2018-2019
C.A.R.E. Program
The Columbia Activities, Recreation and Education program

Child’s Name________________________________________ Grade ________ Teacher ________________

Parents Name________________________________________ Start Date______ School _________________

We welcome you and your child to the C.A.R.E Program at Columbia Elementary School.  Afterschool Child Care services are available to children grades TK through 8.  

PLEASE NOTE: 
THE CARE PROGRAM CANNOT ENROLL YOUR CHILD THE SAME DAY YOUR REGISTRATION IS RECEIVED.

There is a $20.00 non-refundable Registration Fee for new enrolling participants only. 
To secure your child’s enrollment, attach the Registration Fee and payment for your first week to the completed packet and return to the Columbia School District Office.  

For detailed information on our program, policies and fees please refer to the Parent Handbook. 

Please circle the days attending for the first week of care as well as the “Normal Schedule” portion below.

                             DAYS NEEDED               		                                         PRICE
                            FOR 1ST WEEK                                                   $43.00 flat fee per week (per student)
                              M T W TH F                                                 **Plus $20 registration fee PER CHILD

Future weeks will be scheduled using the C.A.R.E. Program Schedule Change/Cancel/Payment form provided in the C.A.R.E. room.

AFTER SCHOOL             DAYS NEEDED (NORMAL SCHEDULE)                 
2:00-6:00 (TK-8 grade)	             M  T  W  TH  F                     	     	

* TIMES AND PRICES ARE SUBJECT TO CHANGE DUE TO SCHOOL SCHEDULE CHANGES

The C.A.R.E. Program

Participant Enrollment Form

Child’s Name ________________________________ M/F _____School___________ Teacher ___________

Mailing Address _______________________________Zip_________   Birth Date ___________ Grade _____

Email Address_________________________________ Ethnicity (optional) ____________________________
□ Contact first?					     Work		       Home                     Cell
Mother’s Name __________________________Phone # __________ Phone # ________Phone#__________

Mother’s Home Address _____________________________________________________Zip_____________
□ Contact first?			            	     Work		       Home                      Cell
Father’s Name __________________________Phone # ___________ Phone # _________Phone#_________

Father’s Home Address ______________________________________________________Zip_____________

ADDITIONAL EMERGENCY CONTACTS – Also authorized to pick up child (MUST BE 18)

1.  Name _______________________________________________   Phone # __________________________

2.  Name _______________________________________________   Phone # __________________________

3.  Name _______________________________________________   Phone # __________________________

 Call Emergency Hospital	    Other	Explain: ________________________________________

ADDITIONAL NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (MUST BE 18)

1.  Name _______________________________________________   Relationship _______________________

2.  Name _______________________________________________   Relationship _______________________

3.  Name _______________________________________________   Relationship _______________________

4.  Name _______________________________________________   Relationship _______________________

5.  Name _______________________________________________   Relationship _______________________

 See custody or legal documents on file.

Signature of Parent or Authorized Representative:

_______________________________________________   Date ____________________________________

Pg. 1

CONSENT FOR EMERGENCY MEDICAL TREATMENT

As the parent or authorized representative, I hereby give consent to the C.A.R.E. Program to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.) Osteopath (D.O.) or Dentist (D.D.S.) for _________________________________________________ (Child). This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of the child named above. 

_______________________________________		________________________
       Signature of Parent or Authorized Representative			 	            Date

Parent’s Employer:   _____________________________________________________________

Employer Phone # ______________________________________________________________
(Important is different from parent’s extension)

HEALTH AND DEVELOPMENT HISTORY

My child has the following food and /or medication allergies: ______________________________________
________________________________________________________________________________________

My child takes the following prescription medications: ___________________________________________
Time of day _____________    Side Effects ______________________________________________

Please explain any special needs or disabilities for your child: ______________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Pg. 2

The C.A.R.E. program

Permission to Share Information Form

In order to provide the best possible care for your child, please complete the following:

I, _______________________________ (parent/guardian) authorize the C.A.R.E. program staff to seek and/or share important information from/with the appropriate School District personnel which is pertinent to the well being of my child, ________________________(child name) during his/her time spent in the C.A.R.E. Program at Columbia School.  The information discussed will be kept confidential and may include but is not limited to:
	
-	Homework
-	Discipline
-	Health Issues
-	Child’s Welfare
-	I.E.P. (Individual Education Plan) Information

__________________________________			
Child Name

__________________________________
Parent Name	

__________________________________		__________________________
Parent Signature					           Date

                                                                                                                                               

                                                                                                                                                                                                   Pg. 3 

SITE COPY

Child Name:

