ROBERT AND DOROTHY LUDWIG SCHENECTADY JEWISH COMMUNITY CENTER

KID’S TIME

2011-2012 REGISTRATION FORM

* Each form must be accompanied by a NON-REFUNDABLE 10% deposit

* Registration begins Friday, April 1, 2011

* Registration is on a first come, first serve basis

* Registration must occur by Monday, August 22, 2011 to avoid a $35 late charge

Child’s First Name: _____________ Child‘s Last Name: _____________

Please check off the days you would like your child to attend:

____Monday ____Tuesday ____Wednesday ____Thursday ____Friday

Please register my child for the:

_____Full-day program (pick up prior to 6:00 p.m.)

_____Half-day program (pick up prior to 4:00 p.m.)

Please indicate which Kid’s Time site you would like your child to attend:

___ Birchwood ___ Craig ___ Hillside ___Rosendale

Child's Birthday _____/_____/_____ Gender ______Male _____Female

Grade (as of September 2011) _________ School ____________________________

Street Address: ________________________________________________________

City, State, Zip: ________________________________________________________

Home Phone: _____________________________________________

Parent’s Name: ______________________ Occupation: _______________________

Work #: ______________________ Cell #: _______________________

Parent’s Name: ______________________ Occupation: _______________________

Work #: ______________________ Cell #: _______________________

E-mail Address: _____________________________________________________________

Are you interested in serving on a Kid’s Time program committee? Yes ____ No ____

The Kid’s Time program provides services to all children regardless of sex, race, creed, color, religion, handicap or national origin.

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I understand and agree to the following:

1. I will make all tuition payments in a timely fashion as specified: Half the yearly tuition is due in September. The remainder is due in January. Alternate payment plans such as monthly payments are also acceptable. There are no reductions or credits for illnesses, vacations, or school closings.

2. If my child will not be attending Kid’s Time on her/his regular day, I will call the JCC prior to her/his usual arrival time. Failure to do so may result in my child being removed from the program.

3. The Center will provide me with a parent manual detailing Kid’s Time policies.

4. The Kid’s Time program schedule corresponds to the Niskayuna School calendar.

5. If a behavior problem arises, I understand that attempts will be made between the staff, the parent, and the child to rectify the situation. If, after these attempts, the situation continues, I realize that my child may, at the sole discretion of the Kid’s Time program; be temporarily or permanently removed from the program. A discipline policy will be provided to families in August.

6. I must notify the School-Age Director in writing, if I plan to withdraw my child before the end of the school year. If I notify the JCC in writing, I am responsible for all the time my child attended, plus an additional 10% of the yearly fee. If I remove my child and fail to notify the JCC in writing, I will be responsible for all fees.

7. Scheduled Niskayuna School District early dismissal days are included in my tuition fees. On early dismissal days children must bring a lunch. Kid’s Time will not operate on days when school closes early due to inclement weather or any other unforeseen circumstnace. Vacation Days and Snow Days are an additional fee and require pre-registration.

8. I will remit the 10% deposit upon enrollment, which is non-refundable, but is applicable towards the last month of tuition.

9. I understand that there will be a $26 service charge for any checks returned to the JCC.

10. I understand that if I pick my child up late, I will incur the following fees:

4:00 p.m. pick-up - I will be charged $6.90 per hour/per child

6:00 p.m. pick-up- I will be charged $1.50 per minute/per child

11. There will be a $10 processing fee for any changes that you make to your child’s schedule.

12. I understand that the JCC is not responsible for any items lost while at the Kid’s Time program.

13. A copy of this form is available upon request.

I have read and understand this registration form in full and agree to all terms.

