Eastchester After School Youth ProgramREGISTRATION APPLICATION

A Program of Julia DyckmanAndrus Memorial Inc.

E.A.S.Y.

Child’s Name ______Address ______

Date of Birth ______Gender ______

Mother’s Name ______Father’s Name ______

Home Address ______Home Address ______

______

Home Phone ______Home Phone ______

Cell Phone ______Cell Phone ______

Business Phone ______Business Phone ______

Email ______Email ______

Child’s Grade: ______School: ______Teacher: ______

Emergency Notification (must be filled in)

Name ______Phone ______

Indicate medical or other condition(s) requiring special attention: ______

(e.g. medical limitations on child’s activities, allergies, medications, etc.) If None, state, None.

Doctor ______Address ______

Phone ______

Dentist ______Address ______

Phone ______

Medical Form Required

Enrollment Information (Monthly Contract Duration)

Scheduled Monthly (Must Commit for a minimum of 1 month)

Occasional Use (Subject to space availability)

Days of Week: ______Monday ______Tuesday ______Wednesday ______Thursday ______Friday

Start Date: ______Yearly Membership Fee is $50 (Over Please)

Program Site: Anne Hutchinson School Mill Road Eastchester, NY 10709

Phone: 914-961-3717 Fax: 914-961-3752 Email:

Eastchester After School Youth ProgramREGISTRATION APPLICATION

A Program of Julia Dyckman Andrus Memorial, Inc.

TO COMPLETE THIS APPLICATION

Application Checklist
  1. Enclose a check for $50, payable to Andrus, for a non-refundable family registration fee which enrolls your child/ren in the program for any or all sessions that are offered during the current school year. (Refund is made if a child cannot be admitted for a lack of space.)
  2. Complete and return the Application for Registration, the signed Parent Consent form, and the signed Policy Statement.
  3. Attach a current medical form.
  4. Mail the check, full application, signed Consent & Policy forms, and medical form to:
Eastchester After School Youth Program, 60 Mill Road,Eastchester, NY10709

IMPORTANT NOTICE

New York State Office of Children & Family Services, with whom we are registered, permits E.A.S.Y to accommodate a child only when all the documentation is completely filled out, signed and received by us, i.e., the full application, signed policy & consent forms, and medical forms. Students whose records are incomplete are placed on a waiting list, unable to use the program.

If enrolling more than one child, kindly use separate forms. Please make a copy of the completed application(s) for your files.

Enrollment is on a first come, first serve, space available basis. For further information, contact E.A.S.Y. at:

961-3717

Thank you for your confidence in our program.

Program Site: Anne Hutchinson School Mill RoadEastchester, NY10709

Phone: 914-961-3717 Fax: 914-961-3752 Email:

Eastchester After School Youth Program A Program ofJulia Dyckman Andrus Memorials, Inc.

PARENT CONSENT FORM

I consent to the enrollment of ______

(child’s name)

in the program offered by Eastchester After School Youth Program (E.A.S.Y.) and have been advised of the policies regarding fees, transportation, and services by E.A.S.Y. and the New York State Office of Children & Family Services regulations under which it operates.

I give permission to E.A.S.Y. for the following:

  1. To seek emergency medical treatment for my child in the event I cannot be reached.
  2. To have my child participate in the field trips and outings under the supervision of the E.A.S.Y. staff.
  3. To transport my child from/to site to/from school s/he is enrolled utilizing buses provided by the EastchesterUnionFreeSchool District.
  4. To allow my child to be photographed and to allow any pictures in which my child appears to be released for publication in newspapers, brochures, for fund-raising or public relations.
  5. To release my child to any of the following people if I am unable to pick him/her up providing I notify the teacher-in-charge (please include names and phone numbers):

5a ______

NameTelephoneCell Telephone

5b ______

NameTelephoneCell Telephone

5c ______

NameTelephoneCell Telephone

5d ______

NameTelephoneCell Telephone

Beginning on Month ______Day______Year______

I agree to pay for the care of my child in accordance to the following FEE SCHEDULE:

FAMILY REGISTRATION FEE: $50

SCHEDULED MONTHLY RATES

5 Days$425Occasional$45 per day

4 Days$375

3 Days$310

2 Days$230

1 Day$170

Sibling Discounts…………………………………………..15% first additional child, 25% 3rd or more.

