Transportation to the Safe Haven After-School Program Dear Parents, Please be advised that it is your responsibility to contact the Brunswick City Schools Transportation Department to arrange your child’s transportation from their school to the Safe Haven Program at the Brunswick Recreation Center. Please visit the Child Care Transportation Arrangement Form at http://ww3.bcsoh.org/reg/view.php?id=30829. The first day of school is Wednesday, August 17, 2016 and the last day of school is May 26, 2017. When ask on the form the name of the child care provider, please put “Safe” as first name and “Haven” as the second name. The Recreation Center address is 3637 Center Road, Brunswick, OH 44212. Our phone number is 330-273-8000. Thank you, The Safe Haven Staff
The Brunswick Community Recreation and Fitness Center SAFE HAVEN 2016-17
After School Program, Winter Break & Spring Break
REGISTRATION FORM (Please print legibly)
Enrollment deadline for the first week is Friday, August, 5, 2016. Enrollment maximum is 70 students on a First-come, first-serve basis.
FIRST NAME __________________________________ LAST NAME_______________________________________ NICK NAME ______________ Age _____Birth Date ____________ Grade (in fall ’16) _____ School_______________________________________________________________ Address _______________________________________________ City _____________________________ ST ________ Zip__________________ Mother Email __________________________________________ Father Email ____________________________________________ (For information regarding the Safe Haven Program) Please check parent to contact first.
□Mother/Guardian’s Name____________________________________________ Employer__________________________________________ Work #__________________________________________________ Cell # __________________________________________________________
□Father/Guardian’s Name ____________________________________________ Employer__________________________________________ Work #__________________________________________________ Cell # __________________________________________________________ Release Form: By signing this, the undersigned releases and absolves the City of Brunswick, the Brunswick Community Recreation & Fitness Center (BCRFC), the Brunswick Parks and Recreation Department, and its representatives from any liability for any injury, accident or illness that might be suffered by the child of the undersigned while in attendance at the BCRFC Safe Haven Program, at off-site field trips, and during transportation to and from the BCRFC. My child has my permission to participate in the above program. I assume responsibility for any injuries incurred while participating in said program. I understand that the Safe Haven Program reserves the right to reject any and all applicants.
Parent/Guardian Signature
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Date _________________________________
INDIVIDUALS APPROVED FOR PICK-UP I hereby give my consent for the staff of The BCRFC to release my child to the individuals listed below. A valid photo ID is required for pick-up. Name _____________________________
Relationship to Child____________________________
Phone _____________________________
Name _____________________________
Relationship to Child____________________________
Phone _____________________________
Name _____________________________
Relationship to Child____________________________
Phone _____________________________
Name _____________________________
Relationship to Child____________________________
Phone _____________________________
MEDICAL RELEASE FORM If neither parent/guardian can be reached, contact the person listed below:
NAME _______________________________ EMERGENCY NUMBER ________________________ RELATION TO CHILD _________________________
TO GRANT CONSENT In the event reasonable attempts to contact me at one of the above phone numbers have been unsuccessful, I hereby give consent for: 1. The administration of any treatment deemed necessary by Dr._____________________ (preferred physician) or Dr._______________________ (preferred dentist) or in the event the designated practitioner is not available by another licensed physician or dentist; and 2. The transfer of the child to ____________________________ (preferred hospital) or any hospital reasonably accessible. This authorization doesn’t cover major surgery unless the medical opinions of two (2) other licensed physicians or dentists, concurring in the necessity of such surgery, are obtained prior to the performance of such surgery.
