san gabriel valleyymca - ymcasgv.org · field trip: knott's berry farm - buena park 100 acts...

San Gabriel ValleyYMCA

YMCA OF ORANGE COUNTY | ymcasgv.org/sdc

San Gabriel Valley YMCA Mauricio Hinjosa (626) 261-1527 sgvymca.org

Week 1 June 11 -15

Theme: Y Nation Focus Activities: Pen Pals-Sending acts of kindness to another YMCA Field Trip: 6/6 Jumpin Jammin - West Covina100 Acts of Kindness: Pen Pals

Week 2 June 18-22

Theme: Exploration Focus Activities: Reduce paper and plastic waste Field Trip: 6/12 Aquariuam of the Pacific - Long Beach100 Acts of Kindness: Bring your lunch in a reusable lunch bag instead of a plastic or paper bag

Week 3 June 25-29

Theme: Innovation Focus Activities: Helping the Homeless Field Trip: 6/20 Scandia - Ontario 100 Acts of Kindness: Make Care Bags For Homeless Individuals

Week 4 July 2-6

Theme: Inspiration Focus Activities: Family Appreciation Field Trip: 6/6 John’s Incredible Pizza – Montclair100 Acts of Kindness: Make a Family Love Box for home

Week 5 July 9-13

Theme: Fascination Focus Activities: Sharing Love with our Furry Friends Field Trip: 7/3 Medieval Times - Buena Park 100 Acts of Kindness: Make Treats to Donate to Local Animal Shelter

Week 6 July 16-20

Theme: Animation Focus Activities: Help our Earth Field Trip: Knott's Berry Farm - Buena Park 100 Acts of Kindness: Collect and recycle bottles

Week 7 July 23-27

Theme: Celebration Focus Activities: Brighten a Senior Citizen’s Day Field Trip: 7/18 Rancho Cucamonga Quakes Game - Rancho Cucamonga100 Acts of Kindness: Decorate Placemats and Make Cards for a Senior Center

Week 8 July 30-Aug 3

Theme: Imagination Focus Activities: Give back to your Community Field Trip: 7/23 Glow Zone - Huntington Beach100 Acts of Kindness: Donate Food to the Food Pantry

Week 9 Jug 6-10

Theme: Illumination Focus Activities: Appreciating our Community Helpers Field Trip: 7/31 On-Site Game Trucks 100 Acts of Kindness: Recognize school personnel and local Firefighters

Summer Day Camp 2018 Weekly Themes

*Field trips will be held on Tuesday of every week, EXCEPT Week 2 (Wednesday) & Week 7(Monday)**Field trips are subject to change

7:00am-8:20am Drop Offs, Good Morning, and Settling in

8:30-8:50am Clean Up & Breakfast

9:00-9:40am Songs, Cheers, and Indoor Group Activity

9:40 - 9:50am Morning Huddle &Group Divisions

9:50-10:45am Indoor Focus Activity #1 - Younger

Outdoor Activity #1 - Older

10:55-11:50am Indoor Focus Activity #1 - Older

HEPA Activity #1 - Younger

11:50 - 12:00pm Clean-Up and Wash-Up

12:00-12:50pm Combine for Lunch

12:50 - 1:00pm Clean-Up & Group Divisions

1:00-1:55pmIndoor Focus Activity # 2 - Younger

HEPA Focus Activity #2 - Older

2:05 -3:00pm Outdoor Focus Activity #2 - Younger Indoor Focus Activity #2 - Older

Wash-Up

Family Style Snack

Groups combine-Individual Choice (Outdoors /Open Centers)

Clean up, Ready for Home

Summer Day Camp 2018 Daily Schedule

3:00-3:10pm

3:10 -3:30pm

3:40 - 5:50pm

5:50 - 6:00pm

Week of: June 11th -15th Theme: Y NATION

Monday Wednesday Thursday Friday Focus Activities:

-Get to Know Me Page-Headbands

EMM & 100 Acts of Kindness

Sending Kindness

Outdoor Activity: -Muscle Man Tag-Roller Ball

Focus Activities: -Sun + Plants -Summer Goals -Name Tape Painting

Tuesday FIELD TRIP:

