New Child Care Form

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YMCA of Metropolitan Denver Childcare

Please fill out this required Medical Information & Emergency form. Please note this process can take 15-30 minutes to complete depending on if you have everything you need to complete.

Information/Items Needed:
- Proof of Immunizations or exemption
- Insurance Information (Name of Insurance, ID number, and Group #)
- Doctor’s name, phone, and address
- Dentist’s name, phone and address
- Hospital’s name, phone, and address
- Picture of the child
- Emergency contacts Info (name, address, phone)
- Any medical information paperwork
- Health Appraisal Form for Y Academy Childcare Program only

Site Location
Please select the site location for your child*

CHILD INFORMATION
Child Name*
Birth Date*
mm/dd/yyyy
Gender*
School Name*
Current Grade in School*
Street Address*
City, State*
Postal Code*
Phone*
Phone Type*

LandlineMobile
Secondary Phone*
Secondary Phone Type*

LandlineMobile
Child Photo*

Size limit 3 MB and must be image file type
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FAMILY INFORMATION
Parent/Guardian #1
Name*
Relationship to Dependent*
Street Address*
City, State*
Postal Code*
Phone*
Phone Type*

LandlineMobile
Email*
example@example.com
Parent/Guardian #2
Name
Relationship to Dependent
Street Address
City, State
Postal Code
Phone
Phone Type

LandlineMobile
Email
example@example.com
Siblings also attending program

WORK INFORMATION
Parent/Guardian #1
Employer*
Occupation*
Work Street Address*
City/State*
Postal Code*
Work Phone*
Work Phone Type*

LandlineMobile
Times at work*
Parent/Guardian #2
Employer
Occupation
Work Street Address
City/State
Postal Code
Work Phone
Work Phone Type

LandlineMobile
Times at work

EMERGENCY CONTACTS
Emergency Contact 1
Emergency Contact Name*
Address*
Primary Phone*
Secondary Phone*
Email*
example@example.com
Emergency Contact 2
Emergency Contact Name*
Address*
Primary Phone*
Secondary Phone*
Email*
example@example.com
Emergency Contact 3
Emergency Contact Name*
Address*
Primary Phone*
Secondary Phone*
Email*
example@example.com

PICK-UP LIST CONTACTS
Please list any non-parent adults (up to 5) allowed to pick up your child from the program (Emergency contacts are NOT considered authorized pickups - please add them again here if needed).
How many non-parent adult pick-up contacts would you like to add?*
Pick-Up Contact 1
Authorized Pick-Up Name*
Address*
Primary Phone*
Secondary Phone*
Relationship to child*
Pick-Up Contact 2
Authorized Pick-Up*
Address*
Primary Phone*
Secondary Phone*
Relationship to child*
Pick-Up Contact 3
Authorized Pick-Up*
Address*
Primary Phone*
Secondary Phone*
Relationship to child*
Pick-Up Contact 4
Authorized Pick-Up*
Address*
Primary Phone*
Secondary Phone*
Relationship to child*
Pick-Up Contact 5
Authorized Pick-Up*
Address*
Primary Phone*
Secondary Phone*
Relationship to child*
Who should NOT pick up your child?

BASIC MEDICAL INFO
Hospital information
Hospital of Choice*
Hospital Phone #*
Hospital Address*
Child covered by medical insurance?*
Insurance information
Insurance Company*
Insurance Subscriber Name*
Insurance Phone #*
Insurance Policy Number*
Additional Details
Doctor/Clinic Information
Name*
Contact Phone Number*
Doctor Type*
Address*
Additional Details
Dentist information
Name*
Contact Phone Number*
Address*
Additional Details

ALLERGIES
Does your child have any known allergies?*

YesNo
Please specify the type(s)*

EnvironmentalFoodMedication
Please provide details including allergen name, reaction when exposed, severity of reaction, preferred actions if exposed, and additional information. *

