY M EWBER AOO:

$ 96 $ 136

$ 191 $ 272

$ 207 $ 295

$ 414 $ 589

$ 4,966 $ 7,067

* Household is synonymous with family and means a group of related or unrelated individuals who are not residents of an institution or boarding house, but who are living as one economic unit sharing housing and all significant income and expenses.

THIS SCALE DOES NOT APPLY TO HOUSEHOLDS THAT RECEIVE CALFRESH,KIN-GAP,OR FDPIR BENEFITS OR CHILDREN WHO ARE RECIPIENTS OF CALWORKs. THOSE CHILDREN ARE AUTOMATICALLY ELIGIBLE FOR FREE MEAL BENEFITS.

Program Participant Policies and Authorization

Electronic Funds Transfer (EFT) Authorization Form - Child Care Account Holder Information:

Last Name:________________________________________________________ First Name: ____________________________________________ Middle Initial: _____

Home Address: _____________________________________________________________________________________________________________________________________________ Street Unit# City State Zip Code

Home Phone: _____________________________________________________ Work/Cell Phone: ________________________________________________________________

Financial Information (choose one):

Checking / Savings

Financial Institution: _______________________________________________

Account Number (last 4): _________________________________________

Routing Number (last 4):__________________________________________

Date of Draft: 1st

Credit Card Card Type: Visa / MasterCard / AmEx / Discover Last 4 of Card Number: __________________________________________

Expiration Date: __________/____________

Date of Draft: 1st

Electronic Funds Transfer (EFT) is the automated monthly deduction from your credit card, checking or savings account to pay for your Y Program. To authorize the deduction you must complete this Authorization Form. The Y will process your paperwork and notify your bank.

Please Initial:

____ Drafting Date: EFT deductions will only be taken out on the 1st of each month.

____ Cancellations: Program participants may cancel at any time provided that you notify the Y, in writing, 2 weeks prior of

the requested cancellation date. Cancellations may NOT be processed over the phone. I further understand that canceling and/or leaving the program does not relieve me of the responsibility of paying my account in full.

____ Absenteeism: There is no credit for absences or vacations. The program payment is required whether your child is in

attendance or not. ____ Account Changes, Insufficient Funds, Declined and/or Closed Accounts: You must notify the Y of any bank account or

credit card changes, submit the new information and pay any outstanding balances. All bank drafts or credit cards returned due to insufficient funds or any other reason will be charged a $20 processing fee.

____ YMCA Child Care Changes: YMCA Child Care fees are subject to change. The Y will make attempts to notify all program

participants in advance of any adjustments/changes made. I understand the above information and agree to the terms. I understand that I am responsible for delinquent payments and additional charges made to the Y for returned drafts, declined credit cards, insufficient funds, change in account or closed account.

I hereby authorize the YMCA of Greater Long Beach to initiate debits to my checking/savings or credit card account as indicated. I understand it will take 2 weeks to cancel and/or leave the program. All program fees are NON-REFUNDABLE and NON- TRANSFERABLE.

___________________________________________________________ __________________________________

Signature of Account Holder Date

Office Use Draft Amount: Draft Start: Draft End: Staff I.N.:

Dear School Office,

My child, ______________________________, is enrolled in the Los Cerritos YMCA After School Academic Enrichment Program. He/she will (circle one): be picked up each day by the Los Cerritos YMCA van/walk over to the Y program’s classroom promptly when school is dismissed. Please dismiss him/her promptly and remind him/her to go directly to the area

indicated above. If any disciplinary problems arise, please do not keep my child after school. The Los Cerritos YMCA is willing to work with you at his/her after school program if you wish to pursue disciplinary measures.

Thank you,

_______________________________________ Parent/Guardian Signature

(OFFICE COPY)

LOS CERRITOS YMCA 15530 Woodruff Avenue, Bellflower CA 90706 P 562 925 1292 F 562 925 2191

_________________________________________________________________________________________________________________

Dear Teacher,

My child, ______________________________, is enrolled in the Los Cerritos YMCA After School Academic Enrichment Program. He/she will (circle one): be picked up each day by the Los Cerritos YMCA van/walk over to the Y program’s classroom promptly when school is dismissed. Please dismiss him/her promptly and remind him/her to go directly to the area indicated above. If any disciplinary problems arise, please do not keep my child after school. The Los Cerritos YMCA is willing to work with you at his/her after school program if you wish to pursue disciplinary measures.

Thank you,

_______________________________________ Parent/Guardian Signature

(TEACHER COPY)

LOS CERRITOS YMCA 15530 Woodruff Avenue, Bellflower CA 90706 P 562 925 1292 F 562 925 2191

Cut here

LOS CERRITOS YMCA PROGRAM LOCATIONS

Los Cerritos YMCA Los Cerritos YMCA Administrative Office Servicing ABC, Paramount & BUSD 15530 Woodruff Avenue 15530 Woodruff Avenue Bellflower, CA 90706 Bellflower, CA 90706 Hours: Monday through Friday, 9:00 am – 6:00 pm Ph: 562.650.8513 Ph: 562.925.1292 License # 198017013 Fax: 562.925.2191

Stephen Foster Elementary School Intensive Learning Center Servicing Foster Students Servicing ILC Students 5223 E. Bigelow Street 4718 E. Michelson Street Lakewood, CA 90712 Lakewood, CA 90712 Ph: 562.455.5226 Ph: 562.233.7748 License # 198015310 License # 198015673

Esther Lindstrom Elementary School Las Flores Elementary School Servicing Lindstrom Students Servicing Lindstrom, Jefferson & Ramona Students 5900 N. Canehill Avenue 10039 Palm Street Lakewood, CA 90713 Bellflower, CA 90706 Ph: 562.916.5814 Ph: 562.677.6102 License # 198015674 License # 198018579 Mariposa Center (formally Progress Park Plaza East) Servicing Paramount Schools 15500 Downey Avenue Paramount, CA 90723

Ph: 562.925.1292 License # 198019540

2018/2019 PROGRAM FEES

Before School: $174/Month (School Days Only)

Breaks Included-August start only

After School: $302/Month (School Days Only)

$374/Month (Breaks Included)

Before & After School: $477/Month (School Days Only)

$549/Month (Breaks Included) Paramount Kinder PM $377/Month $449/Month

Paramount Kinder AM & PM

(School Days Only)

$554/Month

(Breaks Included)

$629/Month $629 (School Days Only)

(Breaks Included)

Annual Registration: $50/Year

Non School Days and Day Camps

Individual School Holidays: $42/Day

School Breaks / Day Camps:

$210/Week

Annual Registration:

$50/Year