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YWonderful Kids Child Enrichment Center Programs 2021-2022 Enrollment (YWCA Lancaster)

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YWonderful Kids Child Enrichment Center Programs
2021-2022 Enrollment Packet
Child’s Name: ____________________________________________
Parent Name: ____________________________________________
Early Learning Center SDoL School Age Child Care
-FOR OFFICE USE ONLY-
_____ Financial Forms
_____ Contracted Schedule Form
_____ Emergency Contact form-MUST BE COMPLETE
_____ Child Health Assessment
_____ Getting to Know Your Child Form
_____ CACFP Paperwork
Payment Information: _____ Funded Caseworker: _____________________
_____ Self-Pay Record Number: ____-_____________
Checked By: __________________ Sibling name for discount __________________________
-FOR OFFICE USE ONLY-
$__________ Registration
$ __________ Deposit or ELRC Co-pay
$__________ First Week Fee
(Only when program already started)
$__________ Key Cards
(Additional cards- $15.00) Refunded upon card return
$ __________ Total
Receipt Number: ____________________
Cash Check # ________ Money Order #_________ Credit Card # ________ TE #__________
Initials: ______________________________ Date: _________________________________
Start Date: ___________________________ Site Assigned: __________________________
Data entry & Health Assessment Completed
___/____/____ By: ________
Ledger/Tuition/Schedule Completed
___/____/______ By: ______
Payment Option
___Tuition Express Automatic
(Attach form will be processed once file is
entered into Pro-Care)
___ My Pro Care
(www.myprocare.com
use e-mail address
given to center to setup account)
YWonderful Kids
Child Enrichment Center
2021-2022
Child’s Full Name ____________________________________ Start Date:_____________ Site:______________________
Age:__________ Birthdate:______________ Gender:_____ Race:___________ Grade:______
Address ___________________________________________________________________________________
Home Phone # _________________
Annual Household Income: ____$0-$9999 _____ $10,000-$14,999 ____ $15,000-$24,999____ $25,000-$34,999 ____ $35,000-$49,999
____$50,000-$74,999 ___ $75,000-above Number of household members: __________
* Information required for YWCA funding source
Please attach an IEP or IFSP for your child if applicable. Indicate with a check mark one of the following:
_____ I am providing a copy of my child’s IEP/IFSP
_____ I am not providing a copy of my child’s IEP/IFS
_____ This is not applicable to my child
PUBLICITY AND PHOTO CONSENT AND RELEASE
For good consideration, which I hereby acknowledge, I grant to the YWCA Lancaster (“the YWCA”) and its licensees,
successors and assigns (collectively called the “Licensed Parties”) worldwide, absolute, and irrevocable permission to use, reproduce,
print and/or publish my name, likeness, image, voice, and/or appearance (“the Material”) in any media, including but not limited to
photographs, video recordings, audiotapes, digital images in which I may be included intact or in part, composite or distorted in
character, sound or form, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or
reproduction hereof. I agree that the Material may be used for any purpose consistent with the YWCA’s mission, including in new
releases’, advertisements, publications, marketing campaigns, media coverage, videos, web sites, billboards, and any other
promotional or educational materials compiled by or on behalf of the YWCA.
I understand and agree that the YWCA has and will have complete ownership of the Material, and that I will not receive any
compensation for the use of the Material.
I hereby release the Licensed Parties from any and all claims out of their use of the Material as agreed to in this document,
including without limitation any claims based on the right of publicity or privacy, misappropriation or misuse of image, and/or
defamation, including liability by virtue of blurring, distortion, alteration, optical illusion, or use in composite form whether international or
otherwise. I further hereby waive any future right to prior review of any use of the Material.
_______ Permission is granted for photo/video reproduction of my child to be used in YWCA Lancaster publications, social media, and
classroom purposes.
_______ Permission is NOT granted for photo/video reproduction of my child to be used in YWCA Lancaster publications, social media,
and classroom purposes
___________________________________________ _________________________________ ___________
Parent/Guardian’s Signature Child’s Name Date
Please sign and date below that you have received the YWCA Lancaster Child Enrichment Center Parent Handbook.
