Registration

 JOURNEYS OUT YONDER

REGISTRATION FORM

Print and complete this form to register each child for Summer JOY,  After-school JOY, School Break JOY, and/or FIT with JOY.

Choose the program you’d like to register your child for:

1. After-School ($20)/Early Release ($30) Adventures :  

Monday (CRES) __  Tuesday (CCS)__ Wednesday (CRES) __ Thursday (RMS) __

2. School Vacations ($65 per day):

Thanksgiving Break (2015) ____            Spring Break (2016) ____

3. Friday Interest Trips (FIT) for Homeschool ($65 per day)

Date ______________  Activity _______________________

4. Summer JOY ($65 per day) _______/days                                                                                                    Email or call Mary to confirm dates requested

 Name of Child:

1)_____________________________Age:____ DOB:___________

 PRIMARY CONTACT AND RELEASE PERSONS* :

*Write “same” if information is repeated

Parent/Guardian #1:________________________________

Relationship to Child/Children: __________________________

Home Phone: ____________________

Cell Phone:______________________

Home Address:___________________________________________

Email:____________________________________

Parent/Guardian #2:____________________________________________

Relationship to Child/Children: __________________________

Home Phone: _____________________

Cell Phone:_______________________

Home Address:_________________________________________

Email:__________________________________

EMERGENCY CONTACTS (If different from above)

Name #1:___________________________________

Relationship to Child/Children: __________________________

Home Phone: _____________________

Cell Phone:________________________

Home Address:______________________________________

Email:_______________________________

Name #2:________________________________

Relationship to Child/Children: _________________________

Home Phone: _____________________

Cell Phone:______________________

Home Address:____________________________________

Email:_____________________________

* The people above may be contacted and are authorized to pick up my child if there is a medical or other emergency and I cannot be reached.

ENROLLMENT AGREEMENT  

Please initial each section listed below, then sign and date the last page

SECTION 1: TUITION AND FEES

______TUITION CONDITIONS:                                                                                                            1. After-School/Early Release Adventure $20/30 per day.                                               I understand that I am enrolling my child for a total of 14 weeks, from Sept. – Dec., 2015.       2. School Breaks $65 per day                                                                                                           3. Friday Interest Trips $65 per day                                                                                       4. Summer JOY $65 per day

______PAYMENT AND REFUND POLICY: I understand that in order to secure my child’s position, tuition is due and payable 2 weeks after confirmation. If you cancel 7 days prior to the first JOY, you receive a full refund minus a $10.00 administration fee. If you cancel between 7 and 5 days before the first JOY, you receive a 50% refund. If you cancel within 4 days prior to your start date, you will not receive a refund. In the event of last-minute illness (with a Dr. note), 75% of the cost of your class will be credited to any future programs with Journeys Out Yonder, within 6 months of your missed class. If you need a payment plan, please contact Mary at 970-618-1450 or email me at journeysoutyonder@gmail.com.

______LATE OR UNPAID TUITION: If payment is not received when due, I agree to pay a late fee of $25 per week that tuition is late.

______CHARGES AND PROCEDURES FOR LATE PICK-UP: JOY pick-up time is predetermined by parents and Mary, at the Carbondale Branch Library. I understand that if I fail to pick up my child by the predetermined time, I will be charged a late fee of $1 per every minute beyond that time.

______RETURNED CHECKS: I understand a processing fee will be charged to my account for any checks returned for any reason, and I am responsible for this fee in addition to any charges that my bank may charge me.

 SECTION 2: DAILY PROCEDURE

______ILLNESS/MISSED DAYS:  I understand that I will be notified if my child becomes ill during the day, and that I will pick up my child promptly.  I understand that no refunds will be given for my child’s sick days, but students may make up missed days (on a different day or full day) within one month if there is space in another camp.  My child must be free of a fever, cough, vomiting or diarrhea for a total of 24 hours.