MEDICATION AND TREATMENTS
Does the member routinely take medications?*

YesNo

Please list any possible side or adverse effects, or special instructions

ADDITIONAL QUESTIONS
Please let us know what your child identifies as: Asian, Black/African, Caucasian, Hispanic/Latino, Native American, Pacific Islander, prefer not to answer, Other. Please write all that apply.*
Any behavior or special considerations?*

YesNo
Please explain*
Please describe redirection techniques used at home
What are you hoping your child will accomplish in the YMCA program?*
Is there any other information that would be important to share with our staff about your child?
The person described herein has my permission to participate and engage in all child care activities (which may include swimming, gymnastics, roller or ice skating, fields trips-walking/riding, transportation and other activities which may involve certain risks) except as otherwise noted:*

YesNo
Please include exclusion from authorizations
I hereby give my permission for the YMCA staff to apply sunscreen to my child before going outdoors on an as needed basis. I understand that it is my responsibility to supply the sunscreen for my child. I am also aware that the YMCA cannot provide sunscreen due to the Department of Human Services rules and regulations.*

YesNo
Any special application needed?
Will additional sun protection be required/provided (e.g. shirts, hats, etc.)?
Please list any medical or mental conditions we should know about

OTHER CONSIDERATIONS
Please indicate if your child has any other considerations with the following:
Are there any specific communications methods or needs we need to be aware of? (For example, does your child use sign language, can they read and write, etc.)*

YesNo
Please explain*

FILES NEEDED FOR YMCA OF METROPOLITAN DENVER
Immunization Record*

Colorado Law requires the CERTIFICATE OF IMMUNIZATION form to be completed for each participant attending Colorado Camps. Kindly attach a completed copy. Size limit 3 MB.
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The YMCA of Metropolitan Denver requests the following documents/forms below, if applicable to the member.
Medical Health Appraisal (*Childcare Only)

Please upload your child’s most recent Medical Health Appraisal. Please remember to fill out and sign the top box of the form. This form needs to be completed and uploaded at every well child visit. Size limit 3 MB.
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Medication Administration

If your child will be taking medication during program hours, kindly attach a copy or include a completed "Medication Administration Permission for School and Child Care" form. Size limit 3 MB.
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Allergy and Anaphylaxis Plan

If your child has any severe allergy, kindly attach a completed "Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders" form. Size limit 3 MB.
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Asthma Care Plan

If your child has asthma, kindly attach a completed "Colorado School Asthma Care Plan" form. Size limit 3 MB.
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Legal Court Documentation

Colorado State Law prevents the Y programs from withholding a child from their Legal Parent or Guardian without proper and Legal Court Documentation If you are requesting the Y program to not release your child(ren) to a Legal Parent or Guardian, please attach current Court documentation supporting the request to deny Parent or Legal Guardian pick up. Size limit 3 MB.
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Special Medical Needs

Size limit 3 MB
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Behavioral Plan

Size limit 3 MB
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Other

If there is something else you feel we should have on file, please upload it here. Size limit 3 MB.
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WAIVERS

Please enter your initials to agree to all waivers below
The aforementioned health history is correct, and I understand that no medication will be administered unless the “Parent/Guardian Request for Giving Medicine and Release Agreement” is completed and signed by the Parent/Guardian.*
Initials
I have received and agree to follow the rules, guidelines, procedures and policies described in the parent information materials.*
Initials
I understand that the YMCA has supervisory control over YMCA staff only during YMCA sanctioned programs and/or events. Any arrangement outside these sanctioned programs and/or events is the sole responsibility of the parent/guardian.*
Initials
I understand the fee structure for YMCA programs, and will pay according to the prescribed payment plan unless prior written agreement has been made with the Child Care Director.*
Initials
In the event I cannot be reached in an EMERGENCY, I hereby give permission, to the physician selected by the YMCA to secure treatment, hospitalize and order injection, anesthesia or surgery for my child at my expense.*
Initials
I give my permission to the YMCA, without obligation to me, to use any photographs, film footage, tape recordings which may include my child’s image or voice for purposes of promoting or interpreting YMCA programs.*
Initials
The terms herein shall serve as the parent/guardian authorization release, and assumption or risks for claims arising from incidents surrounding child care programs for my child, myself, my spouse, my heirs, executor, administration, assignees, and for all other members of my family.*
Initials
Dear Parents/Guardians,

