3520 S.E. Yamhill Street E Portland, Oregon 97214-0834 . (503) 233-2246

Children’s Club Inc.

______

3520 S.E. Yamhill Street e Portland, Oregon 97214-0834 . (503) 233-2246

Thank you for choosing Children's Club as your childcare provider. We hope to meet all of your expectations.

Children’s Club is a 501(c)3, non-profit, tax exempt organization. In order to keep our fees as low as possible, all families are requested to provide service at Children's Club 2 hours per month (24 hours per year). This can be as simple as helping with cleaning up at the end of the day or helping in the classroom, 30-45 minutes for 3 or 4 days or going on a field trip. We have lots of ideas to fit your schedule and skills. Helpers may be parents grandparents, other family members or friends over the age of 15. If you choose not to aid, your childcare fee will be increased by 5% per month.

Please fill out all forms in this packet

GREEN SHEET (pages 3-4)

Joay Mills, Children's Club Director, will determine you childcare fee, which is based on your income.

PLEASE FURNISH A PROOF OF INCOME DOCUMENT OR YOU WILL AUTOMATICALLY BE PLACED AT THE HIGHEST TIER ON THE SCALE.

See fee Schedule in parent handbook.

PINK SHEET (pages 5-8)

Please make sure that all information is correct and updated as needed. This form is vital to your child's safety as it lists persons allowed to pick up your child and medical information.

BLUE SHEET (page 9-10)

Please determine whether you would like to pay the 5% higher tuition or take part in the assistance program. Fill in the needed information.

IMMUNIZATION FORM. All children who have not attended a Public School are required by Oregon State law to have this form on file.

If this applies to your child PLEASE CONTACT YOUR CHILD'S DOCTOR for a copy of his/her IMMUNIZATION RECORD and submit it to the office.

WHITE SHEETS (pages 11-15)

"Children's Club, Inc.", please enter child's name in sections 1 and 10. Read and initial, if you agree, all other Sections.

PICK-UP POLICY. Please read, sign and date.

THANK YOU,

BOARD OF DIRECTORS, CHILDREN'S Club, Inc.

Green Sheet

Contract for Care

Childrens Club Inc.

3520 SE Yamhill St., Portland, OR 97214 (503) 233-2246

Name of Child:______DOB:______Class: ______Ft/Pt____

Name of Child:______DOB:______Class: ______Ft/Pt____

Name of Child:______DOB:______Class: ______Ft/Pt____

Enrolling Parent:______SS#:______

Home Address:______

Home Phone:______Cell Phone:______Email:______

Parent #1 Work/Day Phone:______Parent #2 Work/Day Phone______

1st day child(ren) will attend:______Anticipated Schedule (days):______(hours):______

In order to receive Services based on our sliding Scale tuition Schedule, each parent or household family member must submit proof of income or the most recent three months upon enrollment. Each parent or household family member will then be required to Submit proof of income every three months thereafter.

Adjustments to the total monthly fee will be made based on these quarterly reports. Failure to Submit proof of income will result in the assessment of our full fee for tuition.

Your first child's care at full fee would be $______/ month

Based on our sliding scale tuition schedule, your first child's monthly tuition is: $______

Based on our sliding scale tuition schedule, your second child's monthly tuition:$______

Your 15% discount for enrolling a second child totals: $______

Based on our sliding scale tuition schedule, your third Child's monthly tuition is: $______

Your 15% discount for enrolling a third child totals: $______

Your total monthly fee for tuition is: $______

Prorated amount (if applicable) due on Or before first day of Service: $______

Your total monthly fee if paid on or before the first Working day of the months: $______

You may choose to waive your 5% early pay discount for the benefit of Children's Club. If you would like to do this, initial here______

If paid by AFS, worker name and branch:______Verified by:______

Children's Club General Payment Policy

● Payment for Service is due in advance.

● Monthly fees are due by the 7th of the month in which care is provided.

● AFS copayments (if applicable) are due by the 15th of the month following the month that billed service was provided.

● If your account is not paid in full by the last day of the month, your child will not receive care for the following month unless аrrалgements are discussed in person and written in conjunction with the Executive Director.