JUMPIN' JAMMIN' - WEST

COVINA

Outdoor Activity: -Individual Choice (Outdoor & Open Centers

Focus Activities: -Getting To Know About ME - Self Portrait -Dream Catchers-Beach Art

Focus Activities: -Building With Legos -Wacky Sack-Finger Painting

Outdoor Activity: -Human Knot -Chair Basketball

What to bring What to bring Wear Sunscreen

Hat & Closed-Toe Shoes Water Bottle

Wear Sunscreen Hat & Closed-Toe Shoes

Water Bottle

What to bring Wear Sunscreen


FIELD TRIP SHIRT





Week of: June 18th -22nd Theme: ILLUMINATION

Monday Tuesday Wednesday Thursday Focus Activities:

-Rainbow Fish Scales -Seashell Turtle

-DIY Ferris WheelEMM & 100 Acts of Kindness

What Matters MostReduce Paper & Plastic Waste

Outdoor Activity: -Mini Golf

-Bean Bag Tag

KICC & Service Learning

Kids’ Comfort Buckets

Outdoor Activity: -Kickball Basketball -Rainbow Tag

FIELD TRIP : AQUARIUM OF THE

PACIFIC - LONG BEACH

Focus Activities: -Mola Design-Building Towers-Ocean Animal Coffee Filter-Shell Fossils

Outdoor Activity:

-Beachball Volleyball-Beanbag Basketball

Focus Activities: -Goldfish Pong-Sting Rays-Fish Bowl

Outdoor Activity: -Bean Bag Games -Sharks & Minnows

What to bring What to bring What to bring Wear Sunscreen



Water Bottle


Water BottleFIELD TRIP SHIRT


Water Bottle



Summer Day Camp Activity Calendar SAN GABRIEL VALLEY YMCA | 1545 E. Merced Ave., West Covina CA 91791 | Mauricio Hinojosa (626) 261-1527 | sgvymca.org

Outdoor Activity:-Hula Hoop Tag-Capture the Flag

Outdoor Activity: -Parachute Football-Dead Ant Tag

Focus Activities: -Paper Plate Aquarium-The Rainbow Fish

Outdoor Activity:

-Individual Choice (Outdoor & Open Centers

What to bring

Friday

Week of: June 25th -29th Theme: Y NATION

Monday Tuesday Wednesday Thursday Friday Focus Activities:

-Lego Buildings -DIY Ferris Wheel

-Exploring With MapsEMM & 100 Acts of Kindness

Make a Family Love BoxOutdoor Activity:

-Dodgeball -Duck,duck,goose!

Focus Activities: -Create Your Own Slime-Make a Crown-Pictionary

FIELD TRIP: SCANDIA - ONTARIO

Focus Activities: -Master Makers-Tape Art-Lego Castles-Pictionary

Outdoor Activity:

-Alaskan Basketball -Freeze Dance

Focus Activities: - Craft Stick Airplane (S.T.E.M.) - DIY Summer Journal - Chocolate-Covered Banana Pops(HEPA)





Water Bottle



FIELD TRIP SHIRT





Week of: July 2nd -6th Theme: ILLUMINATION


-Stained Glass -Human Sundial

-Shadow Chalk Art EMM & 100 Acts of Kindness


Outdoor Activity: -Relay Races

-Steal The Bacon

FIELD TRIP : JOHN'S INCREDIBLE PIZZA

- MONTCLAIR

Focus Activities: -Rainbow-Glowing Bouncy Balls - My Place in the world (KICC) -Group Project: Self-Portrait Quilt(Continued)

Outdoor Activity: -Prisoner -Drip, Drip, Splash!

Focus Activities: - DIY Constellation Flashlight - Super Hero Comic Book/Strip - Fruit and Yogurt Parfait (HEPA)











YMCA CLOSED

In observance of Independence Day

Have Fun and Be Safe!