Every child care center in Colorado is required by law to train specific staff to give medication at their center. This training is recognized and approved by:

- Colorado Department of Education
- Colorado Department of Public Health and Environment
- Colorado State Board of Nursing
- Colorado Department of Human Services- Division of Child Care

After the staff member successfully completes the medication training, your center's nurse consultant will delegate the administration of medication to selected staff members. This process has been developed to ensure safe and proper administration of medication. Non compliance is considered a childcare licensing violation.

This letter describes the authorization forms required in order to administer medication in a child care center.
- Children needing any medication during program hours require completed Medication Authorization(s) that is signed by the child's guardian and health care provider.
Medication includes all prescription medication, over the counter medication, nebulizers and inhaled medication. No Exceptions.

Note: Program staff can only administer medication if the authorization is completed by your health care provider and with parent/guardian signature.

- Children with Severe Allergies requiring medication need a completed health care plan that is signed by your health care provider.
- Children with Asthma that regularly require asthma medication during program hours need a completed asthma health care plan that is signed by your health care provider.
- Children with Special Health Conditions need a completed health care plan signed by your health care provider. This plan will be individually designed for your child; in collaboration with the program's nurse consultant, program staff and the child's parent/guardian.
Initials
I hereby certify that I have received and read a copy of the YMCA of Metropolitan Denver Parent Handbook (copies are available online at www.denverymca.org) I will abide by the policies set forth in the parent handbook. I have also discussed the policies and procedures with my child.*
Initials
I understand that payments are due in full two weeks prior to the start of each week of camp. If full payment is not received by the Monday of the week attending, your child(ren) will not be able to return on Tuesday of that week, or until payment is made in full. I understand that my child will be considered unregistered for Day Camp at the YMCA and will not be able to attend until the payment is collected in full. Further, any cancellation must be submitted in writing two weeks prior to the start of each week. If this is not done, the parent is responsible for that weeks payment.*
Initials
I hereby give my permission for my child to watch G movies at the YMCA. YMCA staff will determine the appropriateness of specific PG movies, and movie titles will be made available to parents prior to showing, a permission slip for viewing the PG movie will be made available for signing prior to the movie being viewed. Alternate activities will be provided for children not viewing the movie.*
Initials
I authorize the YMCA to contact and obtain emergency medical care as needed for my child in the case that I cannot be reached or it is necessary to contact emergency personnel prior to myself.*
Initials
I hereby give my child permission to attend and be transported to and from field trips and special excursions and to and from school in YMCA vehicles or in local school district busses that are contracted with the YMCA of Metropolitan Denver.*
Initials
Screen time is limited to only approved field trip screen viewing as planned activity. The YMCA does not allow electronics use during program hours, and is not responsible for any electronic items that your child(ren) may bring to the program. If your child(ren) do bring electronics and they are using them inappropriately, they will be confiscated and returned to the parent. If a case of inappropriate use occurs, the child will receive suspension or expulsion from the program depending on the instance.*
Initials
I understand that if my child does not wish to participate in the scheduled activity, there may not be an alternate activity, and I (parent) will be responsible for picking up my child prior to the activity start. I understand that if my child requires special medical care or attention that my child may not be able to participate in the full scope of the activity or program as to allow for necessary accommodations for my child’s safety and required medical care as prescribed by the signing physician.*
Initials
BEHAVIOR SUPPORT GUIDELINES
It is the YMCA of Metropolitan Denver’s goal to provide a healthy, safe, and secure environment for all participants. Youth who attend the program are expected to follow the behavior guidelines based on the YMCA’s four core values and to interact appropriately in a group setting.