● You must Submit a "Change of Attendance Form" before adding, reducing changing, or terminating service. This includes vacations arid other temporary changes of attendance. Adjustments to tuition will only be made after this form has been submitted.

● We close at 6:15 PM. You will be charged $1 per minute for every minute you are late in picking up your child past this time.

2nd child discount applies to full time (5 days per week) enrollment only

I have read the above statements and agree to the terms and Conditions stated therein, have also received the Children’s Club Parent Handbook" and agree to the outlined policies and procedures.

Parent/Guardian Signature:______Date: ______

Staff Signature:______Date:______

Pink Sheet

Emergency Medical Treatment Consent Form

Children's Club Inc.

3520 SE Yamhill St., Portland, OR 97214

(503) 233-224

If your child needs emergency medical care while and Children's Club and you aren't available to give formal consent to medical authorities, care may be unnecessarily delayed. To protect your child, leave a completed "Emergency Medical Treatment Consent Form" with us, in the event of a medical emergency, this form must accompany your child to the hospital/clinic so that medical-treatment can be rendered. This form also request parental consent for Children's Club to call an ambulance or transport the child to an available physician or me treatment facility.

I/we,______,hereby authorize Children's Club Inc.,to give consent for all medical and/or surgical treatment that may be required for the child(ren) listed below may be that required in the event of an emergency during our absence, I/we also authorize Children's Club to call an ambulance or to transport the child(ren) to an available physician or medical treatment facility if necessary.

Childs Name______

Child(ren)'s Physician:______

Physician's Address:______

Physician's Phone: ______

Preferred Hospital:______

Health insurance Co.: Member #: Group #:

Parent/Guardian Signature:______Date:______

Staff Witness:______Date:______

OR

I/we,______,hereby deny authorization of

Children's Club to give Consent for medical/surgical treatment for the child(ren) listed above

Parent/Guardian Signature:______Date:______

Staff Witness:______Date:______

Student Registration Information

Children's Club

3520 SE Yamhill St. Portland, OR 97214 (503) 233-2246

Child's name: DOB:

Siblings currently enrolled at Children's Club (First and last names):

Parent Name #1:

Home Address;

Home Phone: Cell Phone:

E-mail:

Workplace:

Work Address:

Work Hours: Work Phone

Parent Name #2:

Home Address:

Home Phone: Cell Phone:

E-mail:

Workplace:

Work Address:

Work Hours: Work Phone

EMERGENCY CONTACT INFORMATION: if neither the mother or the father can be reached, the following person can be contacted on behalf of the child

Name: Phone: Relationship:

Name: Phone: Relationship:

Child's Doctor: Phone:

Address:

Child's Dentist: Phone:

Address:

How will your child be transported to and from Children's Club?

Please list the people who are authorized to take child from building, including transportation home:

Please list any individuals who are specifically NOT AUTHORIZED to leave with your child:

Child's Allergies:

Other Health issues:

Names of other children and adults in household:

Blue Sheet

Dear Parents,

In order for Children's Club to keep tuition rates as low as possible, we request 2 hours of service to Children's Club per month. Service can consist of, helping in the classroom, going on a field trip, maintenance, fund raising, donations of supplies, etc. We will help you find something that will fit your skills and try to accommodate your schedule.

If you decide that you don't have the time to serve these hours you may choose to pay an additional 5% in tuition each month.

PLEASE, make a choice and fill in the appropriate part of the form below.

Thank You!!!!!!!!!

NAME:

PHONE:

I am committed to helping at Children's Club and understand that my commitment is for 2 hours per month, a total of 24 hours per year. If I fail to meet this obligation, I understand that I will be billed an additional 5% tuition fee for each month that this obligation is not met.

I would like to help- What is the best day and time ______

In the classroom______

With field trips ______

With maintenance ______

Donations ______

Fundraisers ______

Others (please list) ______

(signature) (date)

I cannot commit to the required Service hours and choose to pay an additional 5% tuition. (Please call the office for your additional $ amount)

(signature) (date)

Your time is the most valuable commodity and more important then the added tuition, but, to be fair, the choice is yours. If you have questions please call the

Office.

