ROBERT & DOROTHY LUDWIG SCHENECTADY JEWISH COMMUNITY CENTER

2010-2011

MIDDLE SCHOOL AFTER SCHOOL ENRICHMENT PROGRAM (MASEP)

REGISTRATION FORM

* Each form must be accompanied by a NON-REFUNDABLE 10% deposit

* Registration begins Thursday, April 1, 2010

* Registration is on a first come, first serve basis

* Registration must occur by Monday, August 23, 2010 to avoid a $35 late charge

Child’s First Name: ______________ Child’s Last Name: ___________________

Please check off the days you would like your child to attend:

_____Monday _____Tuesday _____Wednesday _____Thursday _____Friday

Child's Birthday _____/_____/_____ Gender _____Male _____Female

Grade (as of September 2010) _________ School ____________________________

Street Address: _________________________________________________________

City, State, Zip: _________________________________________________________

Home Phone: _____________________________________________

Parent’s Name: __________________________ Occupation: __________________________

Work #: ___________________________ Cell #: ________________________________

Parent’s Name: __________________________ Occupation: __________________________

Work #: ___________________________ Cell #: ________________________________

E-mail Address: _______________________________________________________________________

Please register my child for the:

_____Year Round Child-Care Package, which includes JCC membership, Monday through Friday MASEP, vacation programs, travel camp, travel camp extended day and post camp. (NO REFUNDS GIVEN FOR UNUSED TIME)

Are you interested in serving on a ASEP/MASEP Parent Committee? Yes ____ No ____

The MASEP program provides services to all children regardless of sex, race, creed, color, religion, handicap or national origin.

(OVER)

I understand and agree to the following:

1. I will make all tuition payments and obligations in a timely fashion as specified: Half the yearly tuition is due in September. The remainder is due in January. Alternate payment plans, such as monthly payments are also acceptable. There are no reductions or credits for illnesses, vacations, or Center closings.

2. If my child will not be attending MASEP on her/his regular day, I will notify the JCC prior to her/his usual arrival time. Failure to do so may result in my child being removed from the program.

3. The Center will provide me with a parent manual detailing MASEP policies and schedules.

4. The MASEP calendar is based on the Niskayuna School calendar. The Center and MASEP are closed on some Jewish Holidays. These may occur on regular school days, and you will be charged an extra fee if you choose to have your child attend Kid’s Time on these days. You will be provided with these dates in advance.

5. If a behavior problem arises, I understand that attempts will be made between the staff , the parent and the child to rectify the situation. If, after these attempts, the situation continues, I realize that my child may, at the sole discretion of the Center, be temporarily or permanently removed from the program. A discipline policy will be provided to families in August.

6. In order to enroll my child in MASEP, I must be a member in good standing of the Schenectady Jewish Community Center.

7. I must notify the School-Age Director in writing if I plan to withdraw my child before the end of the school year. If I notify the JCC in writing, I am responsible for all of the time my child attended, plus an additional 10% of the yearly fee. If I remove my child and fail to notify the JCC in writing, I will be responsible for all fees.

8. Niskayuna School’s early dismissal days are included in my tuition fees. On early dismissal days, children must bring a lunch. Vacation days, Jewish holiday closings, snow days and certain specialty classes are an additional fee and require pre-registration.

9. I will remit the 10% deposit upon enrollment, which is non-refundable, but is applicable towards the last month of tuition.

10. I understand that there will be a $26 service charge for any checks returned to the JCC.

11. I understand that if I pick my child up late, I will incur the following fees:

6:00 pm pick-up – I will be charged $1.50 per minute/per child

12. There will be a $10 administrative fee for any changes that you make to your child’s schedule.

13. I understand that the JCC is not responsible for any items lost while at the MASEP program.

14. A copy of this form is available upon request.

I have read and understand the registration form in full and agree to all terms.