__________________________________________ _______________
Parent/Guardian’s Signature Date
Child’s Name: _____________________________________________ Site: _____________________________
FINANCIAL INFORMATION
1. At the time of enrollment, a deposit/co-pay equal to the amount of one contracted week is required; in addition to the
Registration and security card fees. The deposit will be credited for the last week of service assuming a two week (14 days)
written notice has been given. These fees are non-refundable.
Please call Early Learning Resource Center at (717) 393-4004 for more information on subsidized care.
2. I understand my bill will be sent weekly via-email to the address I have provided to the YWCA Lancaster. It is my
responsibility to review all correspondence sent from the YWCA Lancaster.
3. I understand that there is an annual non-refundable registration fee for all Programs, and I understand that all Program fees
are based on my contracted schedule. I agree to pay in advance for each week my child is contracted. I also understand that
payment is due the Thursday before the week that service is needed.
4. I understand that billing is based on the full time or part time enrollment for which I have contracted and not for actual
attendance. I understand that no fees will be credited to my account if my child is ill or fails to attend.
5. I agree to pay late fees of $2/minute if my child is not picked up by 5:00 pm.
6. I understand that if my ELRC funding is discontinued I am responsible to pay the entire fee. Per ELRC regulations, if I reach
40 days absent from the program, I am responsible to pay the Center the daily rate for each day absent after the first 40 days.
7. I understand that failure to pay my contracted fees or an unpaid balance will result in my childcare services being interrupted
until said balance is addressed. I understand that there is a $25 charge for all returned checks or declined payments.
Checks are to be made payable to YWCA Lancaster. I understand that it is my responsibility to keep statements, receipts or
canceled checks for income tax purposes. YWCA Lancaster’s Federal ID number is 23-1352609.
PROGRAM INFORMATION
8. All designated individuals understand that my child may not be left on YWCA Lancaster grounds without supervision. I
understand that staff are not prepared to accept my child until 7:00 a.m. I will sign my child in each morning and out each
evening.
9. I understand all forms with the exception of the health assessment must be completed prior to my child starting the program.
10. I understand that I must provide a current health assessment, along with a current vaccination record for my child within 30
days of starting the program. I understand that the YWCA Lancaster reserves the right to suspend care until said assessment
is provided.
11. I understand that my child may not attend the program with any illness that threatens the health of other children. I will be
asked to pick up my child from the program if he/she has a suspected contagious illness.
12. I understand that no medication is administered unless I fill out the medication log completely. Written instructions from a
physician are required for medication administration. All medication must be in the original prescription bottle.
13. I understand that staff must release children to parents unless a court order indicating sole custody is provided to the Program
Director. I also understand that I need to give written permission allowing staff to release my child to any individual other than
the parent/guardian or those persons listed on Emergency Contact form.
14. I understand that all YWCA childcare programs are state licensed programs and that all staff are mandated reporters who are
required to report any evidence of suspected abuse/neglect to ChildLine.
15. I understand that I am responsible for any damages resulting from my child’s actions to either YWCA Lancaster or school
property. The price of any damaged items will be added to my weekly bill.
16. I waive any claim for bodily injury or property damage against any municipalities or boroughs in which YWCA Lancaster
programs participate.
17. In accordance with applicable Federal and State civil rights laws and regulatory requirements, you and your child, as clients of
the YWCA Lancaster, have the right:
-To be provided services by YWCA Lancaster and to be referred for services at other facilities without regard to your race, color,
sexual orientation, religious creed, disability, ancestry, national origin, age or sex.
-Program services shall be made accessible to persons with disabilities through the most practical and economically feasible
methods available. These methods include, but are not limited to equipment redesign, the provision of aids, and the use of
alternative services delivery locations. Structural modifications shall be considered only as a last resort among available methods.
-If you feel you have been discriminated against on the basis of your race, color religious creed, disability, ancestry, national origin,
age or sex, complaints of discrimination may be filed with any of the following:
YWCA Lancaster
Attention: Cathy Lerch
110 North Lime Street
Lancaster, PA 17602
PA Human Relations Comm.