BEHAVIOR GUIDELINES
- We will CARE for ourselves and for those around us
- HONESTY will be the basis for all relationships and interactions
- People are RESPONSIBLE for their actions
- We RESPECT each other and the environment

WHEN A YOUTH DOES NOT FOLLOW THE BEHAVIOR GUIDELINES, WE WILL TAKE THE FOLLOWING STEPS:
1. Staff will redirect the youth to more appropriate behavior.
2. The youth will be reminded of the behavior guidelines and program rules, and a discussion will take place.
3. If the behavior persists, a parent or guardian will be notified of the behavior.
4. The staff will document the situation using a Behavior Support Alert. This written documentation will include what the behavior is, what provoked the behavior, and the corrective action taken. In addition a Behavior Goal Sheet may be necessary.
5. Staff will schedule a conference with the parent or guardian so they can determine the appropriate strategy for resolution.
6. Staff will schedule a progress check or a follow-up conference.
7. If the problem persists, staff will schedule a conference that includes the parent or guardian, youth, staff, and program director.
8. If a youth’s behavior at any time threatens the immediate safety of themselves, other participants, or staff, the parent or guardian will be notified and expected to pick up the youth immediately.
9. If a behavior persists and a youth continues to disrupt the program, the YMCA reserves the right to suspend the youth from the program. Expulsion from the program will be considered in each individual circumstance.

UNACCEPTABLE BEHAVIORS
The following behaviors are never acceptable and will result in an immediate Behavior Support Alert, suspension of a youth for the remainder of the current day. Additional suspension up to expulsion will be considered dependent of behavior and circumstance.
- ENDANGERING THE HEALTH AND SAFETY OF YOUTH, STAFF, OR ANY OTHER PERSON
- STEALING OR DAMAGING YMCA OR LOCATION PROPERTY
- STEALING OR DAMAGING PERSONAL PROPERTY
- LEAVING THE PROGRAM WITHOUT PERMISSION
- CONTINUALLY DISRUPTING THE PROGRAM WITH BEHAVIORS THAT REQUIRE STAFF TO BE TAKEN OUT OF RATIO
- USING PROFANITY, VULGARITY, OR OBSCENITY OR ACTING IN A LEWD MANNER
- REFUSING TO FOLLOW THE BEHAVIOR GUIDELINES OR PROGRAM RULES
Immediate expulsion will occur if a youth is in possession of or using tobacco, alcohol, controlled substances, illegal drugs, firecrackers, weapons, firearms, or explosives.
I have reviewed the Behavior Support Guidelines with my youth. I understand and agree to all of the terms presented in this document.*
Initials

By entering your name and signature, you are supplying a legally binding signature; it confirms that all information provided to the YMCA of Metropolitan Denver is correct to the best of your knowledge, and you confirm each of its waivers, consents, and other permissions. It is your responsibility to keep this information up to date.
Name of 1st Parent/Guardian*
Signature of 1st Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Name of 2nd Parent/Guardian (if applicable)
Signature of 2nd Parent/Guardian (if applicable)

Clear
Date

MonthDayYear
Date
Name of 3rd Parent/Guardian (if applicable)
Signature of 3rd Parent/Guardian (if applicable)

Clear
Date

MonthDayYear
Date
Should be Empty:

	Medication Name	Treatment for	Dose & Frequency	Administered when and by who
1
2
3

Site Location

CHILD INFORMATION

FAMILY INFORMATION

Parent/Guardian #1

Parent/Guardian #2

WORK INFORMATION

Parent/Guardian #1

Parent/Guardian #2

EMERGENCY CONTACTS

Emergency Contact 1

Emergency Contact 2

Emergency Contact 3

PICK-UP LIST CONTACTS

Pick-Up Contact 1

Pick-Up Contact 2

Pick-Up Contact 3

Pick-Up Contact 4

Pick-Up Contact 5

BASIC MEDICAL INFO

Hospital information

Insurance information

Doctor/Clinic Information

Dentist information

ALLERGIES

MEDICATION AND TREATMENTS

ADDITIONAL QUESTIONS

OTHER CONSIDERATIONS

FILES NEEDED FOR YMCA OF METROPOLITAN DENVER

CONSENTS & OTHER QUESTIONS FOR YMCA OF METROPOLITAN DENVER

WAIVERS