HomeMy WebLinkAboutActive Kids Club - Yennadon Registration Package 2017-2018.pdf
Yennadon
Active Kids
Club
September to December 2017
Active Kids Club Registration Checklist
Only 100% complete packages will be accepted for registration of participants. It is
important for licensed programs to have all necessary documents and forms completed
prior to registration. This will also ensure staff are able to plan an appropriate and rewarding
experience for your child at the Active Kids Club program.
Completed registration packages must include the following:
Active Kids Club Program Participant Waiver Form
Tell us About Your Child Form
Immunization Record Declaration Form
Attached Immunization Record
Consent to Disclosure Form
Active Kids Club Guardian Agreement Form with signed initials
Emergency Consent Card
Photo of Participant
Completed Registration Calendar
Credit Card Payment Plan Authorization *if applicable
Attached IEP (School - Individualized Education Program) *if applicable
Attached Custody Agreements or Court Orders *if applicable
Attached Anaphylaxis Forms (available upon request) *if applicable
Attached Care Plan Form (available upon request)* if applicable
Fall Session: September to December 2017
Winter/Spring: January to June 2018
Active Kids Club Registration Information
Registration for participants starts June 9, 2017
6:00 am – 10:00 am at the Greg Moore Youth Centre
Participant packages must be 100% completed in full with all required documents and
pictures attached. Registration is first come, first serve.
Registration for current AKC participants starts November 3, 2017
Currently registered days of care will remain the same. Changes to care are subject to
availability and are on a first come first serve basis.
Registration for new AKC participants starts November 17, 2017
All schools must register on June 9, 2017 at the Greg Moore Youth Centre from 6:00 am –
10:00 am at the Greg Moore Youth Centre. After this time, all registrations must be
submitted in person to the Maple Ridge Leisure Center registration desk. Emailed or faxed
registration packages are not accepted. All packages will be processed according to the
order they were received and are stamp dated and initialed by staff as when they are
received.
Program Inquiries: Registration Inquiries:
Jen Baillie Phone: 604-467-7422
Children’s Programmer Email: registration@mapleridge.ca
Phone: 604-466-4339 Monday to Friday 8am – 7pm
Email: jbaillie@mapleridge.ca Saturday/Sunday 8am – 4pm
*Statutory holidays subject to change hours.
Lara McCreedy
Children’s Programmer
Phone: 604-467-7453
Email: lmccreedy@mapleridge.ca
Active Kids Club Program Participant Waiver
AKC Location: _______________________________________________________________ Participant
Child’s Name: ____________________________ ______________________________________
First Name Last Nam e
Child name preference:_______________________ Age: ___________ Sex: M or F
Birth Date (DD/MM/YYYY):____________________ Care Card #: ____________________________
Child’s 1st Language: _____________________ Child’s 2nd Language: ________________________
Does your child have a life threatening allergy? □ Yes or □ No (check one)
What is the life threatening allergy to? ________________________________________________
*If YES, please complete an Anaphylaxis Emergency Plan form and a Medical Alert Care Plan form. To receive these
forms, please visit the Maple Ridge Leisure Centre Front Desk or email registration@mapleridge.ca
Home Address: ______________________________________________________________________
Postal Code: _________________________ Home Phone : _________________________________
Guardianship
Do you have a custody agreement? □ Yes or □ No (check one)
If yes, please provide a copy of the agreement and written instructions on a separate piece of paper that the Active Kids
Club staff can follow in regards to the agreement.
Parent/Guardian Name(s): ____________________________________________________________
Address (if different from participant home address):______________________________________
City: __________________________________ Postal Code: ________________________________
Phone #’s: (home):# ______________ (Cell): #________________ (Work): # ___________________
(other): #________________ (other): #___________________ Email: _________________________
Emergency Contact
Emergency Contact Name: __________________________________________________________
Relationship to Participant: _________________________________________________________
Phone #(home): ___________________(work): ________________ (cell): ___________________
Emergency Contact (other than above): _______________________________________________
Relationship: ____________________ Phone#: ______________ Alt. Phone # ______________
Office Use Only Enrollment Date Stamp:
Time of Registration:
____________ A.M. / P.M.
Staff Name and Initial:
_____________________
Program Staff Use Only:
Official Start Date: _______________
Official End Date: _________________
Pick Up Authorization
I hereby authorize the following people to pick up my child, at the program location in the event
parent(s)/guardian(s) are unable to and have contacted the Parks & Recreation staff prior to pick
up.
