HomeMy WebLinkAboutC27900 DSUSD & YMCA - Lincoln After School PgrmCITY OF PALM DESERT
Community Services Division
Staff Report
REQUEST: REQUEST FOR APPROVAL OF MEMORANDUM OF
UNDERSTANDING BETWEEN DESERT SANDS UNIFIED SCHOOL
DISTRICT, THE YMCA OF THE DESERT, AND THE CITY OF PALM
DESERT AS IT RELATES TO PARTICIPATION IN AN AFTER
SCHOOL PROGRAM AT LINCOLN ELEMENTARY SCHOOL
SUBMITTED BY: Patricia Scully, CFEE, Senior Management Analyst
DATE: July 10, 2008
CONTENTS: Memorandum of Understanding
RECOMMENDATION:
By Minute Motion, authorize the Mayor to execute a Memorandum of Understanding between
the Desert Sands Unified School District, the YMCA of the Desert, and the City of Palm
Desert as it relates to participation in an After School Program at Lincoln Elementary School
(Contract No. C27900 ).
EXECUTIVE SUMMARY:
The City of Palm Desert is an active participant in after school programs located at Lincoln
Elementary School and Palm Desert Middle School. This agreement will allow this program
to continue for the 2008/2009 academic year at Lincoln Elementary School.
BACKGROUND:
The Lincoln Elementary School After School Program currently serves approximately 100
students and maintains a waiting list ranging from 15 to 30 more. The program costs of
$89,616 are adequate to fund this program in the 2008/2009 school year and have been
approved in the City of Palm Desert's Fiscal Year 08/09 budget. This Memorandum of
Understanding will allow the continued collaboration between Desert Sands Unified School
District and the City of Palm Desert to implement the After School Program at Lincoln
Elementary School and authorizes staff from the YMCA of the Desert to administer the
program. The Memorandum of Understanding is attached and outlines the specific
parameters of this agreement.
CITY COUNCIL STAFF REPORT JULY 10, 2008
RE: MOU BETWEEN DESERT SANDS UNIFIED SCHOOL DISTRICT, THE YMCA
OF THE DESERT, AND THE CITY OF PALM DESERT AS IT RELATES TO
PARTICIPATION IN AN AFTER SCHOOL PROGRAM AT LINCOLN
ELEMENTARY SCHOOL
Therefore, staff recommends that the City Council authorize the Mayor to execute the subject
Memorandum of Understanding.
PATRICIA SCULLY, CFEE '
SENIOR MANA EME T ANAtYST
SHEILA R. GIL IGAN
ACM/COMMUNITY SERVIC
PS:mpg
PAUL S. GIBSON
FINANCE DIRECTOR/CITY TREASURER
CARLOS L. ORT1A
CITY MANAGER
:;ITY COUNCIL AQTION:
APPROVED ✓ DENIED
RECEIVED OTHER
!'4EETINDATE 7
AYES:
NOES :..S(t%1
ABSENT:,,r74P
ABSTAIN: X1
VERIFIED BY:
• 0
j , tine( , KPJ h 1. c)10/eel an of Y/Wo l
f3 /Glm
)riginal on File wit`.h City Clerk's OffirE
Contract No. C27900
MEMORANDUM OF UNDERSTANDING
BETWEEN
THE DESERT SANDS UNIFIED SCHOOL DISTRICT,
THE YMCA OF THE DESERT,
AND THE CITY OF PALM DESERT
AS IT RELATES TO PARTICIPATION IN AN AFTER SCHOOL PROGRAM
AT LINCOLN ELEMENTARY SCHOOL
Whereas, the Desert Sands Un�ed School District (DSUSD) administers, operates, and
maintains schools within the City of Palm Desert (CITI�; and
Whereas, CITY, the YMCA of the Desert (YMCA), and DSUSD all desire to improve after
school programs through grants and in-kind services; and
Whereas, DSUSD supports and has agreed to apply for grant funding and to provide use
of its facilities for after school programs at the Lincoln Elementary School and the Palm Desert
Middle School; and
Whereas, YMCA has agreed to create, operate, and administer such after school
programs at Lincoln Elementary School with the support and cooperation of DSUSD and CITY;
and
Whereas, at its regular meeting of June 26, 2008, the City Council of the City of Palm
Desert approved the 2008/2009 budget, which included $89,616 for after school program
services at Lincoln Elementary School, contingent upon YMCA implementing said program and
DSUSD assuming responsibility as "financial agent" for the administration and distnbution of any
grant monies received as it relates to the above mentioned °After School Program."
Now, therefore, it is agreed that CITY will participate and contribute to an After School
Program as follows:
1. An After School Program will be provided at Lincoln Elementary School within the City
of Palm Desert by YMCA with said program operational plan;
2. DSUSD will provide in-kind services in the form of facility use for the After School
Program;
3. DSUSD will assume responsibility as "financial agent" for administration and
distribution of any grant monies received;
4. CITY will assist DSUSD and YMCA in promoting the After School Program with CITY
through CITY's newsletter, press releases, and other means as deemed appropriate;
Page 1 of 2
Contract No. C 27900
5. Attachments A, B, C, and D shall be considered in effect as part of this MOU, and not
other documents may be introduced for implementation without the consent of ali
parties.
In Witness Thereof, this Memorandum of Understanding has been executed this
day of , 2008, for a period of one year, aRer which it may become
eligible for renewal, subject to agreement by both parties.
DESERT SANDS UNlFIED SCHOOL DISTRICT
Sharon McGehee, Superintendent Date
Attest:
Date
YMCA OF THE DESERT
Rob Bal(ew, Executive Director Date
Attest:
Date
CITY OF PALM DESERT
Jean M. Benson, Mayor Date
Attest:
Date
Page 2 of 2
AITACHMENT A
Lincoln Elementary School After School Program
MEMORANDUM OF UNDERSTANDING
2008-2009 Academic Year
This Memorandum of Understanding (MOU) is entered into by the City of Palm Desert (City), Desert
Sands Unified School District (DSUSD), and the Family YMCA of the Desert (YMCA) to fulfill the
partnership requirements of the Lincoln Elementary School after school program. The intent of this
MOU is to establish the formal working relationship and sets forth the respective parfnership roles and
responsibilities of the City,DSUSD, and the YMCA.
YMCA:
1. Provide NCLB qualified staff inembers for an adult to student ratio not to exceed 1 - 20 for up to 100
students and maintain an active substitute list.
2. Provide a site coordinator to supervise a consistent team of line staff, monitor staff attendance and
punctuality over contract term and maintain records that include a roster of staff qualifications.
3. Site coordinator will plan and administrate after school program in coliaboration with site administrator
with duties to include; daily attendance, snack counts, sign in/out logs. Site coordinator will ensure
compliance with established early release policy.
4. Align all program components with regular school day including discipline.
5. May use district materials, equipment/facilities and assumes the responsibility for such equipment and
agrees to repair or replace any equipment damaged, stolen or lost while under its jurisdiction.
Equipment may not leave school site.
6. Regular communication between The YMCA, The City of Palm Desert, and site staff will include program
updates along with parent communications.
7. Schedule staff development which incorporates trainings provided by DSUSD After School Programs
Department and DSUSD RIMS 10 team.
8. Assure after school staff use of communication system.
9. Submit invoices for staff and materials for training sessions provided by and paid by the After School
Program Department. Invoices should include detailed time sheets and staff development agendas.
10. Submit weekly activity schedules to site administrator for the purpose of evqluation of the program. The
activity schedule should include an outline of services provided, special events and invited guests and
speakers.
11. Agree to follow all DSUSD hiring procedures and provide copies of requested insurance policies as listed
in the Independent Contractors Agreement 8.1.3.
