SAC SUMMER REGISTRATION FORM

SUMMER SCHOOL AGE CARE Full Time Fees (Weekly): 1st Child: $172 2nd Child: $126

Part Time Fees (Weekly): 1st Child: $124 2nd Child: $78

*2 Day Fees (available on indicated weeks): 1st Child: $81 2nd Child: $55

RANK SITES #1, #2, #3

CIRCLE DESIRED DAYS M T W

Week 1

JUNE

4 - 8

Week 2

JUNE

11 - 15

Week 3

JUNE

18 - 22

Week 4

JUNE

25 - 29

Week 5

JULY

2 - 6

Week 6

JULY

9 - 13

Week 7

JULY

16 - 20

Week 8

JULY

23 - 27

Week 9

JULY 30

- AUG 3

Week 10

AUG

6 - 10

Week 11

AUG

13 - 17

Week 12

AUG

20 - 21

[ ] BANGOR: M T W

TH F

M T W

TH F

M T W

TH F

M T W

TH F

M T

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

M T W

TH F M T

HOLMEN:

[ ] EVERGREEN

[ ] SAND LAKE

[ ] VIKING (Full-time only)

[ ] HOLMEN LUTHERAN

W

TH F

M T W

TH F

M T W

TH F

M T W

TH F

M T

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

M T W

TH F M T

LA CROSSE:

[ ] EMERSON

[ ] HARRY SPENCE

[ ] LONGFELLOW

[ ] NORTHSIDE

W

TH F

M T W

TH F

M T W

TH F

M T W

TH F

M T

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

M T W

TH F M T

TH F M T W

TH F

M T W

TH F

M T W

TH F

M T

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

M T W

TH F N/A

ONALASKA:

[ ] EAGLE BLUFF

[ ] IRVING PERTZSCH

[ ] NORTHERN HILLS TH F M T W

TH F

M T W

TH F

M T W

TH F

M T

TH F N/A N/A N/A

M T W

TH F

M T W

TH F

M T W

TH F N/A

* First day of program may change due to last day of school **No programs on Wed, July 4

ADVENTURE DAY CAMP - Full-Time Rate Only - 1st Child $179 2nd Child $133 Weeks 1 & 12 Rate: 1st Child $126 2nd Child $82

INDICATE DESIRED WEEKS

BY CHECKING BOXES [ ]

Week 1

JUNE

6 - 8

W - F

Week 2

JUNE

11-15

M - F

Week 3

JUNE

18-22

M - F

Week 4

JUNE

25-29

M - F

Week 5

JULY

2-6

M - F*

Week 6

JULY

9-13

M - F

Week 7

JULY

16-20

M - F

Week 8

JULY

23-27

M - F

Week 9

JULY 30

- AUG 3

M - F

Week 10

AUG

6 -10

M - F

Week 11

AUG

13-17

M - F

Week 12

AUG

20-22

M - W

ADVENTURE DAY CAMP [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]

GRAND FINALE Please select a program by checking a box below:

Program Location: Dahl YMCA [ ] Houser YMCA [ ] Holmen Lutheran [ ] Omni Center [ ]

Dates: Wed, Aug 22 - Fri Aug 24 Wed, Aug 22 - Fri Aug 24 Wed, Aug 22 - Fri, Aug 24 Mon, Aug 20 - Fri, Aug 24

Fees: 1st Child: $124 2nd Child: $ 78 1st Child: $124 2nd Child: $ 78 1st Child: $124 2nd Child: $ 78 1st Child: $172 2nd Child: $126

CHILD’S NAME (first, middle initial, last) Date of Birth: GRADE AS OF 9/1/18: GENDER:

PARENT/GUARDIAN HOME ADDRESS , CITY, STATE, ZIP

HOME PHONE# CELL PHONE # EMAIL ADDRESS

By signing below, I agree to all policies listed in this brochure including any policies regarding fees, deposits, schedule changes and cancellations.