______SUNSCREEN USE:  JOY provides sunscreen protection of at least 30 SPF for children, when necessary.  Sunscreen will be re-applied upon manufacturers specifications, after water play, or if outdoors for an extended period of time. Hats and long sleeved shirts and pants are also a safe sun shield.

______MODEL RELEASE: The company, its agents, affiliates, and licensees,

___may  ___may not use photographs, reproductions, images or sound recordings of my child for website or print advertising, publicity or any other lawful purpose.

______STATE INSPECTIONS: I understand that the state child care enforcement and administration agency and the local child protective services has the authority to interview children or staff, to inspect and audit child or facility records, to interview children privately, to observe the physical condition of the children in the program, to make provisions for the independent medical examination by a licensed physician of any child, and to contact and instruct any other appropriate authority to do the same, without prior notice or consent by myself or by JOY.

______ ADMITTANCE:  No child will be discriminated against for disabilities.  All efforts will be made to accept a child into the JOY program, as long as the child and said special needs can be adequately supported.

______WITHDRAWAL FROM PROGRAM by JOY: JOY reserves the right to a two (2) day trial period for each child in any program.  If, in the event that JOY staff determines that JOY’s program is not a good fit for my child, JOY must give me notice by e-mail, phone, or in person one (1) day prior to termination. All fees will be reimbursed.

______WITHDRAWAL FROM PROGRAM by parent: I am allowed to withdraw my child at any time provided all fees and charges are current. I understand all fees are non-refundable in the event of withdrawal.

______MEDIA: I understand that JOY may use educational media (television, video, or computer). I reserve the right to deny this media use.

______EMERGENCY:  In the event of a medical emergency, all proper first aid will be administered; including calling 911 if necessary.  Parents will be notified after the child’s immediate needs have been addressed appropriately.

SECTION 3: HOLIDAYS, ABSENCES AND CLOSINGS

______ABSENCES/VACATIONS: I agree to inform JOY immediately if my child will be absent on any day. I understand that no credits or refunds will be made for occasional absences (i.e. vacation or change of plans).  My regularly contracted tuition is due for all weeks.

______JOY STAFF ILLNESS/FAMILY EMERGENCY: I understand that I am allowing for 3 sick days for JOY staff and that every effort will be made to find a substitute teacher.  If no substitute is found, I can make up the days missed by JOY staff at no extra charge.  I agree to have a back-up plan for my child in the event that JOY staff is absent.  I will be given notice as late as the day before the scheduled care of my child.

______JOY CLOSURE: I understand the company’s intention is to provide programs every day that is in the scheduled contract, but that natural disasters may disrupt programs. I agree, in case of this event, I will continue to be responsible for tuition for up to three business days. Severe weather may require moving class indoors, in a public space.

SECTION 4: PERSONAL BELONGINGS

_____ Children’s belongings must fit into a backpack, and it is the responsibility of each child to carry and care for their own belongings.

_____ VALUABLES: JOY recommends leaving electronics and other valuables at home.  Use of phones for photography and audio recording may be possible.

_____ JOY is not responsible for lost or stolen items.  Small cameras may be a nice addition to capturing the day’s activity.

_____ JOY PROPERTY:  All JOY equipment will remain with JOY staff.

SECTION 5: DISCIPLINE

JOY staff will not use any form of physical punishment or humiliation with a student or about his/her ethnic group or religion.  JOY will not deprive any child of food as punishment.  If necessary, Mary will discuss discipline issues with parents.   

SECTION 6: STATE LICENSING AND OUR POLICIES

______ALL POLICIES & STATE REGULATIONS: I understand the above policies are not all-inclusive, that all involved parties are bound by state regulations and that my enrollment constitutes my acknowledgement of, and agreement to abide by, all Policies and state regulations. To file a complaint against JOY contact Denver Division of Childcare: 1575 Sherman Street, 1st floor, Denver CO 80203 or call 303.866.5948.