________________________ _________________________ ______________

Name of Parent or Legal Guardian Signature of Parent or Legal Guardian Date

(Please Print)

2010-2011 MASEP

CHILD INFORMATION SHEET

CHILD'S NAME (Last) ______________________________ (First) ______________________________

GRADE (Entering) ___________ BIRTH DATE ____/____/____ AGE_______ GENDER________

HOME ADDRESS: STREET_______________________________________________________

CITY____________________________________________ ZIP__________________

HOME PHONE_______________________ SCHOOL ATTENDING_______________________________

CHILD LIVES WITH: _____Both Parents _____Mother ______Father

Other (PLEASE EXPLAIN) ____________________________________________________________________________________

Parent’s (or guardian) Name: ____________________________________________________________

Occupation __________________________________________________________________________

Business # _________________________________ Cell #____________________________________

Parent’s (or guardian) Name: ____________________________________________________________

Occupation _________________________________________________________________________

Business # _______________________________ Cell #______________________________________

STARTING WITH YOURSELF, PLEASE LIST IN ORDER ALL PEOPLE TO CONTACT IN CASE OF EMERGENCY:

1)___________________________/__________________/____________________/_______________/____________

Name Work Phone Home Phone Cell Phone Relationship to child

2)___________________________/__________________/____________________/_______________/____________

Name Work Phone Home Phone Cell Phone Relationship to child

3)___________________________/__________________/____________________/_______________/____________

Name Work Phone Home Phone Cell Phone Relationship to child

4)___________________________/__________________/____________________/_______________/____________

Name Work Phone Home Phone Cell Phone Relationship to child

5)___________________________/__________________/____________________/_______________/____________

Name Work Phone Home Phone Cell Phone Relationship to child

ONLY PEOPLE LISTED ABOVE MAY PICK UP YOUR CHILD

(OVER)

MEDICAL CONCERNS (ALLERGIES, VISION/HEARING IMPAIRMENTS, MOTOR SKILLS, ETC.): ________________________________________________________________________________________________________________________________________________

IS YOUR CHILD ON ANY MEDICATION? _____________ PLEASE SPECIFY______________________

________________________________________________________________________

________________________________________________________________________________________________________________________________________________

NAME OF ANY MEDICATION TO BE ADMINISTERED WHEN AT MASEP (ADDITONAL APPROPRIATE PAPERWORK REQUIRED: _______________________________________________________________________________________

WHEN/AMOUNT: _______________________________________________________________________________________

PLEASE LIST ANY SOCIAL CONCERNS: (DEATH, DIVORCE, SEPARATION...) _______________________________________________________________________________________

_______________________________________________________________________________________

PLEASE LIST YOUR CHILD'S INTERESTS AND HOBBIES: ____________________________________________________________________________________________________________________________________________________________________________

PLEASE LIST ANY PSYCHOLOGICAL CONDITIONS OR FEARS:

______________________________________________________________________________________

______________________________________________________________________________________

PLEASE DESCRIBE ANY OTHER INFORMATION THAT WILL HELP US CARE FOR YOUR CHILD:

______________________________________________________________________________________

______________________________________________________________________________________

NAME OF PHYSICIAN_________________________________________ PHONE #________________

NAME OF DENTIST_________________________________ ________ PHONE #_________________

WHAT WAS YOUR PREVIOUS CHILD CARE ARRANGEMENT (IF NOT ASEP/MASEP):

______________________________________________________________________________________

I AGREE THAT IN CASE OF ACCIDENT OR INJURY, EMERGENCY MEDICAL CARE MAY BE GIVEN IN THE EVENT THAT I OR, PERSON(S) DESIGNATED, CANNOT BE REACHED.

I WILL PROVIDE ALL SPECIAL INFORMATION TO ASSIST THE SJCC MASEP PROGRAM IN CARING FOR THIS CHILD (IEP, DIET, HABITS, ETC.)

________________________ ___________________________ _____________

Name of Parent or Legal Guardian Signature of Parent or Legal Guardian Date

(Please Print)