Signature:___________________________________________ Printed Name:_________________________________________________ Date:________________

*

*

*

*

*

2018 Summer School Age & Day Camp Payment Options

Child(ren)’s Name:______________________ Parent(s) Name:______________________

SUMMER CARE PAYMENT METHOD:

Coupon book Weekly Bank Draft Weekly Credit Card Draft YMCA Employee Payroll Deduct

I receive Child Care Assistance from the State. I receive Financial Assistance from the YMCA

BANK DRAFT INFORMATION: VOIDED CHECK REQUIRED

_________________________________________________ _____________________________________________ ____

Parents Name Full Name of Bank

____________________________________________________ _______________________________________________ _________________ ______________________________

Bank Address– City, State, & Zip Code Transit Routing Number Account Number

I authorize you and the financial institution listed to initiate electronic Debit entries to my account to be payable to the order of the La Crosse Area Family YMCA. I agree that your rights in respect to each such check shall be the same as if it were a check drawn on you and signed personally by me. The authority is to remain in effect until revoked by me in writing, and until you actually receive such notice I agree that you shall be fully pro-tected in honoring any such check. I further agree that if any such check be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of membership.

____________________________________________________________ _______________________________ _

Signature Date

Credit Card Number_____________________________________________________________________

Expiration Date____________________ 3 Digit Security Code (Back of Card) _______________

Name on Credit Card___________________________________________________________________

I authorize you and the financial institution listed to initiate electronic Debit entries to my account to be payable to the order of the La Crosse Area Family YMCA. I agree that your rights in respect to each such check shall be the same as if it were a check drawn on you and signed personally by me. The authority is to remain in effect until revoked by me in writing, and until you actually receive such notice I agree that you shall be fully protected in honoring any such check. I further agree that if any such check be dishonored, whether with or without cause and whether intentionally or inadvert-ently, you shall be under no liability whatsoever even though such dishonor results in the forfeiture of membership.

___________________________________________________ ____________________________ ____

Signature Date

CREDIT CARD DRAFT:

DEPOSIT PAYMENT METHOD: Each family pays a non refundable, non transferable $20.00 deposit per week registered, unless they receive County and/or Financial Assistance. (EX: 3 weeks of registration=$60.00 deposit.) The deposite is applied to the rate indicated to the rate indicated on the registration form.

Check Credit Card Cash

In order to receive a refund, cancellation must be made by Monday, two weeks prior to cancellation, State Assisted and

Financial Assistance families will need to pay $20 per week per family to cancel. The $20 registration deposit collected at the

time of registration is non-refundable. All cancellations must be submitted via email to childcarebilling@laxymca.org.

I also have a child in the YMCA Child Care Center

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

For my participation in activities to be conducted by the La Crosse Area Family YMCA, I hereby give my permission and

consent, now and for all time, to the La Crosse Area Family YMCA, the National Council of Young Men’s Christian Associations

of the United States of America (YMCA of the USA) and third parties collaborating with the La Crosse Area Family YMCA

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 the La Crosse Area Family YMCA 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 the La Crosse Area Family YMCA, I authorize, according to this Release, shall belong to the La Crosse Area

Family YMCA, YMCA of the USA and third parties collaborating with the La Crosse Area Family YMCA 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 the La Crosse Area Family YMCA;

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

experience the La Crosse Area Family YMCA will not be subject to any obligation of confidentiality and may be shared with

and used by the La Crosse Area Family YMCA, YMCA of the USA and third parties collaborating with the La Crosse Area

Family YMCA and/or YMCA of the USA;

- the La Crosse Area Family YMCA, YMCA of the USA and third parties collaborating with the La Crosse Area Family YMCA

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 the La Crosse Area Family

YMCA; and

- the La Crosse Area Family YMCA, YMCA of the USA and third parties collaborating with the La Crosse Area Family YMCA

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 the La Crosse Area Family YMCA for any purpose without compensation to me.

I agree that my consent and this release are irrevocable. I hereby release and discharge the La Crosse Area Family YMCA,

YMCA of the USA and third parties collaborating with the La Crosse Area Family YMCA 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 the La Crosse Area Family YMCA as described herein.

Photo/Talent Release:

I hereby irrevocably release, consent and allow the La Crosse Area Family YMCA and its agents to use my

photograph/likeness/voice, as it pertains to my participation with the YMCA, in any manner for promotional efforts without

expectation of any reimbursement in connection with its use.

Child’s Name (printed): __________________________________________________________________________

Age: _________ Address: _____________________________________________________________

I am the Parent/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 Parent/Legal Guardian: ____________________________________________________________ Date: ____________________________

LA CROSSE AREA FAMILY YMCA

PHOTO AND VIDEO/AUDIO RECORDING RELEASE

Child’s Name: ______________________________________

Parent/Guardian Name: ___________________________________

1. I have read through and agree to the policies and procedures listed in the YMCA School Age Care Family Handbook. I

understand that I have access to the Family Handbook as well as the DCF 251- Licensing Rules for Group Child Care

Centers by visiting the YMCA's website at laxymca.org.