12. Students will not be asked to fund raise without consent of the site administrator and the City of Palm
Desert.
13. Will follow two step action plan which includes a preliminary meeting between DSUSD ASES Director or
designee, site administrator or designee, YMCA, and a representative of the City to form an action plan
with specific mutually agreed upon recommendations. A secondary follow up meeting will be held
between DSUSD Director of After School Programs or designee, site principal or designee, YMCA, and a
representative of the City within two weeks of the initial meeting to evaluate effectiveness of the action
plan. If requirements are still not met even after corrective efforts, Section 6 of the Independent
Contractors agreement will be in effect.
14. The YMCA will supervise and coordinate the civic engagement/mentoring program between the City
and site, which will be implemented at the beginning of the academic year.
15. A yearly report of in-kind services and ihe appropriate estimated value will be submitted by the YMCA
to the DSUSD After Schools Program Depprtment for reporting purposes.
16. Purchases of equipment or materials must be approved by the City prior to entering into any
agreement for same. Use of funds provided by the City for implementation and/or operation of this
after school program to purchase fixed assets or materials and/or equipment which will be retained by
DSUSD and/or the YMCA is strictly prohibited.
This MOU is for activities rendered between July 1, 2008, and June 30, 2009. If modifications are
necessary to complete this agreement, they will be added or subtracted by mutual consent of all
parties involved.
ATTACHMENT B
DESERT SANDS UNIFIED SCHOOL DISTRICT
INDEPENDENT CONTRACTOR SERVICES AGREEMENT
This Independent Contractor Services Agreement dated the day of , 2Q_
("Agreement"), is entered into in the County of Riverside, State of California, by and between
Desert Sands Unified School District ("District"), and ("Consultant").
WHEREAS,
A. The District desires to contract for
services to be performed by Consultant; and
B. Consultant is qualified to provide these services ("Services") and is willing to do so under
the terms of this Agreement; and
C. Both the District and Consultant desire to memorialize the terms and conditions of their
Agreement.
D. This Agreement complies with the Public Contract Code requirements for selection of an
independent contractor in the following circumstances (Check one or more):
X The Services to be provided constitute special services pursuant to Government
Code section 53060.
,The Services to be provided have been bid pursuant to Public Contract Code section
20111.
_X_Other: Program funding provided by the City of Palm Desert in the amount of
$89,616.00
NOW,THEREFORE, in consideration of the covenants and agreements hereinafter set forth,
the parties agree as follows:
1. DUTIES OF CONSULTANT
1.1. Consultant shall perform the services described in the scope of work attached and
incorporated as Exhibit"A," in accordance with:
1.1.1. The standards of its profession and to District's satisfaction;
1.1.2. This Agreement; and
1.1.3. The Consultant's proposal to the District dated
Independent Contractor Services Agreement
Where terms of this Agreement, including Exhibit"A" hereto, conflict with
terms of other incorporated documents, the terms of this Agreement and Exhibit
"A" shall take precedence.
1.2. Consultant shall be solely responsible for the professional performance of the
Services, and shall receive no assistance, direction, or control from the District,
except as specifically indicated in this Agreement.
1.3. Consultant shall coordinate its Services with those of District staff and other
District consultants, and take direction as to timing and coordination from the
District's representative or as the District specifies.
2. COMPENSATION
2.1. [FIXED FEE—Include if this is the preferred payment structure.]
District shall pay Consultant for services described in Exhibit
"A" and satisfactorily completed
l�
[ALTERNATIVE: HOURLY FEE WITH NOT TO EXCEED AMOUNT]
District shall pay Consultant for services described in Exhibit"A" and
satisfactorily completed, on an hourly basis using the fee structure described in
Exhibit"B," not to exceed a total of$ without prior written approval
by the District.
2.2. Consultant shall invoice the District monthly, showing an itemization of the hours
worked, the services rendered and the associated charges. District shall pay
Consultant all undisputed amounts within thirty(30) days of receipt of the
Consultant's invoice.
2.3. The rate of compensation to Consultant may be revised only by prior written
approval of both the District and Consultant.
3. TERM
3.1. The term of this Agreement shall be for one L1� year, from July 1, 2008,
through June 30, 2009. (Not to exceed five (5) years.)
3.2. This Agreement will terminate upon the completion of the Services or when
terminated as set forth herein,but in no case more than five (5) years from the
date of commencement of this Agreement,
Independent Contractor Services Agreement
4. CONSULTANT'S STATUS
4.1. Consultant shall act as an independent contractor and shall not be an employee,
officer, agent, partner, or joint venturer of the District by virtue of this
Agreement.
4.2. Consultant shall have and shall require its employee(s) and/or subcontractor(s) at
all times during the performance of the Services of this Agreement to have all
applicable licenses, certificates, and permits usual and/or necessary for
conducting the Services hereunder, if any.
S. CONFLICT OF INTEREST
5.1. Consultant understands that its professional responsibility is solely to the District.
Consultant warrants that it and its employees and/or subcontractors presently have
no interest and will not acquire any direct or indirect interest that would conflict
with its performance under this Agreement, including, without limitation, any
direct andlor indirect interest in any of the following:
5.1.1. Entity(ies) performing services in the same discipline and in competition
with any independent contractor under contract with the District;
5.1.2. The District.
6. TERMINATION
6.1. The District may terminate this Agreement by giving ten (10) days written notice
to the Consultant. The District may terminate the Agreement without cause.
6.2. Consultant may terminate this Agreement by giving thirty(30) days written notice
to the District. The District shall pay Consultant for the work done or services
rendered to District's satisfaction up to the time of termination within thirty(30)
days of Consultant's submittal of its final invoice.
7. OWNERSHIP OF WORK
All documents furnished to Consultant by District, and all designs, plans, software,
reports, specifications, drawings, schematics, prototypes, models, inventions and all other
information and items made or developed under this Agreement, and copyrights
therefore, are District's property and shall be given to District within seven (7) calendar
days of the completion of Consultant's services, or within seven (7) calendar days of the
termination pursuant to this Agreement.
8. INSURANCE
8.1. The Consultant shall procure and maintain at all times it performs any portion of
Independent Contractor Services Agreement
the Services the following insurance with minimum limits equal to the amount
indicated below.
8.1.1. Commercial General Liability and Automobile Liability Insurance.
Commercial General Liability Insurance and Any Auto Automobile
Liability Insurance that shall protect the Consultant, the District, and the
State and their trustees, officers, employees, representatives, and agents
from all claims of bodily injury, property damage, personal injury, death,
advertising injury, and medical payments arising from performing any
portion of the Services. (Form CG 0001 and CA 0001) (Refer to chart
below.)
8.1.2. Workers' Compensation and Emplovers' Liability Insurance. Workers'
Compensation Insurance and Employers' Liability Insurance for ail of its
employees performing any portion of the Services, in accordance with the
provisions of section 3700 of the California Labor Code ("Workers'
Compensation Statute"). If any class of employee or employees engaged
in performing any portion of the Services under this Agreement are not
protected under the Workers' Compensation Statute, adequate insurance
coverage for the protection of any employee(s) not otherwise protected
must be obtained before any of those employee(s) commence performing
any portion of the Services. (Refer to chart below.)
8.1.3. Professional Liabilit�Errors and Omissions). Professional Liability
(Errors and Omissions) Insurance as appropriate to the Consultant's
profession. (Refer to chart below.)