C.A.R.E. Program

1)    Parents are responsible for informing the Columbia District office staff of any changes in their child’s attendance schedule, address, phone, work, or emergency telephone numbers, etc.
2)    “Schedule Change/Cancel/Payment” forms must be filled out correctly and completely with the child’s name and days of planned attendance clearly marked according to the instructions on the Form. When a “Schedule Change/Cancel/Payment” form is not submitted by payment day, your child will be scheduled and charged for 5 days. Once charges have been posted to your account for the upcoming week they will not be removed. 
3)    Please use the “Schedule Change/Cancel/Payment” form to notify the District office/C.A.R.E. staff of any changes to upcoming schedules.
4)	There is a Flat fee charge per week. You may choose a varying schedule, Monday through Friday. Without a written doctor’s note, weekly charges will remain the same regardless of absences, illness, vacations, etc.  The Columbia School District Office must be notified before the end of each week your child is absent due to custody reasons.
5)	The Columbia School Office requires prior notification if your child is to be absent for any reason.  Two weeks’ notice of withdrawal along with payment for those weeks is required when the child care site is maintaining a waiting list for enrollment. 
6)	Avoid the $5.00 “Overdue Balance” fee by making payments no later than Wednesday the week before attendance. (See Parent Handbook) All child care fees are due in ADVANCE, by check, cash or money order made out to Columbia School. Accounts that are past due for two weeks may be suspended until paid in full-NO EXCEPTIONS.
7)	A $25.00 fee will be charged for each check returned from your bank. 
8)	Each family may receive an Account History Report if requested. All account discrepancies must be adjusted within 30 days of receipt when there are any questions regarding charges and /or payments, or we will accept your statement as being correct. All accounting concerns must be directed to Bridget in the Columbia School District Office.
9)	We will provide a year-end report of all payments made on your account. These will be available the last week in January.
10)	When possible, you will be notified 30 days before fee changes are implemented.
11)	Children coming directly from school dismissal will be signed in by child care staff and only an authorized adult (must be 18) with identification will be permitted to sign them out upon leaving.  On days of full-day care (7:30am - 6:00pm) parents are to walk their children into the classroom to sign them in upon their arrival.
12)	In the event the C.A.R.E. program must be closed due to inclement weather, you will be notified via the radio or autodial.  If your child’s school is closed, so is the after school program.
13)	The C.A.R.E program is closed for the following holidays:  New Year’s Eve, New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving and the day after, Christmas Eve and Christmas Day.  The C.A.R.E. program will be closed all SIP and all School holidays.
14)	The center will close promptly at 6:00 p.m.  There is a late pick-up fee of $1.00 for every 1 minute you are late after the first 5 minutes picking up your child.  In the event we cannot reach you or an authorized person by 7:00pm, the Shasta County Sherriff/ Child Protection Agency will be called.
15)	Medications can only be given with specific written instructions from the physician.  Directions on the bottle must include dosages, times and dates that medication is to be administered.  Children cannot attend if they are ill, you must make alternate arrangements for child care. (See the Health Policy in your Parent Handbook).
16)	The after school staff will act according to his/her best judgment in any emergency requiring medical care.  Parents will be notified immediately and are responsible for the cost of all medical care.
17)	If deemed necessary for the safety of your child or others, the C.A.R.E. program staff has permission to restrain and/or physically remove a child from an unsafe situation.  Parents will be notified if this circumstance occurred.
18)	Nutritious snacks are provided daily.  Please advise us of any special dietary needs using the forms provided.
19)	Photographs or likeness or voice of your child may be used in promotional material such as brochures, newspaper, or radio releases without reimbursement for such photographs or promotions.
The C.A.R.E. program is a non-profit child care center.  The operation of our program is overseen by the Columbia School District Board of Directors.  For the names and addresses of current members, please contact the Child Care Director.

C.A.R.E. Program WAIVER:
All of the information contained on these forms required by the C.A.R.E. program, is as accurate as possible.  I agree to allow C.A.R.E. to use photos taken of my child for promotional materials.  I also agree to abide by the rules of the C.A.R.E. program in regard to my child being in their program.  The C.A.R.E. program reserves the right to dismiss a child for continual behavioral problems.  I understand that the C.A.R.E. program carries no medical insurance, and I, intending to be legally bound hereby for myself, my heirs, executors, and administrators, waive and release all rights, claims and damages that my son or daughter may incur against the C.A.R.E. program, and its representatives, successors, and assigns, for any and all injuries suffered by my son or daughter in this program. I also understand that all items brought from home must be clearly labeled with my child’s name and that the C.A.R.E. program is not responsible if these items become lost, stolen, or damaged.
I HAVE RECEIVED MY COPY OF THIS DOCUMENT AND PARENT’S HANDBOOK.  MY SIGNATURE ACKNOWLEDGES MY UNDERSTANDING OF AND AGREEMENT TO THE C.A.R.E. PROGRAM CHILD CARE POLICIES.