________________________ _________________________ ______________

Name of Parent or Legal Guardian Signature of Parent or Legal Guardian Date

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2011-2012 KID’S TIME

CHILD INFORMATION SHEET

CHILD'S NAME (Last) ______________________________(First) ______________________________

GRADE (Entering) ___________ BIRTH DATE ____/____/____ AGE_______ GENDER________

HOME ADDRESS: STREET_______________________________________________________

CITY_________________________________ STATE _______ ZIP__________________

HOME PHONE_______________________ SCHOOL ATTENDING_______________________________

CHILD LIVES WITH: _____Both Parents _____Mother ______Father

Other (PLEASE EXPLAIN) ____________________________________________________________________________________

Parent’s (or guardian) Name: ______________________________________________________________

Occupation _____________________________________________________________________________

Business # _________________________________ Cell #______________________________________

Email: __________________________________________________________________________________

Parent’s (or guardian) Name: ______________________________________________________________

Occupation _____________________________________________________________________________

Business # _________________________________ Cell #______________________________________

Email: __________________________________________________________________________________

STARTING WITH YOURSELF, PLEASE LIST IN ORDER ALL PEOPLE TO CONTACT IN CASE OF EMERGENCY:

1)___________________________/__________________/____________________/_______________/______________

Name Work Phone Home Phone Cell Phone Relationship to child

2)___________________________/__________________/____________________/_______________/______________

Name Work Phone Home Phone Cell Phone Relationship to child

3)___________________________/__________________/____________________/_______________/______________

Name Work Phone Home Phone Cell Phone Relationship to child

4)___________________________/__________________/____________________/_______________/______________

Name Work Phone Home Phone Cell Phone Relationship to child

5)___________________________/__________________/____________________/_______________/______________

Name Work Phone Home Phone Cell Phone Relationship to child

ONLY PEOPLE LISTED ABOVE MAY PICK UP YOUR CHILD

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MEDICAL CONCERNS (ALLERGIES, VISION/HEARING IMPAIRMENTS, MOTOR SKILLS, ETC.): ____________________________________________________________________________________________________________________________________________________________________________________

IS YOUR CHILD ON ANY MEDICATION? _____________ PLEASE SPECIFY________________________

____________________________________________________________________________________________________________________________________________________________________________________

NAME OF ANY MEDICATION TO BE ADMINISTERED WHEN AT CRAIG KID’S TIME (ADDITONAL APPROPRIATE PAPERWORK REQUIRED) PLEASE NOTE AT HILLSIDE, ROSENDALE AND BIRCHWOOD: EPIPENS, INHALERS AND NEBULIZERS ARE THE ONLY MEDICATIONS THAT CAN BE DISPENSED:

__________________________________________________________________________________________

WHEN/AMOUNT: ___________________________________________________________________________

PLEASE LIST ANY SOCIAL CONCERNS: (DEATH, DIVORCE, SEPARATION...) __________________________________________________________________________________________

__________________________________________________________________________________________

PLEASE LIST YOUR CHILD'S INTERESTS AND HOBBIES: __________________________________________________________________________________________________________________________________________________________________________________

PLEASE DESCRIBE ANY PSYCHOLOGICAL CONDITIONS OR FEARS:

_________________________________________________________________________________________

_________________________________________________________________________________________

PLEASE PROVIDE ANY OTHER INFORMATION THAT WILL HELP US CARE FOR YOUR CHILD:

__________________________________________________________________________________________________________________________________________________________________________________

NAME OF PHYSICIAN_________________________________________ PHONE ____________________

NAME OF DENTIST_________________________________________ PHONE _____________________

WHAT WAS YOUR PREVIOUS CHILD CARE ARRANGEMENT (IF NOT KID’S TIME)

_________________________________________________________________________________________

I AGREE THAT IN CASE OF ACCIDENT OR INJURY, EMERGENCY MEDICAL CARE MAY BE GIVEN IN THE EVENT THAT I OR, PERSON(S) DESIGNATED, CANNOT BE REACHED.

I WILL PROVIDE ALL SPECIAL INFORMATION TO ASSIST THE SJCC KID’S TIME PROGRAM IN CARING FOR THIS CHILD (IEP, DIET, HABITS, ETC.)

___________________________ _____________________________ ____________

Name of Parent or Legal Guardian Signature of Parent or Legal Guardian Date

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