______RULES AND REGULATIONS OF FAMILY CHILD CARE HOMES:  I understand that JOY is not required to have a childcare license as per the general rule 7.701.11.b2. Click on the link for information on Colorado’s Rules and Regulations of Family Child Care Homes.

______NO MODIFICATIONS: No terms of this Agreement may be modified or deleted by any person except in cases of policy or rate change by the Director, Mary, in which case all clients must be notified by email.

_____ Immunizations: My child is immunized as per the requirements of his/her school.  All other residents have been given full physicals with healthy results.

_____  JOY is a smoke, tobacco and drug free environment!

______ These policies have been reviewed with me by JOY staff. I understand and will comply with the policies in this contract.  The policies in this contract supersede all other previous documents.

Parent/Guardian Name:_______________________________________

    Signature:___________________________________Date:___________

Director’s Signature:__________________________________Date:___________

 

AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR

I __________________________________ authorize JOY staff to provide medical care to my child(ren), within their medical training.

In the event of an emergency requiring a physician’s care, please provide the following information:

Physician’s Name: ____________________________________________

Phone Number:____________________

Address:_____________________City:______________State:_____Zip:_______

Preferred hospital for emergency:_______________________________________

I (we) _______________________________ and __________________________, do hereby state that I am (we are) parent(s)/legal guardian(s) of _________________________________, a minor child age ______, born on _______________, who resides with me (us) at _______________________________________________________________.

I (we), ________________________________________ authorize, for emergency purposes only, a JOY staff member to transport the above minor by ambulance and consent to any necessary examination, anesthetic, medical diag­nosis, surgery or treatment, and/or hospital care to be rendered to the minor under the general supervision of any physician or surgeon licensed to practice medicine in the State of Colorado. Allergies to drugs, foods or other pertinent information: _______________________________________________________________________________________________________________________________________________________________________________________________.

Parent/Guardian signature: _____________________________________Date: __________

Director Signature: __________________________________________________________

 AUTHORIZATION FOR TRANSPORTATION OR EMERGENCY

JOY staff has permission to transport your child, ____________________________, during programs. For emergency purposes, JOY staff has permission to transport your child, ______________________________, to emergency care, or to evacuate any premises we may be in.

Parent/Guardian Signature:___________________________________Date:___________

Witness:____________________________________Date:___________

PARENTS/GUARDIANS OF CHILDREN AGES 6 AND OLDER: Transportation from school grounds and in the community is only by means of walking, biking and public transportation. Only under certain circumstances, by prior arrangement and agreement, shall a child be transported in Mary’s personal vehicle.

Parent/Guardian Signature:

__________________________________  Date: ___________

Witness:

___________________________________Date: ___________

CHILD PROFILE: Please explain to us about your child to help us meet his or her individual needs. Please invite your child to help you fill this out. Put extra information on back of form if needed.

1. What would you like most for your child to experience with JOY?

________________________________________________________________________________________________________________________________________________________________________________________________

2. What does your child enjoy doing the most? ________________________________________________________________________________________________________________________________

 3. How does your child express anger or react to frustration?

________________________________________________________________________________________________________________________________

 4. Does your child have any particular fears? If so, please explain.

________________________________________________________________________________________________________________________________

5. How does your child react to change (such as being left by parents, starting a new program, etc.)?

________________________________________________________________________________________________________________________________

6. How would you describe your child (personality characteristics)? ________________________________________________________________________________________________________________________________

7. What do you enjoy the most about your child? ________________________________________________________________________________________________________________________________

8. Is there anything else in your child’s experience you would like to tell us so we can better meet his/her needs?

________________________________________________________________________________________________________________________________________________________________________________________________

 I have a clear understanding of and agree to the policies of Journeys Out Yonder

 Parent/Guardian Signature:____________________________________Date:_________

Director Signature:_____________________________Date: _________

 

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