Harrisburg Regional Office
333 Market Street-8
th
Floor
Harrisburg, PA 17101
Department of Human Services
Bureau of Equal Opportunity
Room 223, Health & Welfare
Building
P.O. Box 2675
Harrisburg, PA 17105
U.S. Department of Health and
Human Services
Office for Civil Rights
Suite 372, Public Ledger Building
150 S. Independence Mall West
Philadelphia, PA 19106
18. I will notify the YWCA Lancaster of any change on the enrollment forms and will verify by signature that all information is
correct semi-annually.
_______________________________________ ____________ _________________________ ______________
Primary Parent/Guardian Signature Date YWCA Lancaster Signature Date
________________________________________ ____________
Secondary Parent/Guardian Signature (optional) Date
Please sign after January 2022 Annual Review
I have reviewed my child’s registration and made necessary corrections. _______________________________ ________________
Parent/Guardian Signature Date
CHILD HEALTH ASSESSMENT
LENGTH/HEIGHT
WEIGHT
HEAD CIRCUMFERENCE
BLOOD PRESSURE
IN/CM %ILE
LB/KG %ILE
IN/CM %ILE
(BEGINNING AT AGE 3)
/
PHYSICAL EXAMINATION
=NORMAL
IF ABNORMAL - COMMENTS
HEAD/EARS/EYES/NOSE/THROAT
TEETH
CARDIORESPIRATORY
ABDOMEN/GI
GENITALIA/BREASTS
EXTREMITIES/JOINTS/BACK/CHEST
SKIN/LYMPH NODES
NEUROLOGIC & DEVELOPMENTAL
DATE
DATE
DATE DATE DATE
COMMENTS
HIB
HEP B
VARICELLA
PNEUMOCOCCAL
OTHER
SCREENING TESTS
DATE TEST DONE
NOTE HERE IF RESULTS ARE PENDING OR ABNORMAL
LEAD
ANEMIA (HGB/HCT)
URINALYSIS (UA) at age 5)
HEARING (subjective until age 4)
VISION (subjective until age 3)
PROFESSIONAL DENTAL EXAM
HEALTH PROBLEMS OR SPECIAL NEEDS, RECOMMENDED TREATMENT/MEDICATIONS/SPECIAL CARE
(ATTACH ADDITIONAL SHEETS
IF NECESSARY)
NONE NEXT APPOINTMENT - MONTH/YEAR:
MEDICAL CARE PROVIDER:
SIGNATURE OF PHYSICIAN OR CRNP:
ADDRESS:
PHONE:
LICENSE NUMBER:
DATE FORM SIGNED:
Parents may
write
immunization
dates,
health
professionals
should
verify
and
complete
all
dat
a.
Parents &
Child
Care Providers
fill-in
this
p
art.
Health history and medical information pertinent to routine child care and
emergencies (describe, if any):
NONE
Date of most recent well-child exam:
Do not omit any information. This form may be updated by
health professional. (Initial and date new data.) Child care
facility needs 2 copies.
Allergies to food or medicine (describe, if any):
NONE
CHILD’S NAME: (LAST)
(
FIRST)
PARENT/GUARDIAN:
DATE OF BIRTH:
HOME PHONE:
ADDRESS:
CHILD CARE FACILITY NAME:
FACILITY PHONE:
COUNTY:
WORK PHONE:
PA child care providers must document that enrolled children have received age appropriate health services and immunizations that meet the
current schedule of the American Academy of Pediatrics 141 Northwest Point Blvd., Elk Grove Village, IL 60007. The schedule is available at
< www.aap.org > or Faxback 847/758-0391 (document #9535 and #9807). Print copies provided by DPW have the schedule on the back of the form.