Outdoor Activity:

Outdoor Activity:

-Teacher's Carlot-Fruit Basket

Outdoor Activity:


Friday

Week of: July 9th -13th Theme: Y NATION


-‘Getting to Know You’ Game -Self Portraits

-Painting in Salt EMM & 100 Acts of Kindness

Sending KindnessOutdoor Activity: -Blob Tag

-Drip, Drip, Splash!

Focus Activities: -Picture Pieces -Around the World -Walking Water Experiment(STEM)

Tuesday FIELD TRIP:

MEDIEVAL TIMES -

BUENA PARK

Focus Activities: -Make Your Own Slush (Science) -Team Cup Stack -Group Project: Self-Portrait Quilt -Art Effects

Outdoor Activity: -Prisoner -Cross The River






Water Bottle


Hat & Closed-Toe Shoes Water Bottle & FIELD TRIP

SHIRT





Week of: July 16th -20th Theme: ILLUMINATION


-Stained Glass -Human Sundial

-Shadow Chalk Art EMM & 100 Acts of Kindness


Outdoor Activity: -Relay Races

-Steal The Bacon

Focus Activities: -Kaleidoscope -After Image -100 Cup Challenge

KICC & Service Learning Kids’ Comfort Buckets


FIELD TRIP : KNOTT'S BERRY FARM -

BUENA PARK








Water Bottle


Water Bottle & FIELD TRIP SHIRT






Outdoor Activity:



Outdoor Activity:

Friday

Week of: July 23rd -27th Theme: Y NATION


-Picture Pieces -Around the World -Walking Water Experiment(STEM)

Tuesday

Focus Activities: -Coffee Filter Summer Flowers -Field Trip Journal

Outdoor Activity: -Don’t Wake the Dragon -Headman





What to bring


Water Bottle





Week of: July 30th -Aug 3rd Theme: ILLUMINATION


-Stained Glass -Human Sundial -Shadow Chalk Art

EMM & 100 Acts of Kindness What Matters Most

Reduce Paper & Plastic WasteOutdoor Activity:

-Relay Races -Steal The Bacon

Focus Activities: -Kaleidoscope -After Image -100 Cup Challenge

KICC & Service Learning Kids’ Comfort Buckets


FIELD TRIP : GLOW ZONE -

HUNTINGTON BEACH








Water Bottle








FIELD TRIP : QUAKES GAME - RANCHO

CUCAMONGA


Outdoor Activity:


Outdoor Activity:

What to bring



What to bring


Water Bottle

Friday

Week of: Aug 6th -10th Theme: Y NATION

Monday Tuesday Wednesday Thursday Friday Focus Activities:

-‘Getting to Know You’ Game-Self Portraits -Painting in Salt

EMM & 100 Acts of Kindness Sending KindnessOutdoor Activity:

-Blob Tag -Drip, Drip, Splash!

Focus Activities: -Picture Pieces -Around the World -Walking Water Experiment(STEM)

ON-SITE FIELD TRIP: GAME TRUCKS








Water Bottle







Week of: Aug 13th - 17th

Monday Tuesday Wednesday Thursday

What to bring What to bring What to bring


What to bring What to bring

Friday


Outdoor Activity:

SEE YOU NEXT YEAR !!!!!

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized Representative CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE

( ) ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE

FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE

( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE

( ) MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE

( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE

( ) PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST HOME TELEPHONE

( ) BUSINESS TELEPHONE

( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

NAME ADDRESS TELEPHONE RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE

( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE

( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

■ CALL EMERGENCY HOSPITAL ■ OTHER EXPLAIN:

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

TIME CHILD WILL BE CALLED FOR

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

LIC 700 (8/08)(CONFIDENTIAL)

DATE OF ADMISSION DATE LEFT

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE

NAME RELATIONSHIP

STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT CHILD’S NAME SEX BIRTH DATE

FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN? DATE OF LAST PHYSICAL/MEDICAL EXAMINATION

DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)WALKED AT* MONTHS

BEGAN TALKING AT* MONTHS TOILET TRAINING STARTED AT*

MONTHS

PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:

■ Chicken Pox

■ Asthma

■ Rheumatic Fever

■ Hay Fever

DATES

■ Diabetes

■ Epilepsy

■ Whooping cough

■ Mumps

DATES

■ Poliomyelitis■ Ten-Day Measles

(Rubeola)■ Three-Day Measles

(Rubella)

DATES

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

DOES CHILD HAVE FREQUENT COLDS? ■ YES ■ NO HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF

DAILY ROUTINES (*For infants and preschool-age children only)

DIET PATTERN: (What does child usually eat for these meals?)

