Page 1 of 9 Dear Parent/Guardian, Enclosed you will find the 2019

Page 1 of 9

Dear Parent/Guardian,

Enclosed you will find the 2019-2020 Waltham Boys & Girls Club’s After School Program application.

Please review the packet making sure all forms have been completed and signed before submitting.

NEW Parents MUST attend a mandatory orientation, in order to complete member registration.

Orientation dates will be determined by the After School Program Director on a case to case basis.

Your application will NOT be accepted until all forms are complete and an orientation date has been

scheduled.

-Child’s Enrollment Form

-First Aid & Emergency Medical Care Consent Form

-Current Physical and Immunization History

-Medication Consent Form (Dr. Consent form is required if applicable)

-Individual Health Care Form (if applicable)

-Small Group and Large Group Transportation Plan and Authorization Form

- Swim Consent form

-Tuition Policies

-6pm Waiver Form (optional)

-Oral Health Waiver

-Library Release (optional)

-School Information Release (optional)

Note: All Licensed Afterschool Program members MUST have a current membership. If a child does not

have or needs to renew an expired membership, please see the Membership Coordinator. A $20.00

annual membership fee is required for all new/renewed memberships.

If you may have any questions or concerns, please contact me at (781) 893-6620 EXT. 14.

Thank you for choosing the Waltham Boys & Girls Club’s After School Program.

Sincerely,

Cheryl Wiggins

Licensed Childcare Director

cwiggins@walthambgc.org

Page 2 of 9

2019-2020 AFTER SCHOOL PROGRAM SACC

CHILD ENROLLMENT FORM

Days of attendance: __Monday __Tuesday __Wednesday __Thursday __Friday

Orientation date (office use only): __________________________________

Child Information

Child’s Name: Date of Birth:

Age at Admission: Date of Admission:

Child’s Home Address:

Primary Phone Number: Alternate Phone Number:

Primary Language: Identifying Marks:

Eye Color: Hair Color: Skin Color:

Sex: Height: Weight:

Parent/Guardian Information

Parent/Guardian Name: Relationship to Child:

Home Address:

Primary Phone Number: Alternate Phone Number:

Email Address:

Business Name: Business Phone Number:

Business Address:

Parent/Guardian Information

Parent/Guardian Name: Relationship to Child:

Home Address:

Primary Phone Number: Alternate Phone Number:

Email Address:

Business Name: Business Phone Number:

Business Address:

Additional Information

Child’s special interest/hobby:

Current School:

School Address: School Phone Number:

Teachers Name: Grade:

I certify that documentation of physical examination and immunizations is in accordance with public

school health and public health requirements and lead poisoning screening. These documents are on

file at my child’s school. Parent/Guardian initials:

Please attach the most recent physical and immunization record along with this completed application.

Parent/Guardian Signature Date (valid for one year)

Page 3 of 9

2019-2020 AFTER SCHOOL PROGRAM

FIRST AID & EMERGENCY MEDICAL CARE CONSENT FORM

Child's Name: Date of Birth:

I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child

first aid/CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring

medical attention for my child. However, if I cannot be reached, I hereby authorize the Waltham Boys &

Girls Club’s After School Program to contact emergency medical personnel to transport my child to the

nearest medical care facility.

Child's Physician Name:

Address: Phone Number:

Child's Allergies:

Chronic Health Conditions:

Individual Health Plan for child with a chronic health condition? If yes, please attach.

Copies of any custody agreements, court orders, and restraining orders pertaining to the child? If yes,

please attach. Copies of documentation is required.

Special limitations or concerns?