1. ___________________________ Phone Number: _______________________________
2. ___________________________ Phone Number: _______________________________
3. ___________________________ Phone Number: _______________________________
4. ___________________________ Phone Number: _______________________________
Social Information
Please list any siblings that live with your child and also attend the same school or AKC:
Name: ____________________ Relationship: ___________________ Birthdate: ________________
Name: ____________________ Relationship: ___________________ Birthdate: ________________
Name: ____________________ Relationship: ___________________ Birthdate: ________________
Name: ____________________ Relationship: ___________________ Birthdate: ________________
Natural Disaster Information
Out of Province Contact: This person would be contacted in the event of a natural disaster and
there was no local phone service. Please ensure an area code is included with the phone number.
Name: ________________________ Phone number + area code: __ ________________________
Relationship: __________________ Geographical location: _______________________________
Name: ________________________ Phone number + area code: ___________________________
Relationship: __________________ Geographical location: _______________________________
Photos
I, the undersigned, parent/guardian do hereby agree to all the individual(s) names herein to be
photographed and pictures to be used solely for the purposes of promoting City of Maple Ridge
programs.
□ YES or □ NO (check one)
Medical Information
Please ensure all information is completely filled out as this information is used is for staff to
provide medical treatment and information for your child in the event of an illness or injury.
Doctor’s name: _______________________________ Dr. Phone #: ________________________
Does your child: (Identify the child’s name if they have any of the following considerations)
Have any medical conditions (i.e. Asthma)?
□ YES or □ NO if yes please explain below:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Take any medication (include type, dosage, times of self-medication)?
□ YES or □ NO if yes please explain below:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have any allergies (include those to food, medication, sunscreen and environment)?
□ YES or □ NO if yes please explain below:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have any limitations that would mean the child could not participate in activities?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have any fears that leaders should be aware of (e.g. water, bees)?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Medical Release:
It is our policy to notify a parent when a child is ill or needs medical attention. In the event we
cannot contact you and we need to get immediate help for your child, we require a signed
consent to do so.
1. I give consent for my child to be taken to the nearest emergency medical centre by
ambulance when I cannot be contacted.
2. I give consent for my child to receive medical treatment.
Signature of parent/guardian ___________________________ Date: _______________________
Witness: _____________________________________________
Important Information
Does your child know how to swim? □ YES or □ NO (check one)
Current level of swim lesson: ____________
Do you give permission for staff to administer sunscreen to your child?
□ YES or □ NO (check one)
Does your child have an IEP (Individual Education Plan) in School?
□ YES or □ NO (check one)
*If YES, please attach a copy of the IEP to your child’s registration package. This document will help staff
better understand your child’s learning style and how to best communicate with them during the program.
Please list any family information or special instructions the Active Kids Club staff should be
aware of while your child is in care:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please list any other comments or concerns that you have:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I consent to my child’s participation in the Active Kids Club Program. I am aware that there
are risks associated with the participation in the program, including the risk of injury, and I
consent to my child’s participation in spite of such risks. I acknowledge that it is my
responsibility to advise the City of Maple Ridge of any medical or other conditions which may
affect my child’s participation in the Active Kids Club Program and have listed them above. I
have read this form and understand and accept its terms.
Parent/Guardian Signature Printed Name
Date
Personal information requested on this form is collected under the authority of the Freedom of Information and Privacy Act
(Act). Unless otherwise specified, the information gathered will be used by the City of Maple Ridge for pursuant to S.26 of
the Act. Questions about the collection, use, and disclosure of this information should be directed to Laurie Darcus,
Manager of Legislative Services and FOI Head, Clerks Department, City of Maple Ridge, 11995 Haney Place, Maple Ridge,
BC V2X 6A9, ldarcus@mapleridge.ca, 604-467-7482.
Tell us about your child…
We hope that all the children benefit from being in Active Kids Club. By providing us with some
information about your child we can create an environment where your child can have fun, learn
and feel successful in the program.
Child’s Name: ____________________________
Age: ________
The most important thing to know about my child is:
_________________________________________________________________________________
_________________________________________________________________________________
What are your child’s strengths?
_________________________________________________________________________________
_________________________________________________________________________________
What challenges does your child face?