Type of Coverage Minimum
Re uirement
Commercial General Liability Insurance and Any Auto
Automobile Insurance, including Bodily Injury, Personal Injury,
Property Damage, Advertising Injury, and Medical Payments
Each Occurrence $ 1,000,000
General A re ate $ 1,000,000
Professional Liabili $ 1,000,000
Workers Com ensation Statutory Limits
Em lo er's Liabili $ 1,000,000
8.2 Proof of Carriage of Insurance. The Consultant shall not commence performing
any portion of the Services until all required insurance has been obtained and
certificates indicating the required coverage has been delivered in duplicate to the
District and approved by the District. Certificates and insurance policies shall
include the following:
8.2.1. A clause stating: "This policy shall not be canceled or reduced in
required limits of liability or amounts of insurance until notice has been
mailed to the District, stating date of cancellation or reduction. Date of
Independent Contractor Services Agreement
cancellation or reduction shall not be less than thirty (30) days after date of
mailing notice."
8.2.2. Language stating in particular those insured, extent of insurance,
location and operation to which insurance applies, expiration date, to whom
cancellation and reduction notice will be sent, and length of notice period.
8.2.3. An endorsement stating that the District and the State and their agents,
representatives, employees, trustees, officers, consultants, and volunteers are
named additional insureds under all policies except Workers' Compensation
Insurance, Professional Liability, and Employers' Liability Insurance.
8.2.4. An endorsement stating that Consultant's insurance policies shall be
primary to any insurance or self-insurance maintained by District.
8.2.5. With the exception of professional liability insurance, if applicable, all
policies shall be written on an occurrence form.
8.3. Acceptability of Insurers. Insurance is to be placed with insurers with a current
A.M. Best's rating of no less than A: VII, unless otherwise acceptable to the
District.
9. INDEMNIFICATION
To the furthest extent permitted by California law, Consultant shall, at its sole expense,
defend, indemnify, and hold harmless the District, the State of California, and their
agents, representatives, officers, consultants, employees, trustees, and volunteers (the
"indemnified parties") from any and all demands, losses, liabilities, claims, suits, and
actions (the"claims") of any kind, nature, and description, including, but not limited to,
personal injury, death, property damage, and consultants' and/or attorneys' fees and costs,
directly or indirectly arising out of, connected with, or resulting from the performance of
the Consultant's Services pursuant to this Agreement or from any activity, work, or thing
done, permitted, or suffered by the Consultant in conjunction with this Agreement, unless
the claims are caused wholly by the sole negligence or willful misconduct of the
indemnified parties. The District shall have the right to accept or reject any legal
representation that Consultant proposes to defend the indemnified parties.
10. NON- ASSIGNMENT
This Agreement is a personal services agreement. Consultant shall not assign this
Agreement or any portion of it to any third party without the written consent of the
District. Any purported assignment without prior written consent of the District shall
automatically terminate this Agreement.
11. FINGERPRINTING OF EMPLOYEES
Consultant shall comply with the provisions of Education Code section 45125.1
Independent Contractor Services Agreement
regarding the submission of employee fingerprints to the California Department of
Justice and the completion of criminal background investigations of its employees.
Consultant shall not permit any employee to have any contact with District students until
the Consultant has verified in writing to the governing board of the District that the
employee has not been convicted of a felony, as defined in Education Code section
45122.1. Consultant's responsibility shall extend to all employees, subcontractors,
agents, and employees or agents of subcontractors regardless of whether those individuals
are paid or unpaid, concurrently employed by the District, or acting as independent
contractors of the Consultant. Verification of compliance with this section shall be
provided in writing to the District prior to each individual's commencement of
employment or performing any portion of the Services and prior to permitting contact
with any student.
12. CONFIDENTIALITY
The Consultant and all Consultant's agents, personnel, employee(s), and/or
subcontractor(s) shall maintain the confidentiality of all information received in the
course of performing the Services. This requirement to maintain confidentiality shall
extend beyond the termination of this Agreement.
13. NOTICES
13.1. Any notice required or permitted to be given under this Agreement shall be
deemed to have been given, served and received if given in writing and either
personally delivered or deposited in the United States mail, registered or certified
mail, postage prepaid, return receipt required, or sent by overnight delivery
service or facsimile transmission, addressed as follows:
District Consultant
Desert Sands Unified School District Family YMCA of the Desert
47-950 Dune Palms Road 43930 San Pablo Avenue
La Quinta, CA 92253 Palm Desert, CA 92260
Attn: Attn: Rob Ballew
13.2. Any notice personally given or sent by facsimile transmission shall be effective
upon receipt. Any notice sent by overnight delivery service shall be effective the
business day next following delivery thereof to the overnight delivery service.
Any notice given by mail shall be effective five (5) days after deposit in the
United States Mail.
14. WAIVERS
The waiver by either party of any breach of any term, covenant, or condition herein
Independent Contractor Services Agreement
contained shall not be deemed a waiver of such ternn, covenant, or condition, or any
subsequent breach of the same or any other term, covenant, or condition herein contained.
15. SEVERABILITY
If any term of this Agreement is held invalid by a court of competent jurisdiction, the
remainder of this Agreement shall remain in effect.
16. INTEGRATION/ENTIRE AGREEMENT OF PARTIES
This Agreement constitutes the entire agreement between the parties and supersedes all
prior discussions, negotiations, and agreements, whether oral or written. This Agreement
may be amended or modified only by a written instrument executed by both parties.
17. CALIFORNIA LAW
This Agreement shall be governed by and the rights, duties and obligations of the parties
shall be determined and enforced in accordance with the laws of the State of California.
The parties further agree that any action or proceeding brought to enforce the terms and
conditions of this Agreement shall be maintained in the county in which the District's
administrative offices are located.
ACCEPTED AND AGREED on the date indicated below:
Dated: , 20_ Dated: , 20_
Desert Sands Unified School District
(District) (Consultant)
By: By:
Print Name: Print Name:
Print Title: Print Title:
Independent Contractor Services Agreement
ATTACHMENT C
LINCOLN ELEMENTARY SCHOOL AFTER SCHOOL PROGR.AM
GENERAL REGISTRATION FORM
Please Print Student's FULL Name Student ID# School Grade Year
ASES (After School Education & Safety) is an academic and enrichment intervention program for elementary school
students in Desert Sands Unified School District that supplements the regular school day. The program will take place
immediately upon the end of the regular school day including early release and minimum days until 6 p.m.
beginning Tuesday, September 2,2008 through June 12, 2009. Space is limited by available funding.
Program Requirements
• Students MUST attend daily unless absent during the regular school day.
• Abide by DSUSD and school's Code of Conduct.
• Students MUST be signed out by an authorized adult with a valid I.D no later than 6pm.
• Students leaving before 6pm must have a valid reason. Early releases are limited to parallel programs, family
emergencies and illnesses.
• Students may not walk home without or be transported by an unauthorized person.
• Failure to comply with program requirements may result in dismissal from the program.
EMERGENCY CONTACTS/AUTHORIZED ADULTS
� )
Mother/Guardian Address City/Zip Telephone/Cell Phone
� )
Father/Guardian Address City/Zip Telephone/Cell Phone
� )
Other Authorized Persons/Relative/Neighbor who will accept responsibility for student Telephone/Cell Phone
�)
Other Authorized Persons/Relative/Neighbor who will accept responsibility for student Telephone/Cell Phone
ANY OTHER PHONE NUMBER(S) THAT THE PQRENT/GUQRDIAN CAN BE REACHED AT BETWEEN 1-6 PM:
(Work phone) (cell/pager) (other)
*IF THERE IS A CHANGE IN THE ABOVE INFORMATION, I WILL NOTIFY ASES STAFF IMMEDIATELY
MEDICAL RELEASE/PHYSICAL LIMITATIONS
Does your child have any medical conditions? ❑Yes ❑No Does your child take medications'? ❑Yes ❑No
Does your child have any physical limitations? DYes ❑No Are there any Religious restrictions'? ❑Yes ❑No
Please explain any"Yes"answer.
