Emergency Childcare | Crossroads YMCA

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PROGRAM INFORMATION
Our program is available Monday through Friday 6:30am-7:30pm at Griffith YMCA

Email *

I need care each day from: *

Emergency Personnel Occupation *

Child's Full Name *

Street Address: *

City *

Home Phone *

Cell Phone *

Child's Date of Birth *

YYYY

Does your child have any allergies, dietary restrictions, physical conditions, or special behaviors we should know about? Please list:

Are there any special circumstances that we need to know about to better serve your child? Please list:

Is the child is toilet trained? *

Yes

Parents must provide diapers/wipes for those that are not toilet trained, and also have an extra set of clothes.

Parent / Guardian Name (1): *

Parent/Guardian (1) Birthdate *

YYYY

Parent / Guardian Phone (1): *

Parent / Guardian Name (2): *

Parent / Guardian Phone (2): *

DROP-OFF AND PICK-UP LIST RELEASE & EMERGENCY CONTACTS (Name/Relationship/Phone) Sign child in and out upon drop off and pick up. Please supply in writing names of persons who may pick up your child. *

PHOTO RELEASE We understand in any event that the youth is photographed for purposes of promoting and publicizing the Crossroads YMCA program, we hereby waive all rights to the photographs in which the child appears. We understand that sole ownership and copyright belong to the Crossroads YMCA. The photographs, may be used whole, in part, or in composite as a program sees fit in publication of education material, and the advertising thereof, and any other lawful purpose. *

I accept

Required

I understand Crossroads YMCA is operating as an Emergency Childcare Facility (initial here) *

PARENT STATEMENT OF UNDERSTANDING

PARENT STATEMENT OF UNDERSTANDING

The following information is important for the safety and protection of your child. Please read the information, sign this form and return it to the YMCA.
Please keep and refer to your copy of the Crossroads YMCA childcare polices. Your signature below indicates that you have received them.
I understand that the Y staff and volunteers are not allowed to babysit or transport children at any time outside of the Y program. Immediate disciplinary action will be taken by the YMCA toward staff if a violation is discovered.
I understand that I am not to leave my child in any Y program unless a Y staff is there to supervise my child.
I understand that my child will not be allowed to leave the program with any unauthorized person. Any person authorized to pick-up my child must either be listed with the Y or other arrangements must be made by calling the Y office to inform them of a change.
I understand that should a parent or any unauthorized person arrive to pick up my child who appears to be under the influence of drugs or alcohol my child will not be released into their care.
I understand that the Y is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.
I understand that any belongings brought to the Y by my child are the responsibility of my child only. The Y and its staff will not replace or take responsibility for any lost or broken items.

I release The Crossroads YMCA from any liability, whatsoever, that may result from injuries and subsequent medical attention and will look to The Crossroads YMCA only in the unlikely event of gross negligence and/or willful and want on misconduct.

I hereby grant permission for the staff of the YMCA to take whatever steps necessary to obtain medical care for my child if warranted. These steps include the following: (1) To administer First Aid; (2) To contact parent/guardian or person listed on emergency contact. If necessary, an ambulance will be called to transport the child to an emergency medical center. I understand that I will be held responsible for all medical/ambulance charges.

We do our best to serve every family; however, if a child causes our staff to frequently deviate from our ratio, you may have to send your child with a caregiver. We are unable to accommodate any child that may require one-on-one supervision.

I have read and understand this copy of the Crossroads YMCA childcare policies/procedures and Parent Statement of Understanding.

I accept the Parent Statement of Understanding (initial) *

I have completed the LAUW Healthcare Worker Child Care Application *

Yes

I understand I need to provide the Payment Authorization Letter from Lake Area United Way to the YMCA *

Yes

ANY INFORMATION YOU CHOOSE TO DISCLOSE IS CONFIDENTIAL.

While in program, are there any health conditions that you would like us to be aware of? *

Yes

Other

While in program, are there allergies that we should be aware of? Allergic reaction (describe): *

Are there activities that your child should be exempt from due to health reasons? *

Yes

Other:

Please describe your child’s interactions with children of the same age: *

How would you describe your child’s personality? *

Does your child have any fears that we should be aware of? *

Is there any other information that you would like to share so that we may better understand and work with your child? *

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This form was created inside of Crossroads YMCA Inc. Report Abuse

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