2. I understand that participation in this activity or program carries a risk of injury to me as a participant. This risk of

injury can be significant, with potential for permanent disability or death. I agree to follow all rules of the program or

activity, to act within the limits of my ability, to maintain control of myself and all equipment I may use in the activity,

and refrain from acting in any manner that may cause or contribute to injury of myself or any other person. I fully

understand that such rules and equipment cannot completely eliminate the potential for injury.

3. I acknowledge that the La Crosse Area Family YMCA has made a good faith effort to reduce these risks and to make

this program or activity reasonably safe for my participation. I knowingly and freely assume all such risks, whether

known or unknown, which may be connected with or arise out of the program or activity and accept full responsibility

for my participation. If, in the course of my participation in the program or activity, I observe an unusual or significant

hazard, I will remove myself from participation and bring such hazards to the attention of the program or activity

leader immediately.

4. To the fullest extent permitted by law, I hereby forever indemnify, release and hold harmless the La Crosse Area Family

YMCA, its officers, agents, employees, sponsors, and any owners or lessors of premises or property used in this

program or activity, from any and all liability, claims, damages, losses and expenses of any kind (including attorney

fees), for property damage or personal injury, including disability or death, which may arise in any way out of

participation in programs or activities of the La Crosse Area Family YMCA. I expressly indemnify and hold harmless the

La Crosse Area Family YMCA, its officers, agents and employees, from and against all injury, damage or expenses

arising out of its own negligent acts or omission, unless such expense, injury or property damage result solely from

the gross negligence or willful misconduct of the La Crosse Area Family YMCA and/or its agents, officers, or

employees.

I hereby certify that I am the parent or legal guardian for this participant. I do hereby consent and agree to

his/her release as provided above. In addition, I agree on behalf of myself, my heirs and assigns that all the

terms and conditions of this Release, including the indemnity provisions, shall apply in full force and effect to

us as those terms may relate to my minor child’s participation in the programs and activities.

Parent/Guardian Signature: Date:

____________________________________________________________________ _______________________________________________

Family Handbook Agreement and

Release of Liability

SUMMER SCHOOL AGE SWIM LESSONS June 11 - Aug 10, 2018

As a way to promote safety and a life-long love of swimming and other water-based activities, the YMCA

is offering swim lesson sessions that work in conjunction with most Summer School Age locations. By

signing up for Swim Lessons, your student would take a break during the normal pool visits to

participate in small group instruction. Through this offering, parents have a convenient way to further

enrich their child’s summer of learning and achievement!

To Register:

Families may register in-person at the time of Summer School Age registration or by visiting the Front

Desk at either YMCA branch location.

All Swim Lesson Fees must be paid in-full at the time of registration. Financial assistance is available.

Please note that the YMCA has re-categorized Swim Lesson levels. Please see “Swim Lesson

Curriculum” to find the right swim lesson level for your child.

Similar to all other sessions of swim lessons offered through the YMCA, parents may cancel

registration prior to the start of the session in order to receive a voucher to be applied to their

account. No refunds or vouchers will be provided for cancellations after the start of the session.

School Age Site Class Day Class Time Branch Location Session Period

Eagle Bluff Wednesday 1:00 - 1:40pm Houser Y

Start June 11 - 15 (Week 2)

No Lessons July 2 - 6 (Week 5)

End August 6 - 10 (Week 10)

*Swim lessons at these locations

will only run 7 weeks total

(vs. 8 weeks at the other sites).

As a result, swim lessons at

these two sites will have a

pro-rated fee.

Emerson Monday 1:30 - 2:10pm Dahl Y

Evergreen Monday 1:00 - 1:40pm Houser Y

Harry Spence* Wednesday 1:30 - 2:10pm Dahl Y

Holmen Lutheran* Friday 1:00 - 1:40pm Houser Y

Irving Pertzsch Tuesday 1:00 - 1:40pm Houser Y

Longfellow Thursday 2:15 - 2:55pm Dahl Y

Northside Tuesday 2:15 - 2:55pm Dahl Y

Sand Lake Thursday 1:00 - 1:40pm Houser Y

Swim Lesson Fees: $50 for Family Members $66 for Youth Members $132 Non-Members

For additional information on Summer School Swim Lessons, please contact:

Nick MacDonald - Program Support Specialist (nmacdonald@laxymca.org or 608-519-9914)

Nate Torres - School Age Administrator (ntorres@laxymca.org or 608-519-5495)

LESSON SELECTOR

All age groups are taught the same skills but divided according to their developmental milestones.