SCHEDULED MONTHLY RATES FOR HOURLY PICKUP BY 4:00 pm

5 Days: 185.00

4 Days: 153.00

3 Days: 121.00

PARENT SIGNATURE: ______DATE: ______

Eastchester After School Youth does not discriminate on the basis of religion, race, color, national and ethnic origin in its admission policies or in the administration of its programs. (Over Please)

Program Site: Anne Hutchinson School Mill Road Eastchester, NY 10709
Phone: 914-961-3717 Fax: 914-961-3752 Email:

Eastchester After School Youth Program A Program of Julia Dyckman Andrus Memorial,Inc.

POLICY STATEMENT(Please read carefully & sign)

E.A.S.Y. is open to all children who 1) reside in the EastchesterUnionFreeSchool District and who are enrolled in a Kindergarten through 7th grade program or 2) are enrolled in a EastchesterUnionFreeSchool District Kindergarten through 7th grade program. E.A.S.Y. admits students of any race, religion, color, national and ethic origin to all rights, privileges, programs and activities generally accorded or made to students in school.

  1. For Admission, the parents must complete and sign the forms presented by E.A.S.Y. These include: the Registration Form, the Parent Consent Form, the Policy Statement and the Health form which must be signed by a physician (copy of school physical form is acceptable). No Children can be admitted to the program unless all forms have been submitted, as required by law.
  1. If your child will be absent from E.A.S.Y., you must call 961-3717 by 12:00 PM on the day of the absence. Parents will be expected to arrange for their child to be picked up in the event the child shows signs of infectious disease or other illness while at E.A.S.Y. Children who are ill, as defined by the school district policies, will not be allowed to participate in the program.
  1. The Billing Procedures are as follows:

At the beginning of every month, parents are billed for thenext month based on their monthly schedule. No credit is applied for the bill if a child is absent for whatever reason. Bills are distributed by thebeginning of the month. Payment is due immediately. Payment is late after the 10th. A $20.00 late fee is applied after the 20th. Any bank charges we incur (e.g., for insufficient funds) are billed at $20.00 per occurrence. No child can attend or continue to attend whose parents have not paid their monthly bill on time.

Parents may change their child’s schedule for the coming month if the schedule change is made on or before the 20th of the previous month. This change must be in writing or by phone to the Director only. The first change is free; additional changes prior to the 20th are allowed at $5 per request. If a contracted schedule change is made after the 20th for the upcoming month, parents are still responsible for payment of the original schedule.

  1. All children must be picked up by the parent/s who has registered the child or by an individual designated on the Parent Consent Form.

E.A.S.Y. closes at 6:30 PM daily, and all children must be picked up by 6:30 PM.

FIRST time late: $10 each ½ hour

SECOND time late: $15 each ½ hour

THIRD time late: $20.00 each ½ hour

After the third time late, the child will be dismissed from the program.

  1. Parents must provide an emergency name and telephone number, a person who must be able to pick up the child when necessary, even in inclement weather.
  2. Snacks are provided daily.
  3. E.A.S.Y. staff may not administer medication of any kind to children attending.
  1. E.A.S.Y. reserves the right to refuse an application or dismiss a child at any time. Contractual fees will be refunded on a prorated basis. We agree to observe all rules of the program and to participate in activities at our own risk and in no way hold E.A.S.Y., its officers, directors, and employees liable for accident or illness.

PARENT SIGNATURE: ______DATE: ______

Program Site: Anne Hutchinson School Mill RoadEastchester, NY10709

Phone: 914-961-3717 Fax: 914-961-3752 Email