MEDIA AND PHOTO RELEASE
❑Yes ❑No I allow my ASES student to be photographed for the purposes of documenting and utilizing media venues
(magazine,newspaper,video,etc.) for the public relations aspects of ASES.
Signature Parent/Guardian Print Name Date
Your signature gives permission for your child to participate in the After School Safety and Education Program and for
staff to contact any authorized person you indicated on this form if needed. Remember,your child cannot stay in the
program without accurate contact information.
FOR CHILD CARE USE ONLY
ID#: PAYMENT PUIN:
❑ Monthl ❑ Weeld
. FAMII�Y YMCA S17E: PLAN:
QF THE DESERI" STA FINITIALS: �ARI PUTDATE:
Mission Statement ATTACffi�NT D
To put]udeo-Christian principles into practice through programs that build healthy spirit, mind,and body for all.
MEMBERSHIP AND REGISTRATION APPLICATION
CHILD CARE PARTICIPANT{Name of�hild who will be attending chi)d eare)
Frst Name: Initial: Last Name: Date of Birth: Gender:
_J_�_ [ ]MALE [ J FEMALE
PRIMARY MEMBER (Parent or Guardian for chtidren under 18 years)
Prefix: • Rrst: Inidal: Last: Would you be interested in volunteering? [ )YES
ETNNICITY/AACE:
Billing Address: Apt#:
White
Gty: State: ZIP Code: Black/African American
Aslan
Americdn Indian/Native Alaskan
Gender. [ ]MALE [ ]FEMALE Date of Birth: _I__/ NaUve HawailaN�dNc Istander
Home Phone: Cell Phone: Business Phone: Native Indian/Alaskan&White
Asian&White
�a��, Bladc/African American&White
Native Indian/Alaskan&Black/Afiican
American
Company Name: Hispanic �
Hispanic&White
Street: Hispanic&Black
- � Hispanic&asian
Gty: State: ZIP Code: Hfspanic&Nadve Indtan/Alaskan
Hlspanic&Hawaiian/Paafic Islander
Phone: Fax:
Hispanic&Native Indian/Alaskan&White
HispanicJAsian&White
Hispanic/African American&White
Hispanic/Indian/Alaskan&Black/African
Occupatlon: AmeHcan
I chose not to answer tfiis survey
EMERGENCY CONTAET
Name: Phone: Cell:
�AMILY MEMBER INFORMATION
2ND ADULT ONLY
Frst Name: Initlal; Last Name: Date of Birth: Gender:
_J� [ )MALE [ ]FEMALE
Employer: Cell Phone: Business Phone:
CHILDREN—DEPENDENTS AND APpLICANTS UNDER 18 YEARS OF AGE(DO NOT INCLUDE CHILD CARE PARTICIPANTI
Frst Name: Initlai: Last Name: Date of Birth: Gender:
___/___/_ [ ]MALE )FEMALE
Fint Name: Inidal: Last Name: Date of Birth: Gender:
��_ [ ]MALE [ ]FEMALE
First Name: Initial: Last Name: Date of Birth: Gender:
��J_ [ �MALE [ FEMALE
Frst Name: Initial: Last Name: Date of 8irth: Gender:
_/�_ [ )MALE ]FEMALE
How many persons are in your household? Is the Head of Household? [ ]MALE [ ]FEMALE
H:�Membership Drive`Official Y Membership_CC_AQplication.da Rev.11/27/07 !
I
I
i
I
PLEASE TURN OVER TO SIGN LIABILITY
CII�CLE YOUR COMBINED GROSS ANNUAL INCOME Riveiside-San Diego,CA-1006.
The following information will remalned oonfidential and is necessary tn fulfill YMCA grant requirements.
NUMBER OF PERSONS IN YOUR HOUSEHOLD:
1 2 3 4 5 6 7 8
$0- $0- �0- �0- $0- $0- SO- �0-
20 l50 23 000 25 900 28 750 31 O50 33 350 35 650 37 950
;20,151- ;23,001- �25,901- �28,751- $31,051- $33,351- $35,651- �3Z,951-
32 199 36 799 41 399 45 999 49 699 53 349 57 049 60 699
$32,200- $36,800- $41,400- $46,000- �49,700- $53,350- $57,050- ;60,700-
48 799 SS 199 62 099 68 999 74 499 79 999 85 599 91 099
Ovel Over Over Qver Over Over Over Over
48 3U0 55 2Q0 6Z L00 69 000 74 500 80 000 B5 600 91 100
❑I choose not to provide the above informabon.
RELEASE and WAIVER of LIABILITY AGREEMENT
MEMBER/CHILDREN/GUEST
IN CONSIDERATION of being permitted to utilize the facilities, services, programs and activities af the YMCA and/or for my
children to so participate for any purpose, includfng, but not limited to observation or use of facilities or equipment, or
partidpation in any ofF site program affiliated with the YMCA, the underslgned, for himself or herself and participating
' chlldren and any personal representatives, helrs, and next of kin, hereby acknowledges, agrees and represents that he or
; she has, or immediately upon entering or partic(pa�ng will, Inspect and carefully consider such premises and factlities or the
afflllated program. It is further acknowledged that such entry into the YMCA for observation, use of any facilities,
equipment or particfpation fn any affiliated program constitutes an acceptance that such premises and all fadlities and
equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned
flnds and accepts same as being safe and reasonably suited for the purpose of such observatlon, use or particlpatlon by the
undersigned and such children.
I (We) do hereby assume full responsibility for any and all damages, injuries, or losses that I (We) may sustain or incur, if
: any, while attending or participating in any YMCA facilities, senrices, programs� activities or off-site affiliaCed program
including exercise. I hereby waive all claims against the Family YMCA of the Desert, its instructors, employees or partners
� of said program, individually or otherwise, for any and all daims for injuries or damages I (We) might sustaln. I (We)
� understand that there is a rlsk of fnjury associated with participation in any YMCA program and I (We) certify that I (We)
am in good physicai conditlon and in condition to participate. I (We) certify that all of the information provided on this
; applicatlon is correct and true. �
CONDITIONS OF MEMBERSHIP&ACTIVTiY PARTICIPATION
' MEMBER CONDUCT AND RIGHT TO USE FACILITY: The applicant agrees to ablde by all rules and regulation of the
Family YMCA of the Desert and Its opecatlng units and understands that failure to act in accordance with the rules may
; result in expulsion from the YMCA and cancellatlon of inembership.
PROPERTY LOSS:The applicant(s) understands the YMCA (s not responsible for personal property lost, damage or stolen
whfle us(ng YMCA facilities or particfpating in YMCA programs.
INSURANCE: The applicant(s) understands that the YMCA does not p�ovide any accident or health insurance for its
� members or participants and further understand it is the applicanYs responsibillty to provide such coverage.
PHOTO RELEASE: I understand that any pictures taken of myself and/or my family may be used for publicity purposes.