_________________________________________________________________________________
_________________________________________________________________________________
How can we help your child to build on their strengths and overcome any challenges that they
may face?
_________________________________________________________________________________
_________________________________________________________________________________
What are their favourite games/food/things to do?
_________________________________________________________________________________
_________________________________________________________________________________
What are their least favourite games/food/things to do?
_________________________________________________________________________________
_________________________________________________________________________________
What do you hope that your child will learn or accomplish as a participant in the afterschool
program?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Thank you for taking the time to share this information with our staff.
Immunization Record Declaration
Community Care Facilities (CCF) licenses providing care to children or youth are required to
have a copy of the Immunization Record on file for each person in care in the event that an
outbreak of a communicable disease. This information will assist in the immediate
exclusion of those who are unimmunized.
In recent years, CCF’s appear to be having difficulty in acquiring a copy of the Immunization
Record from families and facilities are being coded for being in non-compliance with the
legislation. To obtain a copy of your child’s Immunization Record please contact your local
health authority. The Maple Ridge and Pitt Meadows communities operate under Fraser
Health authority. To obtain a record from this region please call 604-476-7000.
Although Licensing expects a copy of the immunization record to be on file for each person
in care, this form has been provided to:
assist in identifying those children who are not fully immunized and
assist CCF’s in meeting Section 21(1) (a) of the Child Care Licensing Regulation.
To be completed by Parent/Guardian:
___________________________________ __________________
Child’s/Youth’s Name Date of Birth
Complete Immunization:
Written proof of vaccinations attached
Written proof of vaccinations unavailable
Received immunization in:
___________ ______________ __________ ____________________
Year of last Vaccine City Province (If not in Canada, include country)
Incomplete Immunization:
My child has had some vaccinations
My child has no vaccinations
I do not know
Parent’s/Guardian’s Printed Name Date
Parent’s/Guardian’s Signature
Consent to Disclosure of Information
I,
______________________________________________________________________________
Parent / Legal Guardian Name
consent to the disclosure of information regarding my child. This information will be shared
with the AKC staff where my child attends with the purpose of providing safe
Child’s Name: _________________________________________________________________
Date of Birth: ____________________________ Phone Number: ______________________
I consent to the disclosure of:
All Information, this includes any service providers such as School District 42 and Ridge
Meadows Community Services,
All Information with the exception of the following noted below,
The following specific information only,
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature of Person Giving Consent_____________________________________________
Signature of Witness ____________________________ Date _______________________
Active Kids Club Guardian Registration Agreement
Please refer to the Active Kids Club Parent Package regarding the AKC procedures noted below,
AKC Procedures
Page #
AKC Clause Information
Parent /
Guardian
Initial
New Participants 4 Must wait 7 days after submitting a registration package prior to
attending AKC. First come, first serve basis.
Payments 5 Pre-Authorized Visa/MC payments or full payment for the calendar
intake with cash or debit.
Subsidies 6 Must be approved prior to attending or families can pay in full for AKC
and will reimbursed based on approved subsidy amounts.
Changes to
Registration
6 All changes must be made prior to AKC intake cut offs. Changes are
subject to availability.
Refunds 7 No refunds given after registration cut off dates for intakes.
Drop In’s 7 Drop in and Additional days must be given 24hrs prior to the day
attending and is subject to space available. Space is not guaranteed.
Immunizations 8 Each Active Kids Club participant must provide proof of immunization or
provide a signed document for not immunizations.
Health/ Illness 8 Ill children must not attend Active Kids Club. If a child becomes ill
during care a parent will be notified for pick up.
Non-instruction Days 9 Active Kids Club will not operate on Non-Instructional days, holidays or
school breaks.
Late Pick Up 9 Participants must be picked up before 6:00pm. Pick up’s after this time
are subject to $1/minute charges.
Program Cancellation 9 If the Active Kids Club program is cancelled by Parks, Recreation &
Culture, a full refund will be given to families.
Release of a Child 12 Active Kids Club Staff will only release a child to authorized persons on
the Active Kids Club waiver.
Custody Agreements 12 Families with a custody agreement or court order must provide a copy
with their registration package
Emergencies 12 In the event of an emergency and an evacuation is necessary parents
will be notified immediately for early pick up.