White Sheet

CHILDREN'S CLUB, INC.

Note: If you are submitting this online via email, please be sure to “sign” both print and signature portions of each item to prevent delay in processing this enrollment application.

1. I authorize______to attend Children's Club, Inc, at 3520 SE Yamhill, Portland, Oregon. The following agreements are written on behalf of the above named child.

Print______

Signature ______

2. I understand that the parent or guardian of each child assumes full responsibility for the child until he/she arrives at Children's Clubland after he/she leaves Children's Club each day. Children's Club's responsibility is solely during the time the child is in attendance in the program.

Print______

Signature ______

3. I understand that Children's Club has no responsibility for my child before the program opens each morning (6:15) although my child may be at the location prior to this time.

Print______

Signature ______

4. I understand that only myself, authorized Children's Club staff member

and persons listed on Children's Club application form will be allowed take my child away from the program location at 3520 SE Yamhill, Portland, Oregon. I understand that I must make special arrangements with Children's Club if it is my intention for anyone other than the persons listed be allowed to transport my child to any location away from Children's Club, including child's home.

Print______

Signature ______

5. I agree that my child may have his/her picture taken and used for news or publicity purposes.

Print______

Signature ______

6. I authorize Children's Club to take my child on field trips. I give permission for authorized Children's Club staff members to transport my child by bus, van, or private motor vehicle during trips sponsored by Children's Club. Walking field trips may include the library, nature walks, and neighborhood parks. Walking field trips are from 30th to 39th between Hawthorne and Stark to include Laurelhurst Park. Parents will be informed of field trips other than walking trips, as these are sometimes spur of the moment.

Print______

Signature ______

7. In case of an emergency, I authorize Children's Club to obtain necessary emergency medical care for my child.

Print______

Signature ______

8. I understand that Children's Club assumes no responsibility for administering any medications to my child.

Print______

Signature ______

9. I understand that I must give 30 days written notice of termination of service or reducing days/time of attendance. I will be responsible for paying a 30 day fee if notice is not given.

Print______

Signature ______

10. As parent or guardian for I am authorized to sign these and any other agreements with Children's Club for this child. I understand that is is my responsibility to notify Children's Club Inc of any changes in the above or any other agreements made with Chiildren’s Club Inc, including changes of address, phone number, emergency contacts,

family income, medical conditions, etc.

Print______

Signature ______

11. I have read and fully understand the above.

Print______

Signature ______

PICK UP and SIGN IN POLICY

Dear Parents:

It is very important that when you are leaving your children in our care that you connect with their teacher and that the teacher acknowledges that your child has been left in our care and that you have signed them in on our roster sheets. If your child is neither signed in nor left with teacher acknowledgement then they are not in our care.

It is also of great importance that you sign your child out at the end of each day when you pick them up. The roster, accountability, sheets we use to sign children in and out are a tool used by our staff to track your children while they are in our care. You or an adult authorized by you must sign your child out and connect with the Staff person on duty before leaving with your child.

Please inform all authorized pick up adults of this policy!!

Childrens Club staff is not allowed to sign your child in or out.

ADULTS AUTHORIZED TO PICK UP MY CHILD ARE:

NOT ALLOWED ARE:

Please sign below to acknowledge that you have read and understand this letter

Print______

Signature ______

Dear Parents,

If you committed to 2 hours of service per month it will be your responsibility to turn into the office, the form below indicating what service was performed and

the time and date of Service. If you serve more than 2 hours in a month you will receive a time credit, to be applied to the next month. Please check the black board, in the hall by the SOP room, for a list of jobs that need to be done. If you

have any other ideas please talk to Joay or your child's teacher

______

If we do not receive the form (see below)you will be charged the additional 5% on your billing statement as follows:

No Sept service, billed on Nov. statement

No Oct service, billed on Dec. statement

No. Nov. service, billed on Jan. statement

Etc.

______

Date of service Hours served

Service performed;

Parent signature

Staff signature

Additional forms posted on Bulletin Board next to Parent Boxes.

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