ACCEPTANCE/RELEASE: I (We) acknowiedge the conditions of rriembership state above, for myself and on behalf of the
minor applicants I(sted, if any. I (We) understand that even when reasonable precaution is taken, acddents involving i
participants can still happen. Therefore, I (We) hereby release the Family YMCA of the Desert, its agents, and employees
from any and ali ciaims for injury, iilness, death, loss or damage which may result as a member in any YMCA program
activity, service or facility, i
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Signahire ofApp/icant Dale
Pnnt Name of Pa�ent/Guardian ofapp/icants unde�IB Date
H:\Membership Orive,Offiaal Y Membership_CC_Application.da Rev.11�27/07
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STATE OF CALIFORNIA CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HPALTH AND HUMAN SERVICES AGENCY COMMUNITV CAHE LICENSIN(i DIVISION
IDENTIFICATION AND EMERGENCY INFORMATION
CHILD CARE CENTERS/FAMILY CHILD CARE HOMES
To Be Completed by Parent,Domestic Partner or Authorized Representative
CHILD'S NAME LAST MIDDLE FIRST SEX TEIEPHONE
� �
ADDRESS NUMBER STREET CfTY STATE ZIP BIRTHDATE
FATHER'S/GUARDIAMS/DOMESTIC PARTNER'S NAME UST MIDDLE FIRST BUSINESS 7ELEPHONE
1 �
HOME AD�RESS NUMBER STREET CITY STATE ZIP MOME TELEPMONE
� �
MOTHER'S/GUARDIAN'S/DOMESTIC PARTNER'S NAME LAS7 MIDDLE FIRST BUSINESS TEIEPHONE
l �
HOMEADORESS NUMBER STAEET CITY STATE ZIP HOMETELEPHONE
� �
VERSON RESPONSIBLE FOR CMIID UST NAME MIOOIE FIRST HOME TE�EPHONE BUSINE55 TELEPHONE
1 � � �
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY
NAME ADDRESS TELEPHONE RELATIONSHIP
PHYSICIAN OR DENTISTTO BE CALLED IN AN EMERGENCY
PHYSICIAN ADDRESS MEDICAL PUN AND NUMBER TELEPHONE
� �
DENTIS7 ADDRESS MEOICAL PUN AND NUMBER TELEPHONE
� �
IF PHYSICIAN CANNOT BE REACHED,WHAT ACTION SHOULO BE TAKEN9 '
I
❑CALI EMEROENCY HOSPITAL ❑OTHER EXPUIIN:
NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
(CFkLD WILL NOT BE ALLdWED TU LEAVE WITH ANl'UTHEF PEASON WfTFIOIlT WRfTTEN AIJT}iORIZATION FFK)M A4HEM,DOMESTIC p1AFlTNER OR AUTFIORIZED REPRESENTATIVE) �
NAME RELATIONSHIP �
�
----� --_ — .—__-- ------ --- --- ----- �
I
— ---� ---- — j
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TME GiILD WILL 8E CALLED FOR ^ 1
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SI(3NATURE OF PARENT/GUARDIAN/DOMESTIC PARTNER OR AUTFIORIZED REPRESENTATIVE DATE I
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE
DATE OF ADMISSION DATE LEFf
L1C 700(1/08�(CONfIDENTIAL)
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� STATE OF CAUFORNIA-HEALTH ANO HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCUL SERVICES
_ COMMUNITV CARE UCENSINO
CHILD'S PREADMISSION HEALTH HISTORY-PARENT'S REPORT
CHILD'S NAME SEX BIRTH OATE
FATMER'S/DOMESTIC PARTNER'S NAME DOES FATHER/DOMESTIC PARTNER LIVE IN HOME WITH CHILD7
MOTHER'S/DOMESTIC PARTNER'S NAME DOES MOTHER/DOMESTIC PARTNER L1VE IN HOME WRH CHILD?
IS MAS CHILD BEEN UNDER REGUUR SUPERVISION OF PHYSICIAN4 DATE OF IAST PHYSICAUMEOICAL EXAMINATION
. or�n an an pres oo-age c i ren on
WAIKED AT� BEGAN TALKING AT* TOILET TRAININ6 STARTED AT+
MONTHS MONTHS MONTHS
PAST ILLNESSES—Check illnesses that child has had and s eci a roximate dates of illnesses:
DATES DATES DATES
O Chicken Pox ❑ Diabetes O Poliomyelitis
❑ Asthma O Epilepsy O Ten-Day Measles
(Rubeola)
❑ Rheumatic Fever C] Whooping cough
O Three-Day Measles
❑ Hay Fever f_l Mumps I (Rubella)
SPECIFY ANY OTHEp SERIOUS OR SEVERE ILINESSES OR ACCIDENTS
DOES CHILO HAVE FREOUENT COLDS? ❑ YES ❑ NO HOW MANY IN UST YEAR? UST ANY ALLERGIES STAFF SHOULO BE AWARE OF
DAILY ROUTINES "Forin/ants and preschool-age children onl»
WHAT TIME DOES CHILD QET UP7� WHA7 TiME DOES CHILD OO TO BEDT* DOES CHILD SLEEP WELL9*
DOES CHILD SIEEP DURINO THE DAV7* WHEN9� HOW LONa7*
DIET PATTERN: BREAKFAST WHAT ARE USUAL EATINQ HOURSI
� �V�18►dOQS C�ll�USUB�IY BREAKFAST
Bg110f 1I18SB f1168IS1� LUNCH LUNCH
DINNER
DINNER
ANV FOOD DISIIKES7 ANY EATING PROBLEMS?
IS CHILD TOILET TRAINED?* IF YES,AT WHAT STAGE:* ARE BOWEL MOVEMENTS REGVUR?� WHqT IS USUAL iIME7�
❑ YES ❑ NO ❑ YES ❑ NO
WORD USED FOR'BOWEL MOVEMENT'� WORD USED FOR URINATION+
PARENT'S EVALUA710N OF CHILD'S HEALTH
IS CHIID PRESENTLV UNDER A DOCTOR'S CARE? F YES,NAME OF DOCTOR: DOES CHIID TAKE PRESCRIBED MEDICATION(S)? IF YES.WHAT KIND AND ANY SIDE EFFECTS:
� YES � NO ❑ YES ❑ NO
DOES CHILO USE ANV SPECIAL DEVICE(S): F YES,WHAT KIND: DOES CHILD USE ANY SPECIAL DEVICE(S)AT HOME7 IF YES,WHAT KIND:
� YES � NO � YES � NO
PARENT'S EVALUATION OF CHILD'S PEHSONALITY
HOW DOES CHILD GET ALONO WITH PARENTS,BfiOTHERS,SISTERS AND OTHER CHILDREN?
MAS THE CHILD HAD GROUP PUY E%PERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBIEMS/FEARS/NEEDS?(EXPUIN.)
WHAT IS THE PLAN FOfi CAPE WHEN THE CHILD IS ILL?
REASON FOR REWESTING DAV CARE PUCEMENT
PARENTS/DOMESTIC PARTNER'S SIGNAiLRE IDATE
LIC 702(1/OB)(CONFIDENTIAL)
ADMISSION AGREEMENT
FAMILY YMCA OF THE DESERT
CHILD CARE PROGRAM -SCHOOL AGE
SITE: Family YMCA of the Desert DATE:
ParenYs Name:
Enrollment Date: Termination Date:
Member: YES NO Membership Exp Date:
(circle one)
Payment Due Dates:Payments are due on the 1�of the month if paying monthly or every Monday if paying weekly. The child will be excluded
from the program if the full payment is not received within 10 woricing days.
Monthly/Weekly
Days: M T W TH F
1. Child's Name :
Type of care:School Age:Plan 1 2 3 4 #of Days:2 3 5
Fees: - FA: NO or YES Amount . = your fee_
Monthly/Weekly
Days: M T W TH F
2. Child's Name:
Type of care:School Age:Plan 1 2 3 4 #of Days:2 3 5
Fees: � - FA: NO or YES Amount = your fee^
Monthly/Weekly
Days:MTWTHF
3. Child's Name :
Type of care:School Age:Plan 1 2 3 4#of Days:2 3 5
Fees: - FA: NO or YES Amount .= your fee�
1. I understand that my child is enrolled in the program for the 2008/2009 year, July '08 to
June '09. I understand that I am responsible for the monthly or weekly fees.