Emergency Contacts (In order to be contacted)

Primary Contact Name: Relationship to child:

Address:

Primary Phone Number: Alternate Phone Number:

Do you give permission for child to be released to this person? Yes No

Secondary Contact Name: Relationship to child:

Address:

Primary Phone Number: Alternate Phone Number:

Do you give permission for child to be released to this person? Yes No

Alternate Contact Name: Relationship to child:

Address:

Primary Phone Number: Alternate Phone Number:

Do you give permission for child to be released to this person? Yes No

Parent/Guardian Signature Date (valid for one year)

Page 4 of 9

2019-2020 AFTER SCHOOL PROGRAM

MEDICATION CONSENT FORM 606 CMR 7.11(2)(b)

Name of child: ______________________________________________________________

Name of medication: _________________________________________________________

Please check one of the following:

Prescription: ___ Oral/Non Prescription: ___

Unanticipated Non Prescription for mild symptoms______

Topical Non Prescription (applied to open wound/ broken skin) ______

My child has previously taken this medication__ (Yes or No) __

My child has not previously taken this medication, but this is an emergency medication and I give

permission for staff to give this medication to my child in accordance with his/her individual health care

plan

Dosage:

Date(s) medication to be given:

Times medication to be given:

Reasons for medication:

Possible side effects:

Directions for storage:

Name and phone number of the prescribing health care practitioner:

Child’s Health Care Practitioner Signature Date

I, , (parent or guardian) gives permission to authorize educator(s)

(print name)

to administer medication to my child as indicated above.

Parent/Guardian Signature: Date:

(valid for one year)

For topical, non-prescription NOT applied to open wound / broken skin (parent signature only)

Please sign document regardless of need for prescribed medication

Page 5 of 9

2019-2020 AFTER SCHOOL PROGRAM

SMALL & LARGE GROUP TRANSPORTAION PLAN AUTHORIZATION &

SWIMMING POOL CONSENT FORM (see below)

Child’s name:

My child will arrive at the program: My child will depart from the program:

___Parent Drop Off ___Parent Pick Up

___Supervised Walk ___Supervised Walk

___Unsupervised Walk ___Unsupervised Walk

___Public/Private/Van ___Public/Private/Van

___Program Bus/Van ___Program Bus/Van

___Contract/Van ___Contract/Van

___Private Trans. arranged by parent ___Private Trans. arranged by parent

___Other ___Other

Parent /Guardian Signature: Date

Refer to First Aid and Emergency Medical Care Consent Form for release information.

_____________________________________________________________________________________

SWIMMING POOL CONSENT FORM

Swimming Ability

My child’s swimming ability is:

(Please circle one): No Experience Beginner Intermediate Advance

I, , give my child, ,

Parent/Guardian Name Child’s Name

permission to use the swimming pool area during fun swim while my child is enrolled in the After School

Program. I do understand that my child will be supervised by a certified life guard as well an educator

from the After School Program.

Parent /Guardian Signature: Date:

(valid for one year)

Page 6 of 9

2019-2020 AFTER SCHOOL PROGRAM 6:00PM RELEASE FORM (Optional)

For members 7 years old and older ONLY

I, , agree to have the Waltham Boys & Girls Club’s After School Program

Parent Name

release my child into the General Club program at 6:00pm,

Child Name

Monday through Friday, if I do not pick my child up from the After School Program by 6:00pm. I fully

understand that the General Club Program has an open door policy, meaning they can come and go as

they please, for members 10 years old and up. Our open door policy does not apply to members 9 years

old and under. I understand that Club staff cannot enforce any child in the general Club to stay within

the Club premises.

I further understand that I am responsible for picking up my child up no later than 6:30PM if they are

7-12 years old and 8:30 if they are 13 and up (Tuesday – Friday) and speaking with my child about

staying in the Club, once they are released into the General Club program.

By signing this agreement, I understand that once my child is released into the General Club Program,

the Waltham Boys & Girls Club’s After School Program and its educators and volunteers are no longer

responsible for keeping my child within the Waltham Boys & Girls Club building.

Lastly, I also understand that the After School Program will NOT RELEASE my child into the general

Club program on snow days, holidays, and vacation days.

This agreement is valid for one year.

Parent/Guardian Signature Date (valid for one year)

After School Program Director Date

Page 7 of 9

2019-2020 AFTER SCHOOL PROGRAM POLICIES

Please initial the following statements after you read them.

TUITION COLLECTION AND PROCEDURES Tuition Type (circle one): Voucher or Private Pay

______Full and part time tuition is due on a weekly basis for your child. Payment is due the Thursday

prior of the next week service. If your payment is not received by Friday, service may be

suspended. If service is suspended and action is not taken to rectify the financial situation, the

Waltham Boys & Girls Club reserves the right to terminate your child’s enrollment and fill the

slot with a waiting list candidate.

