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Sherberth Road

Lake Buena Vista

Child CareEnrollment

Central Florida YMCA Family Centers

At the Walt Disney World® Resort

Application for Care

(Complete one per child)

Copy Cast Member WDW ID badge and staple to application

$25 Cast Member Application Fee for Primary Care

$40 Non-Cast member Application Fee for Primary Care

Special instructions: Please List Cast Member Parent First

Please Circle OP or P if not a Cast Member

Parent Name(same as WDW ID):
Pernr Number:OP P / Parent Name:
Pernr Number: OP P
Address: (include apt #) / Address: (include apt #)
Home Phone:
Cell Phone:
Work Phone: / Home Phone:
Cell Phone:
Work Phone:
Email Address: / Email Address:
Employer:
Work Location:
Position/Job/Title:
Work Status FT/PT Seasonal(Circle one) / Employer:
Work Location:
Position/Job/Title:
Work Status FT/PT Seasonal(Circle one)
Marital Status: / Child’s Primary Residence: (Circle One)
Mother/Father/Both/Other
Child Name: / Birthdate:
Is your child toilet trained? Yes No / Gender: Male / Female (circle one)
Primary Language
Secondary Language

Pick-Up Authorization

All adults must show a photo ID when they pick up a child. Your child will be released only to the parent or legal guardian and the persons listed below. Those persons will also be contacted in case of illness, accident or emergency. If for some reason the parents or guardians cannot be reached, the following are authorized to remove the child from the facility: (If none, indicate “none.”)

NameDaytime phone Relationship

Child Emergency Information

Child’s DoctorPhone

Dentist’s NamePhone

Hospital

I do hereby authorize officials of the Central Florida YMCA Family Centers at Walt Disney World® Resort to contact directly the persons named on this card, and do authorize the named physician or associates to render such treatment as may be deemed necessary in an emergency, for the health of said child. In the event that parents, legal guardians, or other persons named on this card cannot be reached, the Center officials are hereby authorized to take whatever action is deemed necessary in the judgment of the health of child.

Signature of Parent of Legal GuardianDate

Additional Emergency Contacts:

NameDaytime phone Relationship

List Allergies:

Health concerns: Specify and explain fully (include chronic conditions, limitations, medications, special needs). Does you child have an IEP (Individualized Education Plan)? If so, it must be provided with your application package.

Permission to Photograph Child

I give the Central Florida YMCA Family Centers at Walt Disney World® Resort permission to have my child photographed/videotaped by the press or staff of the facility to use for public relation purposes at any time.

Signature of Parent of Legal GuardianDate

I do not wish to have my child included in photographs and videotapes.

Signature of Parent of Legal GuardianDate

“The Flu” A Guide for Parents

During the 2009 legislative session, a new law was passed that requires child care facilities, family child care homes and large child care homes provide parents with information detailing the causes, symptoms, and transmission of the influenza virus(the flu) every year during August and September and at enrollment.

My signature above verifies receipt of the brochure on Influenza, The Flu, A Guide to Parents: Date:

Know Your Child’s Day Care Center

Child’s Name

Section 65C-22.006 (4C-1) F.A.C. requires that parents must receive a copy of the Child Care Facility Brochure

(HRS PII 175-24, 2/95), KNOW YOUR CHILD’S DAY CARE CENTER. The parent’s or legal guardian’s signature verifies receipt of the childcare brochure. Please complete the following.

I have received a copy of the Child Care Facility Brochure, KNOW YOUR CHILD’S DAY CARE CENTER.

Parent Name (Please Print)

Signature of Parent of Legal GuardianDate

Parent Handbook Receipt

I have received a copy of the Central Florida YMCA Family Centers at the Walt Disney World Resorts Parent Handbook. I hereby agree to follow the policies set forth in the Parent Handbook.

Section 65C-22.006 (4C-2) F.A.C. requires that parents are notified in writing of the disciplinary practices used by the child care facility. The parents’ or legal guardian’s signature verifies the parents or guardians have been notified in writing (via Parent Handbook) of the disciplinary practices of the childcare facility. Please complete the following:

I,)

Print Name of Parent or Legal Guardian

I have received in writing the disciplinary practices used by the child care facility which is stated in the Parent Handbook.

The fee is set forth and will be in effect until a new agreement is signed.

This fee will be paid in advance. I understand that care will not be provided without this advance payment.

I understand that there is no reduction of fees when my child is out sick or on vacation.

Signature of Parent of Legal GuardianDate

Child’s name ______

Parent/Guardian Policy Acknowledgement Form

______1.I agree to pay the registration fee of ______.

______2.My daily rate is ______with the hourly rate of ______.

4-10 hour day

Cast member ratenon-cast member rate

Infants$44$47

Toddler$42$45

Twos$40$43

Preschool$34$37

School Age$28$31

______3.I understand I have a six minute early drop off and pick up window. There will be an additional fee for early drop off or late pick up. See the Front Desk for fee details.

______4.Over the counter payments:Check, Money Order, VISA/MasterCard/AMEX or cash are due by Sunday for the following week, I will be charged $5.00 a day until my tuition is paid.

Payroll Deduction: Your weekly tuition will be deducted every Thursday for the week in advance through WDW’s payroll. If you elect to pay this way please fill out the entire payroll deduction form at the Front Desk. If you stop your hours (ex. Maternity leave or leave of absence) make sure you stop your payroll deduction.

_____ 5. I understand if I have a fixed scheduled, my days and hours will not change unless I turn in a Schedule Change Request form. The change form must be turned in by the 15th of the current month and will go into effect the first week of the following month, depending on availability.

_____ 6.I understand that if I have a flex schedule, my days and hours change every week. My schedule for the following week needs to be turned in on the Wednesday before the work week by noon. If is not turned in, the same schedule from the previous week will take effect.

_____ 7.I understand if I withdraw my child, a Withdrawal Form must be completed and a two week notice must be given.

______8.I understand that if my child is out sick or on vacation, I am still obligated to pay for those days.

______9. I have received a copy of the Parent Handbook and understand that I am responsible for all content and information outlined in the Parent Handbook.

_____ 10.I have received the Infant Welcome Packet and Less Restricted Environment information (If applicable)

_____11.I have been informed of Life Cubby system and the use of technology in a group care settings.

_____12.Start date______(will be billed starting this Sunday date)

______

YMCA Family Center Enrollment Specialist Date Parent SignatureDate

License #801-8

Revised 1/09