Scya Before & After School Program

SCYA BEFORE & AFTER SCHOOL PROGRAM K – 5 REGISTRATION FORM Participant Information

1. Child’s Name: ______D. O. B. ______School:

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Child’s Address______City______Zip Code______Grade: ______

2. ------

------Child’s Name: ______D. O. B. ______School:

______

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3. Child’s Name: ______D. O. B. ______School:

______

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Parent/Guardian Information:

Name: ______Relationship to Child(ren): ______

Address: ______City: ______State: ______Zip: ______

Phone: ______Cell Phone: ______Parent E-mail: ______

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Address: ______City: ______State: ______Zip: ______

Phone: ______Cell Phone: ______Parent E-mail: ______

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-Any custody issues/ orders of protection in place concerning your child(ren) that we should be aware of? _____ Yes _____No

If yes, please explain and submit a copy of the court order: ______Emergency/Release Information:

Phone: ______Cell Phone: ______Work Phone: ______

------Name: ______Relationship to Child(ren): ______

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Medical Form One for each child is required

If you answer “yes” to any of the following questions a Written Medical Consent Form MUST be completed. The form must be handed in to the Site Supervisor of the program your child will be attending. Parent Initials ______

Allergy Information: Does your child have allergies? Yes _____ No ______If yes please list below.

1. ______2. ______

3. ______4. ______------Medical Conditions: Does your child have any medical conditions? Yes _____ No _____ If yes please list below.

1. ______2. ______

3. ______4. ______------

Medicine Intake: Does your child take any medication? Yes _____ No _____ If yes please list below.

1. ______2. ______

3. ______4. ______------

Does your child have any existing plans such as an IEP, IHP or 504 Accommodation Plan? _____ Yes _____No

If yes, please explain: ______

In the event that my child ______may require medical attention, and I, as well as the emergency contacts listed are unable to be reached, I hereby give consent for the Selden Centereach Youth Association Before and After School Program staff to contact emergency authorities. I understand that my child may be transported to the nearest hospital in which treatment for any condition deemed medically necessary for the welfare of my child will be administered. I am also fully aware that the SCYA Before & After School Program will make every possible attempt to contact me immediately. I understand that the above information is only valid during the time for which my child is enrolled in the SCYA Before and After School Program and this Registration and Medical Form will become void either upon withdrawal from program or end of current school year.

I have read and agree to the above statements and have provided the SCYA Before & After School Program with all the information that I am aware regarding the health of my child.

Signature of Custodial Parent/Guardian: ______Date: ______

SCYA Code of Conduct Agreement

Please read and discuss this agreement with your child before signing.

1. I agree not to leave the SCYA program area unless I am with an adult.

2. I agree to listen to the adult staff members and follow their directions.

3. I agree to respect the personal property of SCYA, the school, and others.

4. I agree to keep my hands and feet to myself. I will not hit, push, punch, pinch,

kick or hurt someone in a mean way.

5. I agree that I must pick up after myself and will put things away.

6. I agree that words should never be hurtful. I will not tease, name call or use bad

language. I will not make fun of anybody.

7. I agree that if I am angry or upset with someone, I will not act out against them;

instead I will find an adult and talk about it.

♦ I understand that if I cannot follow this code of conduct agreement, I may be immediately suspended or dismissed from the SCYA Program. ♦

Signature, Child: ______Date: ______Signature, Parent/Guardian: ______Date: ______Program Site: ______SCYA BEFORE & AFTER SCHOOL HOMEWORK CONTRACT

(Homework/ quiet time is NOT available in the MCCSD Kindergarten Centers)

SCYA schedules approximately 40 minutes of quiet time for homework Monday -Thursday during after care. This schedule may fluctuate due to space limitations, special events, etc. This time is allocated for students to work on homework assignments, to study, and/or to read. During this time, children are directed to work independently. Staff will be available to answer questions regarding homework directions, to provide encouragement, and to oversee that children are quietly on task. If children complete all homework assignments, they will be directed to read/study or participate in staff directed quiet activities. Please note that your child’s participation during scheduled academic time is dependent upon your pick-up time. Together with your child, please review and complete below.

My child and I have agreed that he/she will:

____Make homework assignments his/her first priority during homework time.

____Study during homework time.

____Read during homework time.

____Show SCYA staff my homework. SCYA will check to see that it is legible and that his/her name is on all work.

____Participate in peer assistance/study buddies beyond the designated school/homework time if available.

____Share study materials.

I, ______, agree to provide my child with the specific supplies he/she needs to work on assignments, to review my child’s homework each day and to discuss homework concerns with SCYA and my child’s teacher.

Parent/Guardian Signature: ______Date:______

My child agrees to (check all that applies):

______Try my best to understand my homework assignments.

______Bring books, notebooks, worksheets and other supplies needed for homework, reading and studying. Note: Students cannot return to the classroom after dismissal

______Be quiet during homework/study/reading time. ______Ask for peer assistance.

______Provide peer assistance.

Student Signature:______Date:______

PLEASE READ AND SIGN

IF YOU HAVE ANY QUESTIONS, COMMENTS OR CONCERNS REGARDING THE PROGRAM OR YOUR CHILD DURING THE YEAR PLEASE SPEAK TO THE PROGRAMS SITE SUPERVISOR BEFORE CALLING THE OFFICE.

A FEE OF $1.00 PER MINUTE (PAYABLE AT PICK UP) WILL BE CHARGED FOR CHILDREN PICKED UP AFTER 6:00 PM

ABSOLUTELY NO REFUNDS

CREDITS FOR DAYS PAID WILL ONLY BE ISSUED IN THE EVENT OF A SCHOOL CLOSING, DELAYED OPENING OR EARLY DISSMISSAL.

THERE IS A $30 FEE FOR RETURNED CHECKS. PAYMENTS FOR RETURNED CHECKS MUST BE MADE PRIOR TO THE NEXT CALENDAR MONTH TO MAINTAIN YOUR CHILD’S ENROLLMENT IN THE SCYA BEFORE & AFTERCARE PROGRAMS.

CALENDARS WILL NOT BE ACCEPTED WITHOUT PAYMENT AND ARE DUE ON OR BEFORE THE 15TH OF EVERY MONTH.

CHILDREN MAY NOT ATTEND PROGRAM WITHOUT A CALENDAR OR SCYA OFFICE NOTIFICATION

FOR YOUR CHILD’S SAFETY

PARENTS MUST WALK THEIR CHILDREN INTO MORNING CARE FOR SIGN IN PURPOSES. DO NOT DROP YOUR CHILD IN THE PARKING LOT. ANYONE PICKING UP THEIR CHILD FROM AFTERCARE MUST COME IN AND SIGN THEIR CHILD OUT. CHILDREN ARE NOT PERMITTED TO EXIT BUILDING ON THEIR OWN.

** I have read and understand the above**

______Parent/Guardian Signature Date