2. I understand that the program is CL_OSED for the holidays listed in the parent manual.
3. I understand that I am responsible for a payment every Monday of each week if paying
weekly or the 1st of the month if paying monthly. Any balance due exceeding 10 working
days will result in a loss of childcare. If payment is not received in full or if the YMCA is not
contacted within 10 working days, my account will be turned over to a collection agency.
The YMCA is a non-profit organization and payment is needed to keep the operation
running.
4. I understand that I am responsible for a ONE WEEK WRITTEN NOTICE to withdraw from
the program and the tuition to cover this period.
5. I understand that I am responsible for making prior arrangements in writing with the Site
Supervisor for absences. I understand that my vacation credit is already included in the
monthly fee.
6. I understand that the staff will assume responsibility for my child(ren), from the time I sign
them in, to the time they are signed out by an authorized person. ONLY WRITTEN
AUTHORIZATION FROM THE PARENT WILL BE ACCEPTED, VERIFIED BY THE SITE
SUPERVISOR, FOR PERSONS OTHER THAN THOSE LISTED BY THE SITE
AUTHORIZATION LIST TO PICK UP MY CHILD.
7. I understand that the YMCA does not provide accident insurance.
PLEASE INDICATE YOURS: Type of Insurance:
Company: Policy Number
11
8. I understand if a medicai emergency arises, the staff will first attempt to contact the parents.
The staff will be responsible for calling appropriate emergency personnel to attend to and
transport my child.
9. I understand the importance of up dating ail information that is pertinent to the child's well
being.
10.I understand that I may pick up my child until the center closes at 6pm. After closing there
will be a late charge of$1.00 per minute. I understand that this fee must be paid at the time
of pick up. I understand, should I not have the money, it is then due the following day.
11. I understand if I fail to pay the late fee the folfowing day or if I am constantly late in picking
up my child(ren) I risk losing my childcare spot.
12. I understand that if my child is not picked up by closing time, the staff will attempt to call
those listed on the emergency form. After ONE (1) HOUR, the proper authorities will be
����i� called and the child will be handed over to them.
y'1�l�lIV� �� understand that a non-refundable, non-transferable annual registration/membership fee of
$135.00 is due in order to reserve a spot. I understand that should I leave the program for ny
reason and wish to re-enroll, that I will be required to pay a $55.00 re-enrollment fee.
14. I understand should it be determined by collaboration between staff and parents that
damage to the facility, properties herein, grounds or play equipment was the fault of the
child, I am responsible for the cost or repair.
15. I understand should it be determined by the staff, Site Supervisor, Director of Childcare
Services that my child poses a serious discipline problem, my child may be dismissed from
the program immediately. I understand there are no refund /credit given if the child is
dismissed from tfie program or is in the process of being dismissed.
16. I understand that 1 am responsible and will abide by all the policies concerning admission,
financial obligations and program operations set forth in the Parent Manual.
17. I have received and read the Parent Manual which includes the following documents:
Personal Rights
Parent's Rights
Caregiver Background Check Process
Facing the Facts: A Parent's Guide to the Understanding of Child Sexual Abuse.
18. I have received the Parent Manual and I agree to comply with a{I stated policies concerning
admission, financial obtigations and program operations.
19. I have received a pay scale consisting of the weekly and monthly fees.
Parent's /Guardian's Signature Date
Site Director Signature Date
12
,
STATE OF CAL�FOFiNU-HF�ILTH AND HUMAN SERVICES AOBICY CALIFORNIA DEPAFiTMENi OF SOGA�SERVICES
PERSONAL RIGHTS
Chtld Care Centers
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.
(a) Child Care Centers. Each child receiving services from a Child Care Center shafl have rights which include, but are
not limited to,the following:
(1) To be accorded dignity in his/her persorral relationships with staff and other persons.
(2) To be accorded safe, healthful and comfortable accommodations, fumishings and equipment to meet his/her
needs.
(3) To be free from corporal or unusual punishment, infliction of pain, humiliatlon, intimidation, ridicule, coercion,
threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daify
living functions, including eating, sleeping, or toileting; or withholding of shelter,clothing, medicatlon or aids to
physical functioning.
(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the
provisions of law regarding complaints including, but not limited to, the address and telephone number of the
complaint receiving unft of the licensing agency and of information regarding conHdentlality.
(5) To be free to attend religious serVices or activities of hisJher choice and to have visits from the spiritual advfsor
of his/her choice. Attendance at religious services, either In or outslde the facflft}r, shafl be on a completely
voluntary basis. In Child Cara Centers, dectsions conceming attendance at religfous servicas or visits frorn
spiritual advisors shall be made by the parent(s),domestic partner(s),or guardian(s}of the chlld.
(6) Not to be locked in any room, bui[dirtg,or facliity premises by day or nfght.
(7) Noi to be placed in any restralning device, except a supportive restrainf approved in advance by the licensing
agency.
THE REPRESENTATIVE/PARENTlDOMESTIC PARTNER/GUARDIAN HAS THE R(GHT TO BE INFORMEQ OF THE
APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:
Department of Social Senrices Community Care Licensing
NAME - -
3737 Main Street, Suite 70U
ADORESS
Riverside, California
�Ry LP CODE AREA CODE/fEIFPHONE NIA�ER
92501 (951) 782-4200
DETACH HERE
TO: PARENT/DOMESTIC PARTNER/GUARDIAWCHILD OR AUTHORIZED REPRESENTAT'IVE: PLACE IN CHILD'S FILE
Upon satisfactory and full disclosure of the personal rights as e�cplained,complete the following acknowledgment:
ACKNOWLEQGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the
Caltfornia Code of Regulations,Trtle 22,at the time of admission to:
(PRINi THE NAME OF THE FAGLf7V) (PRINT THE ADDRESS OF THE FACILlTI')
Family YMCA of the Desert 443-930 San Pablo Ave. Palm Desert, Ca. 92240
(PRINT iHE NAME OF THE CHILDj
(SIGNATUHE OF THE REPRESENTATIVE/PARENT/DOMESTIC PARTNER/GUAR�IAN)
(T1TLE OF THE REPRESENTATIVE/PARENT/pOMESTIC PARTNEWOUARDIAN) (DATE�
LIC 613A(1/OB)
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STiQE OF CNJFORNIA--HEALTH AND HURW�SEAVICES AGBJLY GIJFORNIA DEAiMIL1EM OF SOpAL SFANCES
� COMA0.INRY CAAE LICBJSWO DMSiON .
CHILD CARE CENTER
NOTIFICATI�N OF PARENTS'RIGHTS
PARENTS'RIGHTS
As a ParenUDomestic Partner/Authorized Representative,you have the right to:
1. Enter and inspect the child care center without advance notice whenever children are in care.
2. File a complaint against the licensee with the licensing office and review the licensee's public file
kept by the licensing office.
3. Review,at the child care center,reports of licensing visits and substantiated complaints against the
licensee made during the last three years.
4. Complain to the Ilcensing office and inspect the child care center without discrimination or rataliation
against you or your child.
5. Request in writing that a parent not be allowed to visit your child or take your child from the child
care center,provided you have shown a certified copy of a court order.