Allergies: circle one No Yes, list all that apply _________________________________________________________________________________ Medical Conditions/Medications: circle one No Yes, list all that apply _____________________________________________________________ Date of last Tetanus _______________
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I have read the above medical Consent and Release Form and understand and agree to abide by this policy. Parent/Guardian Signature
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REFUSAL TO CONSENT - I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the Brunswick Recreation Supervisor to take the following action: ______________________________________________________ Parent/Guardian Signature
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Date
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Our program standards require that we have documentation that each child’s parent/guardian understands and accepts our policies on the following issues. Please read the policies listed below and sign your initials after each policy to indicate that you understand and will comply. Payment Policy – By signing this form, you are indicating that you understand policies concerning payment, cancellation and refunds. _______initial
I ACKNOWLEDGE THAT PAYMENT IS DUE BY FRIDAY AT 6:00 PM BEFORE THE WEEK OF ENROLLMENT TO AVOID A $15 LATE FEE. _______initial Late Pick up Fees-A$10.00 fee will be charged if your child is not picked up by 6:00 p.m. After 6:15 p.m. a $5.00 fee will be charged for each additional 15 minutes late. If the child is not picked up by 7:00 p.m. and we cannot reach any guardian or emergency contacts, the Brunswick Police Department will be notified. This late pick up fee will be added to your account. _______initial Insufficient Funds Policy – We will gladly accept your checks. However, in the event your check is returned, you will be charged for the fees incurred plus $30 per check. If two or more checks are returned for insufficient funds, you will be required to pay by cash, credit card or money order. Failure to reimburse insufficient funds will result in dismissal from the program. _______initial Refund Policy –A refund request form must be completed and signed. Refunds will be granted after a full review of circumstances is conducted by management. 1. If the program is cancelled by the BCRFC, a refund for the full amount that was paid will be issued. 2. If an individual wants to cancel enrollment in a program, it must be requested at least 5 days prior to the session enrolled. 3. Refunds will not be given if requested less than 5 days prior to the session enrolled. Individuals assume the risk of changes in health or personal schedules. NO REFUNDS WILL BE ISSUED WITHOUT APPROVAL FROM THE BCRFC SUPERINTENDENT. _______initial Medical Treatment – The Safe Haven counselors do not normally administer medication. However, in the event of an emergency in which the parent/guardian cannot be reached, Emergency Medical Staff and the Safe Haven counselors may take appropriate action in the best interest of your child. _______initial Lost Items – I understand that the BCRFC is not responsible for any personal items lost or stolen at or during our program. _______initial
Transportation - I understand that it is my responsibility to contact the Brunswick City Schools Transportation Department to arrange my child’s transportation from their school to Safe Haven at the Brunswick Recreation Center. _______initial
Behavior Expectations and Discipline Policy It is important that staff maintain order and discipline in all programs. Our top priorities are safety and a positive atmosphere for learning and developing skills. The BCRFC staff makes every effort to help children understand clear definitions of acceptable and unacceptable behavior. We ask that you discuss our general rules and policy with your child. Our code of conduct does not permit language or action that can hurt or frighten another person or that falls below a generally accepted standard of conduct. All rules are expected to be followed. Behavior rules will be established and taught to the children at the beginning of each session and will regularly reviewed to ensure the safety of everyone. The following is not condoned by the BCRFC or permitted by our counselors: corporal punishment, ridiculing, threatening, use of inappropriate loud voice, use of profanity, or leaving children unsupervised. A child’s behavior is expected to be consistent with the following: Use appropriate language at all times; cooperate with staff and follow directions; respect other children, staff, equipment, facilities, and yourself; maintain a positive attitude and stay in program areas. Discipline Policy: The following are the steps that will be taken for campers who are not following the rules: A first infraction of any rule or directive will result in a time out not to exceed, in minutes, the age of the child. The child will be counseled about appropriate choices. A second infraction shall result in the same as above, forfeiture of a privilege and a Behavior Note sent home. This will be considered a “Verbal Warning” to the parent/guardian about their child behavior. A counselor will speak with the guardian about the misbehavior when the child is signed out for the day. A third infraction or a first infraction of serious nature will result in an Incident Report* written and filed with the city. This will be considered a “Written Warning” to the parent/guardian about their child’s behavior. A counselor will speak with the guardian about the misbehavior and give them a copy of the report when the child is signed out for the day. A second Incident Report issued will result in a meeting with the parents, the child, and the program supervisor to discuss the situation and possible suspension. Failure of the parent/guardian to attend conference(s) and cooperate will subject the child to suspension or dismissal. A third Incident Report will result in a two week suspension. A forth Incident Report will result in immediate dismissal from the program. If a problem warrants, a city employee may call the parent immediately. *Behaviors that will warrant an Incident Report and may result in immediate suspension or dismissal include, but are not limited to: • Any action that could threaten or pose a direct threat to the physical/emotional safety of the child, other children or staff. • Fighting or physical contact with another person in an angry or threatening way. • Angry or vulgar language including swearing, name calling, and shouting. • Possession of a weapon of any kind. The authorities may be called. • Vandalism or destruction of recreation center property or the property of others. • Behavior which intends to, or results in the theft or destruction of property. • Harassment or intimidation with words, gestures, body language or other menacing behavior, and racism. • Sexual misconduct. • Possession of or use of alcohol or controlled substances unless under the prescription of a doctor.