____________________________________________                        _____________________________
	   Parent or Guardian Signature					               Date
____________________________________________                        _____________________________ 
                          Staff Signature                                                                                                                  Date                                                             Pg. 4
                                 
                                           PARENT COPY

Child Name:

C.A.R.E. Program

1)    Parents are responsible for informing the Columbia District office staff of any changes in their child’s attendance schedule, address, phone, work, or emergency telephone numbers, etc.
2)    “Schedule Change/Cancel/Payment” forms must be filled out correctly and completely with the child’s name and days of planned attendance clearly marked according to the instructions on the Form. When a “Schedule Change/Cancel/Payment” form is not submitted by payment day, your child will be scheduled and charged for 5 days. Once charges have been posted to your account for the upcoming week they will not be removed. 
3)    Please use the “Schedule Change/Cancel/Payment” form to notify the District office/C.A.R.E. staff of any changes to upcoming schedules.
20)	There is a Flat fee charge per week. You may choose a varying schedule, Monday through Friday. Without a written doctor’s note, weekly charges will remain the same regardless of absences, illness, vacations, etc.  The Columbia School District Office must be notified before the end of each week your child is absent due to custody reasons.
21)	The Columbia School Office requires prior notification if your child is to be absent for any reason.  Two weeks’ notice of withdrawal along with payment for those weeks is required when the child care site is maintaining a waiting list for enrollment. 
22)	Avoid the $5.00 “Overdue Balance” fee by making payments no later than Wednesday the week before attendance. (See Parent Handbook) All child care fees are due in ADVANCE, by check, cash or money order made out to Columbia School. Accounts that are past due for one week may be suspended until paid in full-NO EXCEPTIONS.
23)	A $25.00 fee will be charged for each check returned from your bank. 
24)	Each family may receive an Account History Report if requested. All account discrepancies must be adjusted within 30 days of receipt when there are any questions regarding charges and /or payments, or we will accept your statement as being correct. All accounting concerns must be directed to Bridget in the Columbia School District Office.
25)	We can provide a year-end report of all payments made on your account. If requested.
26)	When possible, you will be notified 30 days before fee changes are implemented.
27)	Children coming directly from school dismissal will be signed in by child care staff and only an authorized adult (must be 18) with identification will be permitted to sign them out upon leaving.  On days of full-day care (7:30am - 6:00pm) parents are to walk their children into the classroom to sign them in upon their arrival.
28)	In the event the C.A.R.E. program must be closed due to inclement weather, you will be notified via the radio or autodial.  If your child’s school is closed, so is the after school program.
29)	The C.A.R.E program is closed for the following holidays:  New Year’s Eve, New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving and the day after, Christmas Eve and Christmas Day.  The C.A.R.E. program will be closed all SIP and all School holidays.
30)	The center will close promptly at 6:00 p.m.  There is a late pick-up fee of $1.00 for every 1 minute you are late after the first 5 minutes picking up your child.  In the event we cannot reach you or an authorized person by 7:00pm, the Shasta County Sherriff/ Child Protection Agency will be called.
31)	Medications can only be given with specific written instructions from the physician.  Directions on the bottle must include dosages, times and dates that medication is to be administered.  Children cannot attend if they are ill, you must make alternate arrangements for child care. (See the Health Policy in your Parent Handbook).
32)	The after school staff will act according to his/her best judgment in any emergency requiring medical care.  Parents will be notified immediately and are responsible for the cost of all medical care.
33)	If deemed necessary for the safety of your child or others, the C.A.R.E. program staff has permission to restrain and/or physically remove a child from an unsafe situation.  Parents will be notified if this circumstance occurred.
34)	Nutritious snacks are provided daily.  Please advise us of any special dietary needs using the forms provided.
35)	Photographs or likeness or voice of your child may be used in promotional material such as brochures, newspaper, or radio releases without reimbursement for such photographs or promotions.
The C.A.R.E. program is a non-profit child care center.  The operation of our program is overseen by the Columbia School District Board of Directors.  For the names and addresses of current members, please contact the Child Care Director.

C.A.R.E. Program WAIVER:
All of the information contained on these forms required by the C.A.R.E. program, is as accurate as possible.  I agree to allow C.A.R.E. to use photos taken of my child for promotional materials.  I also agree to abide by the rules of the C.A.R.E. program in regard to my child being in their program.  The C.A.R.E. program reserves the right to dismiss a child for continual behavioral problems.  I understand that the C.A.R.E. program carries no medical insurance, and I, intending to be legally bound hereby for myself, my heirs, executors, and administrators, waive and release all rights, claims and damages that my son or daughter may incur against the C.A.R.E. program, and its representatives, successors, and assigns, for any and all injuries suffered by my son or daughter in this program. I also understand that all items brought from home must be clearly labeled with my child’s name and that the C.A.R.E. program is not responsible if these items become lost, stolen, or damaged.
I HAVE RECEIVED MY COPY OF THIS DOCUMENT AND PARENT’S HANDBOOK.  MY SIGNATURE ACKNOWLEDGES MY UNDERSTANDING OF AND AGREEMENT TO THE C.A.R.E. PROGRAM CHILD CARE POLICIES.

____________________________________________                        _____________________________
	   Parent or Guardian Signature					               Date
____________________________________________                        _____________________________ 
                          Staff Signature                                                                                                                  Date                                                             Pg. 5