DINNER

ANY FOOD DISLIKES? ANY EATING PROBLEMS?

IS CHILD TOILET TRAINED?* ■ YES ■ NO

IF YES, AT WHAT STAGE:* ARE BOWEL MOVEMENTS REGULAR?* ■ YES ■ NO

WHAT IS USUAL TIME?*

WORD USED FOR “BOWEL MOVEMENT”* WORD USED FOR URINATION*

PARENT’S EVALUATION OF CHILD’S HEALTH

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

■ YES ■ NO

IF YES, NAME OF DOCTOR: DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

■ YES ■ NOIF YES, WHAT KIND AND ANY SIDE EFFECTS:

DOES CHILD USE ANY SPECIAL DEVICE(S):

■ YES ■ NO

IF YES, WHAT KIND: DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

■ YES ■ NO

IF YES, WHAT KIND:

PARENT’S EVALUATION OF CHILD’S PERSONALITY

HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?

DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?

REASON FOR REQUESTING DAY CARE PLACEMENT

LIC 702 (8/08) (CONFIDENTIAL)

PARENT’S SIGNATURE DATE

WHAT TIME DOES CHILD GET UP?* WHAT TIME DOES CHILD GO TO BED?* DOES CHILD SLEEP WELL?*

DOES CHILD SLEEP DURING THE DAY?* WHEN?* HOW LONG?*

BREAKFAST WHAT ARE USUAL EATING HOURS? BREAKFAST LUNCH DINNER

LUNCH

Start Date: Height Weight Eye Color Hair Color

Mother/Guardian DOB: Father/Guardian DOB:Mother/Guardian Email: Father/Guardian Email:

Days Per Week

Before/After School

(check all that apply) Before After

Winter Break Spring Break Thanksgiving Break

Summer Break Specify weeks if doing weekly rates (do not

enter if utilizing monthly rates)

Grade Level:

Yes No

Yes No

Yes No

Yes No

Yes No

Date of last physical:

Parent/Guardian Signature: Date:


List Child's Name List Parent Name List Address List Phone List email


PARENT DIRECTORY - CHILD CARE To be posted and shared with other families - YES NO

Please sign below to verify that all information above is true and correct. I give permission as listed above (Yes boxes) for my child's information to be listed in the parent directory.

YMCA OF ORANGE COUNTY - REGISTRATION

MEDICAL INFORMATION

Does your child take prescribed medications?

(If yes, fill out special needs intake form)

List any allergies:

Describe the allergic reaction:

Does your have any allergies (food, medication, environment)?

Does your child have any special needs or need any accommodations?

How many in the last year? Please specify any other serious illness or accidents:Does your child have frequent colds? Yes No

Is your child current on the following immunizations: chicken pox, rheumatic fever, whooping cough, mumps, poliomyelitis, Rubeola, Rubella?

Does your child have any of the following: Diabetes, Epilepsy, Hay Fever, Asthma? If yes, please list.

Please provide immunization history or have on file in school office.

Date of last tetanus shot:

CHILD'S HEALTH STATEMENT: As the parent/guardian of the above named child, I, the undersigned, assert that the information above is true and correct and understand that at a YMCA Child Care Program, physical activity is a regular part of the program. To the best of my knowledge, my child is in excellent physical health and needs no restrictions (except what is listed above) from strenuous activity. If I have any questions regarding my child's health, I understand that is my obligation to seek professional medical advice and to inform the YMCA of any restrictions on my child's activities.

MEDICAL AUTHORIZATION: As the parent, authorized representative, or legal guardian, I hereby give Consent to the YMCA to provide emergency dental or medical care prescribed by a duly licensed physician (M.D.) dentist (D.D.S.) or osteopath (D.O.) for the above name child. This care may be given under whatever conditions are necessary to preserve life, limb or well being of the child above.