6. Receive from the Ilcensee the name,address and telephone number of the local licens(ng office.
Licensing OffiCe Name: Departrnent of Social Services Community Care Licensing
Licensing Office AddresS: 3737 Main StreeL Suite 700 Riverside Ca. 92501 "
Licensing Office Telephone#: (951)782-4200
7. Be irrformed by the licensee, upon request, of the name and type of association to the child care �
center for any adult who has been granted a criminal record exemption, and that the name of the i
person may also be obtained by contacting the local licensing office. I
8. Receive,from the licensee,the Caregiver Background Check Process form.
NOTE: CAUFORN/A STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS Tn THE CHILD CARE CENTER 7U A
PARENT/DOMESTIC PARTNER/AUTHORIZED REPRESENTAT/VE/F THE BEHAVIOR OF THE PARENT/DOMESTlC
PARTNER/AUTHOR/ZED REPRESENTATIVE POSES A RISK TO CHILDREN/N CARE.
For the Department of JusUce"Reglsteied Sex Offender"database,go to www.meganslaw.ca.gov
uC aes(�roe) (Detach Here-ONe Upper Portion to Parents)
---------------------------------------------------------------------------------------------------------------------------
ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS
(Perent/DomesNc Partner/Authorized Represenfative S/gnature Requlred)
I,the parenUdomestic partnedauthorized representative of , have
received a copy of the "CHILD CARE CENTER NOTIFICATION OF PARENTS' RIGHTS" and the
CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.
�
Family YMCA of the Desert
Name of Chld Care Cerrier
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S(gnature(ParenVDomestic Partner/Authorized Representative) Oate i
NOTE: Th/s Acknowledgement must be keptln chlld's flle and a copy ol the Nof!(Ication given to
parenUdomesflc partrtedauthorized representative. I
For[he Department of Jusiice"Reglstered Sex Offender"database go to www.meganslaw.ca.gov
uc�s(iroe) �
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STq�OF CAUFORNIA-HEALTH AND Fri1MAN SERVICES AGENCY CALIFOMlIA DEPAHTMENT OF SOCUL SEFNICES
CONSENT FOR EMERGENCY MEDICAL TREATMENT
Child Care Centers Or Family Child Care Homes
- � ��
AS THE PARENT, DOM�STIC PARTNER, OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
Family YMCA of the Desert TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
FAGILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.)OSTEOPATH (D.O.)OR DENTIST(D.D.S.) FOR
. THIS CARE MAY BE GIVEN UNDER
NAME
WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD
NAMED ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE PARENT,DOMESTIC PAR7NER.OR AUTHORIZED REPRESENTATNE SIGNATURE
- ------'- ----------
HOMEADORESS -
HOME PHONE !WORK PHONE --
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LIC 627(1/0B)(CONflDENT1Al)
Y FAMILY YMCA OF THE DESERT
v+roa,aa:a«ww�. NEEDS QUESTIONNAIRE
��.
���
This form is designed to meet the needs of individual children in YMCA Child Care programs. This is best accomplished
by mutual planning by the parents and staff at the time of admission, as well as ongoing communication throughout each
child's participa6on in the program.
NAME OF CHILD Date of Birth
Site Program
If your answer is YES to any of the following quesbons in Sections I through VI, please complete a"SERVICE PLAN"with
the director.
I. Before and After School Care:
a. YES NO Does your child need help in being able to stay with the larger group of
children?
b. YES NO Is a small group setting more manageable for your child?
c. YES NO Does your child requlre a setting where the i�atio of 1 (staff)to 14
(children)is not sufhcient? If the ansvuer to questlon is YES, please list
� any community resources we could access to meet thls child's need?
!I. All Day Child Care:
a. YES NO Does your chlld's energy level prevent al!day.participat�on in the
program?
b. YES NO Is there a problem with your child participating in swimming and other
activlties?
c. YES NO Is there a problem with your child being transported on field trips without
special equipm�nt?
III. Snack and Meals:
a. YES NO Does your chifd have allergies to certain foods?
b. YES NO Does your child require any special food?
c. YES NO Does your child require speclaf eating apparatus? If so, what?
d. YES NO Does the staff need to fe�d child with or without special eating
apparatus?
IV. Medication:
a. YES NO Does your child need daity ongoing medication to be administered by the
YM�A s�aff? t#se, w#a��
b. YES NO Does speaal apparatus need to be used to administer this mediaation?
If so, what?
V. Toileting procedures:
a. YES NO Does your child need diapering? If so please explain.
VI. Special Equipment:
a. YES NO Dces your child need any special equipment not already discussed? If
so, whaY1
b. YES NO Are there availabfe resources for obtaining special equipment or
supplies, such as eating utensils, large bids, adaptive scissors, toys, or
games, toileting chairs, harnesses, etc.? If so, please list?
Is there a medical diagnosis for the condibons that require accommodaGon?
;
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PARENTS/GUARDIAN SIONATURE DATE
R�tATIONSHIP TO CHILD
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Y FAMILY YMCA OF THE DESERT
ws n�;a�wa�, SER�/ICE PLAN
���.
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Please complete a service plan with the director of your child's program in any area listed below where accommodation is
required as reflected by YES answers on tfie NEEDS QUESTIONNAIRE.
NAME OF CHILD DATE OF BIRTH
SITE PROGRAM
I. Before and After Schoof Care
II.All Day Care
III. Snack and Meals
IV. Medication
V. Toileting Procedures
Special Equipment
ParenYs/Guardian Signature Date
Relationship to child
Staff Signature Date
FAMILY YMCA OF THE DESERT
CHILD CARE REGISTRATION CHECKLIST
1. Enrollment Packaqe
School Aqe Pre-School
Membership Application N/A Membership Application
CC Admission Form N/A CC Admission Form
Chi1d's Pre-Admission Health 8�Medical Consent N/A Child's Pre-Admission Health&Medical Consent
Needs Questionnaire N/A Needs Questionnaire
Personal Rights N/A Personal Rights
Sexual Abuse Information N/A Sexual Abuse Information
Caregiver Background Check Proc. N/A Caregiver Background Check Proc.
Registration Agreement N/A RegistraGon Agreement
Parent Manual N/A Physician Report
Fee's N/A Food Program Form
N/A Equipment List
N/A Parent Manual
N/A Fee's
N/A CDBG Form(Jean Benson Preschool site only)
2.Check the Pre-Admission Health liistory,Physician Report and Needs Questionnaire to see if there is any
clarification needed from the parents,or special arrangements that need to be made.
3. Review the Financial Aspects of the program .
4.Operational Policies and Procedures
Center Policy Immediate Dismissal-Program
Center Hours of Operation Toys from home
Vaca6ons/Holidays Birthdays �
Signing In&Out Clothing
Authorization to pick up children Naps(Blankets
Daity Absences Parent Conferences
Meals&Snacks Parent Bulletin Board
Discipline Parent Newsletter
Special Circumstances Policy Taxes
Incldent Reports Damage to property
Counseling Centers Character Development
5.Health and Safety
Health Madication
Keeping your child home Head Lice
Emergencies/Injuries Accident Insurance
6.Other
Grievance Procedures Special Events:
Calendar Hoe Down
CuRent Support Campaign Walk-a-thon
Other Child Care Sites Volunteering
Parents Signature Date
Site Director: Date
Checklist Completed on with
Parents Name(Please Print)
excel:Parerrt Manual CC Registration Chedclist
A Parent's Guide to the Understanding of Child Sexual Abuse
Sometimes parenfs have to face issues they would rafher avoid.
What Is Sexua/Abuse?
The sexual abuse of a chiid occurs whenever any person forces,tridcs or threatens a child in order to have sexual contact with him/her. This
contact can include such°non-touching'behaviors as an adult exposing himself or asking a child to look at pomographic material. It inGudes
behaviors ranging from sexual handling of child(fondling),to actual genital contact,to intercoursa,to violent rape. In all instances of child
sexual abuse,the child is being used as an objed to satisfy the aduft's sexual needs or desires.