WHICH STAGE IS THE STUDENT READY FOR?

WHAT AGE GROUP DOES THE STUDENT FALL INTO?

Is the student comfortable working with an instructor without a parent in the water?

NOT YET B / WATER EXPLORATION

Can the student respond to verbal cues and jump on land? NOT YET A / WATER DISCOVERY

Will the student go underwater voluntarily? NOT YET 1 / WATER ACCLIMATION

Can the student do a front and back float on his or her own?

NOT YET 2 / WATER MOVEMENT

Can the student swim 10–15 yards on his or her front and back?

NOT YET 3 / WATER STAMINA

Can the student swim 15 yards of front and back crawl? NOT YET 4 / STROKE INTRODUCTION

Can the student swim front crawl, back crawl, and breaststroke across the pool?

NOT YET 5 / STROKE DEVELOPMENT

Can the student swim front crawl, back crawl, and breaststroke across the pool and back?

NOT YET 6 / STROKE MECHANICS

6 months–3 years

PARENT* & CHILD: STAGES A–B

3 years–5 years

PRESCHOOL: STAGES 1–4

5 years–12 years

SCHOOL AGE: STAGES 1–6

12+ years

TEEN & ADULT: STAGES 1–6

* At the Y, we know families take a variety of forms. As a result, we define parent broadly to include all adults with primary responsibility for raising children,including biological parents, adoptive parents, guardians, stepparents, grandparents, or any other type of parenting relationship.

Onalaska Summer School Care July 9 - July 27, 2018

In order to give students a safe and enriching environment throughout the day, the YMCA is offering both morning and afternoon care to wrap around the summer school day. In partnership with the school district, students will have access to a nutritious breakfast, lunch and afternoon snack . Care is conveniently located right on site at Northern Hills. Due to this special summer school arrangement, the regular all-day program at Northern Hills will not be available.

Care Options for Every Schedule

Example Schedule 1: My child only needs wrap-around care in the morning (630am - 8am) OR the afternoon (2pm-6pm)

Parents can register for YMCA AM Care Only or PM Care Only both at Northern Hills.

Example Schedule 2: My child will be attending a full-day of summer school and needs wrap-around care for both the morning (6:30am - 8am) AND the afternoon (2pm-6pm)

Parents can register for YMCA AM and PM Care at Northern Hills

Example Schedule 3: My child will be attending only a half-day of summer school, but still needs wrap-around care in the morning AND the afternoon. Example: a student is in summer school from 8am-11am but a parent needs care from 7am until 5pm.

Parents can register for the regular full-day YMCA programming at either Eagle Bluff or Irving Pertzsch. Parents are responsible for coordinating transportation with the school district in order to get students to and

from summer school and the full-day YMCA program location. Summer school families will not receive a discounted price for regular full-day care at Eagle Bluff or Irving Pertzsch.

Full Time: 1st Child 2nd Child 3rd Child 4th Child Full-Time Only

Due to the unique nature and limited time frame

of the Onalaska Summer School Care program,

the part-time option is no longer being offered.

AM Only $29 $20 $16 $12

PM Only $67 $48 $38 $29

AM and PM $92 $66 $53 $40

Please indicate the desired care by checking the boxes below.

July 9 - 13 July 16 - 20 July 23 - 27

AM Care (6:30 - 8:00am) [ ] [ ] [ ]

PM Care (2:00 - 6:00pm) [ ] [ ] [ ]

To register, please complete bottom of page.

Child’s Name: ___________________________________________________________

Parent Name: ___________________________________________________________

Weekly Deposit

Similar to the all day summer program,

there is a $20 non-refundable deposit per

family per week. (County and FA families

are not required to pay the deposit.)

Families receiving State Assistance and/or

Financial Assistance are required to pay

$20 per week (up to the cost of care) for

any cancelled week.

Cancellation of any week must be made by

Monday, two weeks prior to the start of

the week of care. All cancellations must

be submitted via email to

childcarebilling@laxymca.org.