If yes, what kind: (Permission to medicate form required - available at your child care site)

Side Effects:

Please list any special problems/fears your child may have:

List any foods that are not allowed for your child:

If yes, please explain:

Transitional Kinder

1 2 3 4 5

6 7 8 9 10

School Age (1st - 8th Grade)

CHILD SCHEDULE INFORMATION - CHILD CARE

M T W TH F

SCHEDULE OPTIONS (2, 3 & 5 day plans) BREAK OPTIONS

Kinder Phases Only

Kinder

Child Care Center Attending


Please initial each box below

As the parent or legal guardian of the above named child, I understand, agree to and/or acknowledge the following:

C. If an individual is restricted from signing my child out of the program due to a court-issued restraining order, I must inform the child care director and submit a certified copy of the official court document.

K. I understand that co pays are due on the 1st of the month and any fees not covered by the agency (CHS, Cal Works, OCDE, or any other) becomes my responsibility.

ACKNOWLEDGEMENTS & WAIVERS

L. That the YMCA may terminate my child's enrollment for any of the following reasons:

* Emergency names and phone numbers are incorrect.

* Parent is late picking up child after program center closes or when requested to pick up child.

A. I have received a copy of the YMCA School-Age Child Care Parent Handbook and will comply with the policies set forth. I further acknowledge that I have received copies of the following documents required by the State of California, Community Care Licensing: "Parents Rights", "Personal Rights", "Parent Handbook", "Fees Page" and "Acknowledgement of Receipt of Licensing Reports".

B. That field trips, either by walking or in YMCA vehicles or charter buses, are part of the Child Care program activities. No additional permission slips will be required.

D. That YMCA staff and volunteers are not allowed to babysit or transport my children at any time outside of the YMCA program. E. That should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, for the safety of the child, staff may have no recourse but to contact the police.

* Failure to follow sign in/out policies, including leaving child at center before staff arrive.

* Child leaving program center without authorized written permission.

F. That the YMCA is mandated by state law to report any suspected child abuse or neglect to the appropriate authorities for investigation.G. That per Department of Social Services, Community Care Licensing regulations, my child's file is available for review by DSS and representatives from these agencies may interview my child without prior parental/guardian permission. Law enforcement personnel may also request information in your file and may interview your child if necessary.

H. That program participation requires a YMCA school-age membership to be in good standing and that non-payment of fees will result in my child not being allowed to participate in the program and could result in legal referral with additional costs to myself. I further understand there is an administrative processing fee for any payment returned by my bank or credit card for any reason.I. The YMCA and the staff employed by the YMCA will not become involved in any custodial disputes between parent/guardian. If YMCA document are requested, the court must request them in writing. The staff's responsibility is to provide a safe environment for children.J. I understand that I am required to give 30 days written notice when terminating from the YMCA Child Care Program.

* Failure to notify YMCA that child will be absent.

* Behavior that is destructive to property and/or refusal to replace said property.

* Behavior that is continually disruptive or dangerous to others and/or self.

* Any single incident that is deemed by the center director to be dangerous, harmful or disruptive.

N. Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to release any records necessary for treatment, referral, billing, or insurance purposes. I give permission to the YMCA to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp.

* Harassment, violent behavior or threat of such behaviors against a staff person or other member byparent/guardian or other persons associated to the child.

M. In order to prevent harm, maintain order and safety to campers and staff who are participating in YMCA of Orange County's camping activities, I hereby give permission to the YMCA Camp Director to search my camper’s personal belongings when there is reasonable suspicion that the camper has possession of illegal or dangerous items (i.e. weapons, knives, alcohol, illegal drugs, fireworks or explosives) or the camper seriously violates camp rules and evidence of the infraction can be found through a search of the camper’s personal belongings. To the extent possible, the camper will be present during such a search and the scope of the search will be limited to their belongings.

