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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 M T W Th F 6 7 8 10 12 13 14 15 18 19 20 21 22 25 26 27 28 29 October 2017 M T W Th F 2 3 4 5 6 9 10 11 12 13 16 17 18 19 20 23 24 25 26 27 30 31 December 2017 M T W Th F 1 4 5 6 7 8 Half day 12 13 14 15 18 19 20 21 22 25 26 27 28 29 30 31 November 2017 M T W Th F 1 2 3 6 7 8 9 10 13 14 15 16 17 20 21 22 23 24 27 28 29 30 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.