Reporting Abuse 14 Any allegations of abuse will be reported to the CCFL Licensing Officer
at Fraser Health.
Duty to Report 14 Any suspected or disclosure of abuse will be reported to the Ministry of
Children and Family Development.
Behaviour Plans 16 Children needing additional support with behaviours in the program
may be placed on a behaviour plan to help set expectations.
Consent to Disclose 16 Active Kids Club staff may communicate with school supports and
teachers to gain additional tools to help support participants.
Violence & Aggression 17 Violent and Aggressive behaviour may result in a child being removed
from the Active Kids Club program.
By initialing and signing this document you, the parent/guardian of the Active Kids Club Program, are agreeing
to adhere by the procedures and policies of the Active Kids Club. Further information regarding these policies
is outlined in the Active Kids Club Parent Package. Please ensure you understand each of these procedures
prior to signing. Failure to follow these expectations and agreements may result in the removal of a child care
from this program.
_________________________________
Parent Name
_________________________________ ________________________________
Parent Signature Date
AKC PAYMENT
PLAN AUTHORIZATION
The Pre-Authorized Payment Plan is an optional payment plan, which provides an
opportunity to make monthly payments for Maple Ridge Parks, Recreation & Culture for the
Active Kids Club.
The Pre-Authorized Payment Plan Agreement must be completed and submitted with a valid
Visa or MasterCard credit card number, which does not expire during the pass term.
Visa/debit is not accepted.
Monthly Payment Amount
Monthly payment amounts will be calculated at the time of purchase and are due on the 1st
of each month. When additional days are added, payments will be processed on that day.
Dishonoured Payments
All dishonoured payments will be subject to a $25 NSF service charge that will be added to
your account with Maple Ridge Parks, Recreation & Culture. This payment is due
immediately following notification from Parks, Recreation & Culture staff. If payment is not
received within 10 days, all services will be cancelled until payment has been received.
Credit Card Information
Name on Card: ________________________________________________________
(please print)
Visa MasterCard
Card #: ________ ________ ________ ________
Expiry Date: _____________
Terms and Conditions
I hereby authorize Maple Ridge Parks, Recreation & Culture to charge my credit card on the
1st day of each month for scheduled payments and any additional days requested.
Authorized Signature: _________________________________________
Dated: ______________________________________________________
Please circle ALL the days you would like your
child to be registered in the program.
There is NO Active Kids Club on the blacked out
days due to holidays.
Office Stamp of Date Summited
Parent Signature_________________________
YENN -Active Kids Club
September to December 2017
Child’s Name:________________________ Parent/Guardian Phone: ____________________
Please note: Non-Instructional Days may change in compliance with School District No. 42
Active Kids Club does not run on the first day of school: Tuesday September 5, 2017
There is no half day AKC during gradual entry for kindergarten children.
Please also note SD42 has not confirmed the half and no school days for parent teacher
conferences for 2017/2018. Once the schools have confirmed calendars will be updated.
Total Number of Days: ______ x $19 Total Number of Days: ______ x $19
Total Number of Half Days: ______ x $27
Total Number of Days: ______ x $19
Total Number of Half Days: ______ x $27 Total Number of Days: ______ x $19
Total Number of Half Days: ______ x $27
If you have any registration questions, please call:
Registration Phone Number 604-467-7422
September 2017
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25 26 27 28 29
October 2017
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23 24 25 26 27
30 31
December 2017
M T W Th F
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4 5 6 7 8
Half day
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30 31
November 2017
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EMERGENCY CONSENT CARD
Name of Facility
Child's Name:
Birthday:
Address:
Child lives
with:
Parent's Name:
Work Phone:
Home Phone:
Parent's Name:
Work Phone:
Home Phone:
Emergency Contact:
Phone:
Child's Doctor:
Phone:
1. Allergies
2. Medications
Card Care #:
Date
Effective:
CONSENT CARD
It is the policy of the Active Kids Club program to notify a parent when a child is ill or needs medical attention.
In the event we cannot contact you and we need to get immediate help for your child, we require a signed
consent to do so.
1. I give consent for my child to be taken to the nearest emergency medical centre when I can not be contacted.
2. I give consent for my child to receive medical treatment.
Signature of Parent/Guardian
Picture
of Child
Witness
Date
Personal information contained on this form is collected under the Community Care and Assisted Living Act
and will be used only for the purposes indicated.