CHILD'S NAME BIRTHDATE
ADDRESS
MOTHER'S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER
ADDRESS
BUSINESS NAME BUSINESS TELEPHONE NUMBER
ADDRESS
FATHER'S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER
ADDRESS
BUSINESS NAME BUSINESS TELEPHONE NUMBER
ADDRESS
EMERGENCY CONTACT PERSON(S)
NAME
TELEPHONE NUMBER WHEN CHILD IS IN CARE
PERSON(S) TO WHOM CHILD MAY BE RELEASE
NAME ADDRESS TELEPHONE NUMBER WHEN CHILD IS IN CARE
NAME OF CHILD'S PHYSICIAN/MEDICAL CARE PROVIDER
TELEPHONE NUMBER
ADDRESS
SPECIAL DISABILITIES (IF ANY) ALLERGIES (INCLUDING MEDICATION REACTION)
MEDICAL or DIETARY INFORMATION NECESSARY IN AN EMERGENCY MEDICATION, SPECIAL CONDITIONS
ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD
HEALTH INSURANCE COVERAGE FOR CHILD or MEDICAL ASSISTANCE BENEFITS
POLICY NUMBER (REQUIRED)
OBTAINING EMERGENCY MEDICAL CARE ADMINISTRATION OF MINOR FIRST AID PROCEDURES
WALKS AND TRIPS S
UNSCREEN APPLICATION
TRANSPORTATION BY THE FACILITY WADING
PERIODIC REVIEW
EMERGENCY CONTACT / PARENTAL CONSENT FORM
CODE CHAPTERS 3270.124(a)(b), 3270.181 & .182, 3280 124 (a)(b), 3280.181 & .182: 3290.124 (a)(b). 33290.181
PARENT'S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT
SIGNATURE OF PARENT or GUARDIAN
DATE
SIGNATURE OF PARENT or GUARDIAN
DATE
Financial Information
2020-2021 YWCA Lancaster Rates
Infant, Young Toddlers, Older Toddlers and Pre
School Full-Time Rates
Infants
$265.00 weekly
Young Toddlers
$265.00 weekly
Older Toddlers
$265.00 weekly
Pre School
$265.00 weekly
Pre
-K Counts Before and After Care Rates
Pre-K Counts
(8AM-2 PM)
Schedule is based on the
a school year calendar.
Pre-K Counts Only
Before Care/ASP Care
7AM-8AM & 2 PM-5 PM
$150.00 Weekly
No extra charge for No School Day
School Year
Program (Grade K-5th)
School Age Enrichment
Program
1
-3 days
4
-5 days
Full Day Care Charge:
(7am
-5pm)
$150.00
$180.00
Child(ren) must be enrolled in Cyber Pathways Academy
with School District of Lancaster to be enrolled in Full Day
Program
ERLC clients will be charged the daily rate for days of absence after the 40
th
absence, starting
the 41
th
day of absence.
ERLC Rates Full-time per day
Infants $53.00
Young Toddlers $53.00
Older Toddlers $53.00
Pre School/Pre-K Counts $36.00
School Age Students $36.00
____________________________ __________________________________ ______
Parent/Guardian’s Signature Date Staff Signature Date
Original- Parent/Guardian’s Copy Copy- Child’s File
Contracted Schedule Form
Child’s Name: _____________________________ Start Date: __________________
Primary Guardian Name: ___________________________ Date of Birth: _________ Social Security #_______________
Secondary Guardian Name: _________________________ Date of Birth: __________Social Security #_______________
Preferred email address for communication from YWCA Lancaster: _______________________________________________
To provide a quality program for your child, program staff must be scheduled appropriately. YWCA staff are scheduled in relation to the
number of children attending the program each day.
Schedules are established for the school year because we plan and staff for each child’s contracted attendance. Parent(s)/Guardian(s)
will be given the opportunity to revise the Contracted Schedule Form, if needed, up to two times per school year with a two weeks’ (14
days) notice before the start of the requested change. All changes must be reviewed for space availability in the program requested and
automatic approval should not be assumed. You must contact the Administrative Team at 717-869-5016 to approve any changes to
your contract.
Your contracted fees do not change for days absent or if you are on vacation. If you find your child will be absent from our
program you will need to contact 717-824-4363 by 9:00AM. This allows us to notify our staff and the secretaries of the respective
schools in a timely manner.
If you need to terminate your care, a two week written notice must be submitted to the Administrative Team prior to the last day of
attendance. If two weeks’ notice is not given, you will be charged two week’s tuition from the time of withdrawal.