Account Holders First/LastChild(ren)'s Name(s)

First/Last Daytime Phone Number

Child Care Location

First Payer Amount/Percentage Second PayerAmount /

Percentage

Account Holders First/LasChild(ren)'s Name(s)

First/Last Daytime Phone Number

Child Care Location

Bank Account:

Credit Card Number: Bank Account Number:

Expiration Date: Routing Number:

Billing Information / Electronic Funds Transfer (EFT) Authorization

MULTIPLE PAYING PARTIES SPLITTING PAYMENTS - All charges to take place on the 1st business day of the month

$ or %

This section needs to be cut and shredded after information has been entered

Email Address

Account Holder Signature Date

I hereby authorize the YMCA of Orange County to initiate debits from the Bank/Card account indicated below on the first business day of each month for the monthly child care tuition. I understand and agree to pay a Non-Refundable registration fee upon enrollment/re-enrollment and applicable tuition is also due upon enrollment. Tuition fees will not be refunded without 30-days written notice and I further understand and agree to pay the $25 service charge fee for any and each payment that does not clear my account. Furthermore, I agree to pay a $25 late payment fee for tuition payments not paid in full by the first of the month and understand late payments may result in suspension or termination of child care services.

Email Address

DateAccount Holder Signature

Checking SavingsCredit Card Information

RESPONSIBLE PARTY INFORMATION (The "Responsible Party" is the parent/legal guardian enrolling the child and primarily responsible for payment of fees, signing releases, authorizing individuals to sign in/out the child (on custodial days of attendance) and making any changes to the child's participation in the program.

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTS Child Care Centers

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers. (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are

not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her

needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,

threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing

agency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

Community Care Licensing NAME

ADDRESS

1000 Corporate Center Drive Ste# 200-B

DETACH HERE TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to:

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

LIC 613A (8/08)

(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)

(PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY)

ZIP CODE

CITY OMonterey Park, CA. 91754

AREA CODE/TELEPHONE NUMBER

(844) 538-8766

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISION

CHILD CARE CENTERNOTIFICATION OF PARENTS’ RIGHTS

PARENTS’ RIGHTSAs a Parent/Authorized Representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care.

2. File a complaint against the licensee with the licensing office and review the licensee’s public filekept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against thelicensee made during the last three years.

4. Complain to the licensing office and inspect the child care center without discrimination or retaliationagainst you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the childcare center, provided you have shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: _________________________________________________

Licensing Office Address: _________________________________________________

Licensing Office Telephone #: _________________________________________________

7. Be informed by the licensee, upon request, of the name and type of association to the child carecenter for any adult who has been granted a criminal record exemption, and that the name of theperson may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO APARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVEPOSES A RISK TO CHILDREN IN CARE.

LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)

AC K N OW L E D G E M E N T O F N OT I F I C AT I O N O F PA R E N T S ’ R I G H T S(Parent/Authorized Representative Signature Required)

I, the parent/authorized representative of ________________________________________________, havereceived a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and theCAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

_____________________________________Name of Child Care Center

______________________________________________ __________________Signature (Parent/Authorized Representative) Date

NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given toparent/authorized representative.

LIC 995 (9/08)

For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov

For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

YMCA of Orange County – Sunscreen Utilization Permission Form

Date: ________________________

Name of Child: ________________________

As the parent or guardian of the above child, I give permission for staff at _____________________________ to apply a sunscreen product of SPF 15 or higher to my child, as specified below, when he or she will be engaging in outdoor activities especially during the months of April through September and between the daily times of 10:00 am to 4:00 pm. I understand that sunscreen may be applied to exposed skin, including but not limited to the face, tops of ears, nose, and bare shoulders, arms and legs.

Additionally, I have checked and/or indicated below my directives regarding the type and application of sunscreen:

_______ The staff at ___________________________ may use the sunscreen of their choice (sunscreen must be provided), in keeping with applicable state standards, except for the following (if specified): ___________________________________________________ __________________________________________________.

_______ Only use the following type(s)/SPF of sunscreen: (please provide) ___________________________________________________ __________________________________________________.

_______ For medical or other reasons, please don’t apply sunscreen to the following areas of my child’s body _____________________________________________________________________________________________________.