_______*Parents are required to pay the weekly tuition rate, which includes any full day rates for both

part and full time members. If the child/ren are absent from the program, parents will still be

charged for missed days. Parents will also be charged for any approval closures authorized by

EEC.

________The After School Program requires a two-week notice in writing, for all terminations from the

program. Parents are also responsible for payments during those two weeks.

CHECK-OUT/LATE PICK-UP FEES AND POLICIES

_______During school days, the After School Program closes as 6:00pm. If your child has not been

picked up by closing time, a telephone call will is made to the parent/guardian. If the

parent/guardian cannot be reached at utilizing all known contact numbers, emergency contacts

will be called. If contact is made, then we will ask the emergency contact to come to the

program to pick up your child/ren. If there is no response, steps #1 and #2 will be repeated at

6:15pm and again at 6:30pm. If contact has not been made with the parent/guardian or

emergency person, the designated Waltham Boys & Girls Club’s staff will call the Department of

Children and Family (DCF) Emergency Unit or the police station. Report of the action will be

placed in the child’s file.

________Parents who pick up their children after 6:00pm, will be charged $1.00 per minute per child.

Payment of late fees are due the Thursday prior of the next week of service. If your payment is

not received by Friday, service may be suspended.

_______ I have received, reviewed, and agreed to the ASP Parent Handbook.

I have read the above and agree with the policies and procedures as stated above:

____________ _________ ________________

Parent/Guardian Signature Date (valid for one year)

Page 8 of 9

Oral Health Non-Participation Form

In January 2010, EEC issued new regulations for child care programs that include a requirement that

educators assist children with brushing their teeth if children are in care for more than four hours or if

children have a meal while in care [606 CMR 7.11(11) (d)].

This regulation is intended to:

 Help children learn about the importance of good oral health

 Provide information and resources regarding good oral health to child care programs and

families

 Help address the high incidence of tooth decay among young children in

 Massachusetts, which is associated with numerous health risks.

EEC licensed programs must comply with this regulation. However, parents may choose that their

child(ren) not participate in tooth brushing while present at the child care program.

You do NOT need to fill out this form to have your child(ren) participate in tooth brushing while they are

in child care. However, if you do not want your child to brush his or her teeth while s/he is attending the

child care program, please fill out the information found below. A separate form must be filled out for

each child in care. This form must be renewed annually and will be kept in your child’s record at the

program. Should you change your mind and wish for your child to participate in tooth brushing, this

form may be withdrawn at any time by requesting in writing that it be removed from your child’s file.

Thank you,

Cheryl Wiggins

Licensed childcare Director

I do not wish to have my child participate in tooth brushing while in care at the

Waltham Boys & Girls Club Licensed After School Program

Parent/Guardian’s Name: ____________________________________________

Signature: ______________________________ Date: _____________________

If you have any questions or concerns, please contact: Sarah Hebert at (781) 893-6620 EXT 14

Page 9 of 9

Licensed Afterschool Program

Library Release Form 2019-2020

Dear ASP parents/guardians,

On occasion the Licensed Afterschool Program (ASP) will take small groups of children over to the library

to participate in specific events, activities, arts and crafts, or reading trips. Due to the Waltham Public

Library’s close proximity to the club these trips may be impromptu during scheduled Afterschool

Program Hours (2:30-6:00).

By signing this sheet, you give permission for your child to leave the Waltham Boys and Girls Club with

an Afterschool Program staff chaperone, to partake in the Waltham Public Library’s many offerings, and

return to the club once it is over. In accordance with EEC, child to staff ratio shall never exceed 13:1. This

permission slip will be valid for the duration of the current school year, Sept 2019-June 2020, and will

need to be re-signed with each new school year.

If you have any questions or concerns, please contact me at (781) 893-6620 EXT. 14.

Sincerely,

Cheryl Wiggins

Licensed Childcare Director

____________________________

Child’s Name

_____________________________ ______________________

Parent’s Signature Date (valid for one year)