I understand my bill will be sent weekly via-email to the address I have provided the YWCA Lancaster. I agree to pay in advance for
each week my child is contracted. I understand that payment is due the Thursday prior to the following week service.
Method of payments:
a. Tuition Express is the preferred method of payment at the YWCA Lancaster. By signing up, your account will always be
current and no late charge will be applied to your account. If funds are not available by Friday, you will receive a $25 service
charge for non-sufficient funds.
b. MyProcare, is free online portal for you to access account information and easily pay tuition. Parents/Guardians can sign in and
make credit card payments manually each week. Go to www.myprocare.com
.
c. Children who are picked up after our sites are closed at 5:00 pm will be charged a late fee of a $2.00 per minute, per child. Late
pick up fees will be entered into the child/ren’s account and must be paid with your next weekly fee payment.
d. If balance is not paid in full weekly, a late payment charge of $10 will be affixed to your account.
Persons My Child/ren Can Be Released To:
The YWCA Lancaster has permission to release my child/ren to those person(s) to whom listed here:
Names:
___________________________________________________________________________________________
Please check the days your child is to be contracted.
Example: If you choose a 2 day minimum, you must identify which two days (example: Monday/Tuesday). Days may not be switched at
any time unless you revise your contract.
____________________________ _____ _____________________________ ______
Parent/Guardian’s Signature Date. Director Signature Date
Total # o
f days contracted_______ Total Weekly Fee: _________Sibling name discount: ____________________
Infant, Toddlers, Preschool, Pre-K Counts Student’s Only Time In AM: _______ Time Out PM: _______
Monday Tuesday Wednesday Thursday Friday
____ EHS Program
____ Pre-K Counts 3
____ Pre-K Counts 4
____ Pre-K C BP/ASP
____ EHS Program
____ Pre-K Counts 3
____ Pre-K Counts 4
____ Pre-K C BP/ASP
____ EHS Program
____ Pre-K Counts 3
____ Pre-K Counts 4
____ Pre-K C BP/ASP
____ EHS Program
____ Pre-K Counts 3
____ Pre-K Counts 4
____ Pre-K C BP/ASP
____ EHS Program
____ Pre-K Counts 3
____ Pre-K Counts 4
____ Pre-K C BP/ASP
Total # of days contracted_______ Total Weekly Fee: _________Sibling name discount: ____________________
School Age Students Only Time In AM: _______ Time Out PM: _______
Monday
Tuesday
Wednesday
Thursday
Friday
___ Full day: 7am-5pm
___Summer Camp
___ Full day: 7am-5pm
___ Summer Camp
___ Full day: 7am-5pm
___ Summer Camp
___ Full day: 7am-5pm
___ Summer Camp
___ Full day: 7am-5pm
___ Summer Camp
Start Date: _____________________
Classroom: _____________________
GETTING TO KNOW YOU FORM
Basic Information
Child’s Name: ____________________________________________________________Birthdate:_________________
What time do you expect to drop off/pick up? _____________________________________________________________
Are there any custody agreements that we should be aware of? ______________________________________________
Illness or Injury Contact
If your child becomes ill, who would you prefer us to call?
Name: ___________________________________________________________Phone Number: ___________________
When do you wish to be informed on a minor injury or illness (i.e. scratch, headache, etc.?)
o Immediately by phone
o At pick up
o Other:_____________________________________________________________________________________
Food and Allergy Information
Food Allergies: ____________________________________________________________________________________
Favorite Foods: ____________________________________________________________________________________
Special Information
What are your child’s strengths? ______________________________________________________________________
_________________________________________________________________________________________________
What skills do you most want to see your child develop? ____________________________________________________
_________________________________________________________________________________________________
What are your child’s favorite activities? _________________________________________________________________
_________________________________________________________________________________________________
Please provide any other information that will be helpful for our staff to know that we did not cover on this paper:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Parent/Guardian Signature: ______________________________________________________Date: ______________
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YWonderful Kids Child Enrichment Center Programs 2021-2022 Enrollment (YWCA Lancaster)

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Completed 17 August 2021

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