Parent’s full name (print): _____________________________

Parent’s signature: _____________________________

YMCA OF ORANGE COUNTY

Photo and Video/Audio Recording Release Form

From time to time the YMCA of Orange County takes pictures and/or videos of members/participants while in the normal operation of YMCA programs. Most photos/video are used exclusively within the specific p ogram as postings on bulletin boards, such as to document a service learning project that youth are leading as a part of a designated YMCA activity. Occasionally, the YMCA uses photos, video, and/or audio recordings to share with the community the variety of experiences and opportunities available at the YMCA.

In the event that the YMCA of Orange County uses any photos/video/audio footage for external publication purposes the following release is required.

For my participation (or my child’s) in activities to be conducted by the YMCA of Orange County, I _______________________________, hereby give my permission and consent to the YMCA of Orange County to print, (print legal name)reproduce, edit, broadcast video film, ootage, sound track recordings of me (or my child) for publication, display, sale or exhibition thereof in promotions, advertising and legitimate business uses without any compensation, and/or claim, by me.

I agree that the photograph/video /audio becomes the exclusive property of the YMCA of Orange County and I waive all rights hereto.

I represent that I am over the age of eighteen (18) years and I have read the foregoing and fully understand its contents.

No modifications of this ag eement shall be of any effect unless it is made in writing and signed by all parties in the agreement.

________________________________ __________________________________________________________________________DATE SIGNATURE (Member, Legal guardian)

__________________________________________________________________________________________________________________________________________Child(ren) Name(s)

________________________________ __________________________________________________________________________Phone Number Address

________________________________ __________________________________________________________________________Staff Name Program Name

Release and Waiver of Liability and Indemnity Agreement June 7, 2010

YMCA OF ORANGE COUNTY RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

Adult Member/Participant Name ___________________________ (Please Print)

Child Member/Participant Name ___________________________ (Please Print)

In consideration of participating in any YMCA program or using any YMCA facility, the undersigned agrees to the following:

1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES ANDCOVENANTS NOT TO SUE the YMCA, its directors, officers, employees, andagents (hereinafter referred to as “releasees”) from all liability to theundersigned, his personal representatives, assigns, heirs, and next of kin forany loss or damage on account of injury to the person or property except ascaused by the negligence of the releasees.

2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLDHARMLESS the releasees from any loss, liability, damage or cost they mayincur due to the undersigned’s participation in YMCA programs or use ofYMCA facilities except as caused by the YMCA’s negligence.

THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the laws of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall continue in full legal force and effect.

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made.

_______________________ _________________________ Signature Date

_______________________ _________________________ Emergency Contact Name Emergency Contact Number

YMCA OF ORANGE COUNTY

TRANSPORTATION PASSENGER PROFILE

Participant’s Name: Phone:

Site/Location Name: Branch:

Sex: Male Female Height: Hair Color:

Birth Date: Age: Eye Color:

For identification purposes, please attach a recent photo:

ATTACH PHOTO HERE

SAN GABRIEL VALLEY YMCA – 2018 SUMMER RATE SHEET

(SUMMER LOCATION: MERCED ELEMENTARY

• Registration Fees: $50.00 per child or $100 for family – non refundable

• A sibling discount is available only to the responsible parent, paying full tuition for two or more children. The sibling discount rate is 10% off the oldest child. The multi-child discount is available

for each additional child and Applicable to 3rd party agencies

• When withdrawing from the program, a 30 day written notice is required

• Children must be 4 years and 9 months and entering Kindergarten in the fall school year

• The YMCA is a non-profit organization; we strive to provide eligible members and participants scholarships based on need and availability of funds

• Weekly fees must be paid by the Friday prior to the following week

• Weekly fees not paid by the Friday of the week prior will incur a $25.00 late payment fee and may lead to suspension of services

• Prices are subject to change with a 30 day notice per the discretion of the YMCA

Annual Summer Activity fee of $100 per child due by June 1

SUMMER PRICING REGISTRATION FEES WAIVED FOR PARTICIPANTS ENROLLED PRIOR

TO APRIL 30TH, 2018.

GRADES Kinder-5th

Five Day Rate

Weekly Fee

$140/week

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