'Candy is my best friend. !play at her house a/ot. Today her daddy asked us to look at some pictures. They were nasty pictures of people with
no ciothes on. He said, "Doesn't that look like/un?"1 didn't think so,but!said, 'Yes'"
Who Gets Sexually Abusedl
Any child of any age is a potential vicfim of sexual abuse. Some important fads to keep in mind.....
'Akhough the majority of adults do not sexually assault children,most sexual abuse occurs wifh an adult the child
knows and trusts.
'Most sexual abuse goes unreported and undetected.
'Afthough we do not have exact numbers,some studies have found that one out of every four girls and one of every ten boys
become victims of child sexual abuse by the age of eighteen.
'Children often keep sexual abuse a secret.
"IM�en Mommy goes to work,/stay at Mrs.Jenkin's house. !wish!didn't have to. Mommy says Mrs.Jenkins is a real nice lady,but Mrs.
Jenkins'son, Ralph,sometimes makes me do bad things. Yesterday he made me take off my underwear and he puf his finger in my privafes"
He said, "You betternot tell"."
Children may keep a sexual assault a secret for many reasons. They may fear rejection,blame,punishment or abandonment;they may think
people won't believe them. Boys are less likely tn report an abuse than girls. The closer the reladonsh/p of the offender to the ch!!d,tf►e
less like/y It Is that the child wfll report the Incident
How Can You Determ/ne!f Sexual Abuse Nas Taken Place9
First and foremosf,if your children confide that they have been sexualfy assaulted,belleve theml Children very seldom Ife about such a serious
matter. Also be aware that most sexual abuse does not resuft in the child being violenUy attadced or hurt physically. Often there is no physical
evidence a child has been molested. Fondling,involvement in child pomography and oral sex usually present no physical slgns of abuse. But, if
a child has been physically hartned as a result of sexual abuse,the following may be signs of thfs occunence:
. A discharga from the vagina!area or penis
• Injury to the genitals or anus
• Pain,itching or bleeding in the genital or anal area
• Discomfort in walking or sitting
. The discovery of a sexually transmitted disease.
• Children,especially very young children,are many times unable to verbalize that they have been molested. The following are some
indicators that sexual assautt may have taken place:
• Nightmares and sleep disturbances
• Bedwetting
• Fear of certain places or certain people(such as day care centerora fiiend)
• Lose of appetite
• Clinging to a parent more than usual
. Behaving as a younger child(such as an older chtld sucking hislher thumb)
• Withdrawal
• Excessive masturbation
• Unexplained changes in behavior at school day care,or in relations with peers
• Acting out the abuse wlth dolls,friends,or through drawings
. Keep in mind that although these are the most common signs of sexual abuse,there may be other causes for these changes. However,
sexual abuse shouid not be ruled out as a possibility.
What Can You Do To Prevent Sexual Abuse9
You teach your children many safety rules. You tell them to look both ways before crossing the street what to do if they get hurt,not to talk to
strangers and so on. Discussion relating to sexual abuse prevention can be included in this nortnal teaching process. Your children need not
be made afraid or suspicious of all adults in order to accomplish this. You don't even have to talk to very young children about sex if you don't
want to. Simply make your children aware that if someone touches them or does anything that makes them uncomfortabie,they should report it
to you or another adult that they trust. You can teach your children they have the right to say"NO"if asked to do something that make them
uncomfortable,even if the person who asks is a relative or close friend. Use words your children understand. Let them know they can come to
you to talk about anything that's upsetting to them. Answer any questions your children may have and be calm and matter-of-fact.
Other Things Parents Can Do To Lessen The Risk�f Sexual Abuse.
. Know where your children are and what they are doing
. Know who is with your children. Get to know any adults or older children that have regular contact with your child.
. Check out fully any baby-sitters or day care providers. Ask for references and then check them. Do not use childcare settings
. which prohibit drop-in visiting. Visit your child's day care facility frequently and observe the daily activities.
. Ta{k with your children about the day's activities. Be observant of anything they say or do tAat seems out of the ordinary.
"Uncle Bill takes me ta lots ofplaces and buys me ice cream and stuff. Buf sometimes f don't fee/good when he makes me touch his Yhing: !
want to te!l Mom,but!'m scared she d gef mad."
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What If You Discover Your Chl/d Had Been Sexually Abused�
Children's reactions to being se�cuaity abuse differ greaGy from chiid to child because of the child's age,his/her personality,the nature of the
offense,the offenders relationship to the child and aduft reactions to the discovery of the abuse. Sometimes children do not appear overy
upset by the abuse;often,they are confused or fightened by what they have encountered. You,as a parent,piay an important paR in how the
abuse will at►ed your child both in the short and long tertn.
The following are some suggestions if you discover your child has been sexually abused:
• Believe your child;reinforce that fact he/she is not to blame for what happened.
• Immediatety report the abuse to the proper authorities(see'Contacts and Services'� �
• Assure your child that you still love him/her.
• Ailow your child to talk about the incidents(s),but do not pressure him or her to do so. �
• Let your child know that he/she wil�be protected from further assault. Protection of your child should be your first concern. I
• Seek medical care if you suspect any sexual abuse may have occurred. Although children are rarely seriously damaged physically by sex
offenders,intemai injury may have occuRed and tha risk of a saxuaily transmitted disease must be considered. �
• Discuss any possible medical complications with your physician. �
• Be aware of your own feelings concerning the abuse. Although you may have many feelings ineluding shodc,anger and disbelief,make '
sure your child understands your feelings are not aimed at him/her.
Remember,you have the primary responsibility for your chiid's weii-being. With a litt/e time and etfort you may prevent your child from being I
inju�ed in an abusive situation �
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Just Sexua/Abusel
Be aware of other forms of abuse,especially if your child is left in the care of others. Make it a habit to examine your child's body. (This can be
done in a casualmanner while dressing orbafhing.J Question any unusual marks,bruises,bumps,welts,etc.
While everyone should repoR suspected child abuse and neglect,the Califomia Peaal Code provides that certain professionals and lay-persons
must report suspected abuse to the proper authorities. The mandate reporters include:
Any Child Care custodian(teachers,Ucensing daycare woiicers,foster parents,social workers)
Medtcal Praditioners(physidans,denfists,psychologist nurses)
Non-medical Praciftioners(publ/c health employees,counse%rs,religious practitioners who treat childr�n,probatlon ofh'cers,county wellare
�`department employees). � �
Employees of a child protective agency(sherifl�,Failure to report suspected abuse by a mandated reported(listed above)within 36 hours is a
misdemeanor punishable by up to 6 months in county jail,a fine of not more than$1,000 or both,STATE OF CALIFORNIA
Conta�t and Service A enc To Tele hone
for your information,the following chart Police County Departrnent State or Local Division of I
shows what agencies may assist you in or of Children's or Community Care Licensing 'i
s ecific areas as listed below: Sheriff Social Services i
•ff you believe a child is being(or has been � � I
abused by an individual(relative,&iend)... � Ot � ,
•ffyou believe a child has been assaulted I
by a strauger....................................... �
•ff you believe a cliild is being(or 6as been)
abused iu a licrosed day caro setting(child
care ceater,school,recreational facility,
faznily day care home)........................... �and � �
•If you have auy quesfioas or complaints
conceming the licensing,ocgani�tioq
staffing or programs of a licensed child � i
caze settin
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� HEALTH AND WELFARE AGENCY
Clrftord L AlknDy,Secrntary
DEPARTMENT OF SOGIP.L SERVICES
LirWa S.McMahon,Diredw �
This pamphlet may De repraduced without wiitten permission
PUB 106(8/87) i
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