I have read, understand, and agree with the policies as stated in this document and discussed the expectations of behavior with my child. _______initial I understand that Parents/guardians are required to inform the BCRFC Safe Haven Program in writing prior to a child’s acceptance in a program of any special circumstances which may affect the child’s ability to participate fully and within the guidelines of acceptable behavior, including but not limited to any serious behavioral problems or special circumstances regarding psychological, medical or physical conditions. Upon being informed of such circumstances, the program director may require a conference with the parent/guardian to discuss issues created by these circumstances. _______initial I give my child permission to attend all off-site field trips that occur on the days I have my child enrolled. I also give them permission to visit the Towslee Elementary School’s playground, the library, City of Brunswick’s Nature Center, Buehler’s, and local city parks. I give my permission for photographs and video to be taken of my child during normal program activities to be used in the BCRFC promotional materials without thought of remuneration.
Parent/Guardian Signature
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Date
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Concussion Awareness- By signing below, I am acknowledging that I have received a copy of the “Ohio Department of Health Concussion Information Sheet for Youth Sports Organizations”. This is in accordance with the “Ohio’s Return to Play Law”. Parent/Guardian Signature
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Date
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Activities Permission Slip SWIMMING PERMISSION I, _________________________ (PARENT/GUARDIAN) of ___________________ (CHILD’S NAME) understand that during the BCRFC program the children are taken to the pool for swimming. I am aware that this is on optional activity. _____YES, I give permission for my child to swim during the program. _____NO, I do not give permission for my child to swim during the program. PARENT’S SIGNATURE_______________________________________DATE:_____________ “PG” MOVIES PERMISSION I, _________________________ (PARENT/GUARDIAN) of ___________________ (CHILD’S NAME) understand that during the BCRFC program movies are shown by the Counselors. I am aware that this is an optional activity. I also understand that “G” rated movies are generally shown, but occasionally “PG” movies are requested by the students. ___MY CHILD IS PERMITTED TO VIEW “PG” RATED MOVIES ___MY CHILD IS NOT PERMITTED TO VIEW “PG” RATED MOVIES PARENT’S SIGNATURE_________________________________________DATE:_____________
LIBRARY PERMISSION I, _________________________ (PARENT/GUARDIAN) of ___________________ (CHILD’S NAME) understand that during the BCRFC program students are taken to the Brunswick Community Library. I understand that the BCRFC staff will also give students an opportunity to check out materials from the library if they have their library card on file. I understand that this form will act as my child’s library card and that it will be kept by the staff. This form will be presented to the circulation clerk at the library to check out my child’s books. I am aware that checking out books is an option. Please choose one: _____YES, I give permission for my child to check out books at the library. My child’s Library Card # __________________________ _____NO, I do not give permission for my child to check out books at the library, but I am aware that my child may attend the library for various activities during the program. PARENT’S SIGNATURE_______________________________________DATE:_____________
