1. Healthcare

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FOR YOUTH
OEI,ELOPiiEI'ff
FOR
SOSAL NESPONSIBILITY
BREAK
FUN CLUB
ROCKIAND COUNT YMCA
Available to all students in grades K-5. NYS licensed. Carefully planned indoor and
outdoor activities, supervised by trained YMCA staff
.
.
Crafts, sports, daily swimming
$55 per day YMCA member
WHEN:
TIME:
February
/ $70 per day general public
l5-20th
8:00 to 6:00pm
For more information contact:
Alyssa at [email protected]
Kasey at [email protected]
@
FORHEALTHY LMN6
FUN CLUB
WH EN?
February Break
2/t6, 2/L7, 2/LB, 2/L9 and 2/20
The hours of operation are B:00am to 6:00pm.
wHo?
Students in Grades K through
5
WHERE?
Rockland County YMCA
35 South Broadway
Nyack, NY 10960
WHAT?
Our Fun Club is a carefully planned, flexible program in a supervised environment to care for
children of working parents.
licensed and have a professionally trained staff.
York
State
We are New
We provide indoor and outdoor activities, weather permitting.
and activities'
we provid"
' 'fi'J"otl";t'J*i;'ff1,L:
TUITION
The cost of the program is $65 per day for members and $70 per day for non-members.
Full payment is due by February 9, 2015.
first
come, first serve basis. A minimum of 12 children per day will be
is
on
a
Club
The Fun
required to operate Fun CIub. If the enrollment is not sufficient (by 2/2) and we decide to
cancel, we will refund your full tuition.
(MEMBERSHIP IN THE YMCA IS OPEN TO ALL WITHOUT REGARD TO ETHNIC ANd/OT RELIGIOUS STANDING)
We reserve the right to cancel the program due to an emergency situation. A decision will be made by
7:30 AM. We will make every effort to contact parents. Our utmost concern is for the safety of all the
children, parents and staff.
THERE ARE NO REFUNDS OR CREDITS.
FURTHER INFORMATION
(Ba5)-643-3056,
email: [email protected]
Please contact Alyssa at
or Kasey at (845)-727-0L65, email : [email protected]
Thank you!
w
ehe#m
%Y
2OL5 Rockland County YMCA
eh-Gm
February Fun Club
School Child Attends
Child's Name
Days Attending
2
/ t6
2014-20L5 School Year
Home Address
_2
/
L7
_2
/
LB
_2
/ le
_2
Grade_Age_Birthdate
Gender
State
Street
Home phone
/ 20
Zip
Email Address
Mother's Name
Cell Phone:
Work Phone:
Father's Name
Cell Phone:
Work Phone:
If parents are separated, please provide the following information of the non-custodial parent.
Name
Address
City
State
ZiO
Work Phone:
Cell Phone:
Website
How did you hear about us?
(please circle one)
Email Flyer
Other
Need further information?
PIease contact Alyssa at (Ba5)-643-3056, email: [email protected]
or Kasey at (845)-727-0L65, email : kedwards@rocklandymca,org
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tlte Xffi_
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PrcK uP AUTHoRTZATToN
YMCA POLICY: Your child will not be released into the custody of any person that
you have not specified below as an authorized pick-up person, including other
family members. Telephone approval is not acceptable,
Below please print the full names of any and all persons you authorize to pick-up your
child/children. Please list your and your spouse's names first.
My child/children
may be picked up only by the following:
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
and agree that once my child/children are released into the custody of any of the
above individuals, the YMCA and its staff no Ionger have any responsibility for my child/children.
I understand
Parent/Guardia n Sig nature
PERMISSIONS and REMINDERS
PERMISSIONS
Yes, I give the Rockland County YMCA permission to take photographs or videos of my
-child/children participating in programs and activities. These photographs and/or videos may
appear in newspapers/ magazines, brochures, the Rockland County YMCA After School Facebook
page or other publicity matters. Photographs and/or videos of your child/children will be used
without compensation.
_
If
Yes, I give permission for my child to participate in the daily swim provided by the program.
known, please provide your child/children's swim levels below:
Child's name
Level
Child's narne
Level
Child's name
Level
Parent/ Guardian Signature:
Date:
REMINDERS
.
extreme nature of allergic reactions to nuts, peanuts and tree nuts (and any
products containing these nut products) in some children, the Rockland County YMCA Fun
Club PROHIBITS nuts and/or foods containing nut products on property.
.
Please complete all of the information regarding allergies and emergency information on
the following page of this registration packet.
Due to the
NEWYORK STATE
OFFICE OF CHILDREN ANP FAMILY SERVICES
PHOTO OF GHILD
(Optional)
Does your child have anY allergies?
lf Y'es, what is your child allergic to?
Children who have special health care needs are those who have chronic physical, developmental'
Uenavioral or emotional condition* expected to last '12 months or more and who also require health'and ...
of a type beyond thai required by children generally. lf your child does have special health
*f
^t"O
please
discuss these with your child'care provider.
care needs
ii*i."s
Child's Source of Medical Care/Primary'Care Physician's Name:
Child's Source of Dental Care/Dentist's Name:
Name of Medical Care Facility/Hospiial:
Would you like information on Chitd Health Plus?
E Yes E
No
TELEPHONE NUMBER DURING CHILD CARE
OTHER TELEPHONE NUMBER (check tvpe)
DATE OF DISCHARGE:
DATE OF ACCEPTANCET
E Parent
NAME OF PERSON APPLY1NG FOR CHILD:
!
Guardian
n Garetaker X Rehtive
n otneror pEnsoN LlsrED ABovE: (lF DIFFERENT FRoM GHILD'S):
aiong-ss
o
a
E
6
e
E
6
o
6
o
6
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o
6
o
E
o
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AGREEMENTS
facility and have been advised of the policies re-gardinqadminislration of
I consent to the enrollmeni of the child listed above in this
iacilrtv, and the office of children and Familv senrices reEulations
medicarions, fees, transportati;;;;;ih;;;;i;.r proriu*o uy i"tre
under which it operaies,
(i'e' library, park and playground) away from the facility under proper
I give consent for my child to take part in neighborhood kips
supervision.
child.
EUo
EYes
Et'to
special
ohild's5 rpEurer
prov:ded infonnation
sn mv Gllrrs
lnlormallon on
I have provided
;;;;iL;;#;.rnj
tJ.Jri.t tt,i
I aoree to review and update ihis
sTcNATURE
e
o-
ocrs-Loss-uzgz
EYes
and /or surgical care and hospitalization advised
ln case of accident or injury, I authorize any and all emergency medical, dental,
for the proper health and well-being of my
card)
necessary
of
this
other
side
by the physicians, surgeon or hospital (llsted on the
(1/2005) REVERSE
-
FARENT
oRFrnsot't(s)
needs-(All:fi11:
rlqeqr
\nnErurver
* - -
Plil Piti:1qt*"t:liTMedical
facitity in properry carins for my chitd tn case of an emersr ;nar.
info*"tion *henuver
leeellv
a
"h"'g"
ot'
lnforHatl:l
tr ved
to the provider'
il No