2018 SDC Wait List – 5th – Girls Place, Inc.

Girls Place Policies and Practices

The following section includes information regarding payments, releases and our programming. Please read this information carefully. You will be held responsible for all of the content. Please contact Rachel at rachel@girlsplace.net with any questions.

Registration Fee

If space becomes available, Girls Place requires a fee of $25 when registering for summer day camp. You will be directed to PayPal to pay this fee immediately after completing the form. This fee is nonrefundable and nontransferable. Please DO NOT register if you think you may have an outstanding balance with Girls Place. Members with debt from the after school or athletic program cannot participate in the summer program until their balance is paid off. Please call (352) 373-4475 to check the status of your account. Please note that registration does not guarantee you a spot in the summer program.

Membership

Membership is required to participate in any Girls Place program. If space becomes available, membership fees are $20 for one child and $40 for families with two or more siblings who live in the same home. Membership is nonrefundable and nontransferable. Girls who have participated in after school and athletics in 2018 have already paid their membership fees. New members will be assessed membership when they register for the summer program. Please call (352) 373-4475 if you would like to verify that your membership is paid. Membership is required to secure space in the program.

Weekly Fees

If space becomes available, the first week of fees, regardless of pay rate or week attending during the summer, is due upon registration. Space in the program is NOT SECURE without membership and the first week of fees paid. SPACE IS LIMITED!

Summer Day Camp is paid in advance at a rate of $79 per week. Direct siblings of a child attending are billed at $68 per week, but only if both children attend during that week. Girls Place does not have part-time rates for Summer Day Camp; therefore, checking in for one day requires payment for the entire week.

Financial Assistance

Financial assistance is no longer available.

Hours

Operational hours are 7:30am - 6:00pm Monday through Friday.

GP office hours are 11:00 am-6:00 pm - payments must be made during normal business hours or online

Early Drop Off is available at 7:00am for $1 per day per child, payable in cash when the child is dropped off in the morning.

Activities

Girls participate in a variety of activities throughout the summer that focus on core values held by Girls Place including athletics, character development, and social and life skills. Girls typically participate in field trips several times a week that include swimming, nature trails, museums, libraries, community service and other structured activities. Schedules are available on a weekly basis during the program to inform parents of the field trips for the upcoming week.

Groups

Children are divided into age groups called by color names based on the grade in school in which the child will be attending in August. Pink Group: (K‐1st), Red 2 Group: (2nd), Red 3 Group (3rd), Yellow 4 Group: (4th), Yellow 5 (5th grade), Green Group: (6th‐7th), Blue Group: (8th‐9th). If your child is being held back, please be sure to indicate that grade level. We want to avoid moving girls back during the summer or at the beginning of the school year.

For further information about our programs, please contact rachel@GirlsPlace.net.

By initialing below I, as the parent or legal guardian, acknowledge the following information or policies. I understand that my initials are not required for the photo and social media releases.

Please type in your initials for the following statements.

PAYMENT POLICY : If space becomes available, the registration fee must accompany this application for registration to be accepted. FEES MUST BE PAID IN ADVANCE. The following fees are due to secure space in the program - registration, membership and one week of fees. IF FEES ARE NOT PAID BY IN ADVANCE ON THE THURSDAY BEFORE BY 6 PM, YOUR CHILD WILL BE UNABLE TO ATTEND THE NEXT MONDAY. Families with debt to Girls Place will be sent to collections if the debt is not paid by August 31, 2018.*

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NON‐SUFFICIENT FUNDS (NSF) POLICY : All NSF checks will be charged a $25 fee. Please pay for all NSF checks with cash or money order, as they will not be deposited again. After two returned checks within one year, cash payments will be required thereafter for services plus any bank services accrued by Girls Place.*

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REFUND PRACTICES : By initialing below, I acknowledge that weekly fees will not be refunded once the week begins. Refunds prior to the deadline can only be obtained with the completion of the withdrawal form one week in advance and a $10 administrative fee will be assessed.*

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EARLY DROP OFF/LATE PICK UP POLICY : Summer hours are from 7:30am – 6:00 pm. Early drop off is between 7:00am and 7:29am and is an additional $1/day paid upon arrival in cash. Girls must be picked up by 6:00 pm. Parents or guardians will be charged $1 for every five (5) minutes late beyond 6:05 pm.*

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PHOTO RELEASE: I understand that during activities and events at Girls Place my child may be photographed or videotaped by Girls Place staff. I agree that my child or her likeness can be used in Girls Place publications including newsletters, fliers, and brochures in addition to local newspaper and television promotions.

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SOCIAL MEDIA RELEASE: I understand that during activities and events at Girls Place my child may be photographed or videotaped by Girls Place staff. I agree that my child or her likeness can be used in Girls Place's social media outlets like Facebook, Instagram and Twitter.

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CUSTODY AGREEMENT: I understand that I must provide appropriate documentation if there is a custody agreement or an injunction concerning children that attend Girls Place. I understand that children will be released to either parent unless a court order indicating sole custody is provided to the Program Director.*

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CUSTODY AGREEMENT: I have a custody agreement that affects who is able to be around my child or pick her up.*

Yes or No

BREAKFAST, LUNCH AND SNACK: I understand that Girls Place has applied for the breakfast and lunch program through the School Board of Alachua County. All summer camp participants may receive meals WEEKS 1-8 (minus week 5) regardless of income level. Breakfast tends to be cereal and milk or a pastry and juice. Lunch meals may include a sandwich, crackers and fruit. Members who do not participate are required to bring a lunch. Girls Place DOES provide one free afternoon snack. During afternoon snack, children will have the opportunity to buy snack with items ranging from $0.25-$1.50. We request that parents set up an account in the front office so children will not have cash with them. Additional money can be added to the account at any time. Payments will only be accepted in cash. No refunds will be given.*

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Please indicate below which Girls Place provided meals your child will be participating in. This can be changed in the future and is just to give us an idea of numbers to expect.*

Breakfast
Lunch
Both
None

FOOD ACTIVITIES: I give my child permission to participate in food related activities and events where outside food may be consumed (i.e. nutrition, cookouts).

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ACHIEVE: I understand that as a part of the summer program, my child will be participating in a year-round educational program to combat summer learning loss. I understand that activities will include academic enhancement, one-on-one tutoring or mentoring, and educational field trips.*

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BRAINPOWER: I understand that as a part of the summer program, my child will be participating in Social and Emotional skills building led by our BrainPower staff and partners. Social and emotional learning contributes to positive decision making and improve attitudes about self and others.*

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PARENT GUIDE: I understand the the Girls Place parent guide is available at www.girlsplace.net and acknowledge that it is my responsibility to review and abide by the material. The parent guide covers information such as our policies and procedures on discipline and explusion.*

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SURVEYS: I understand that my child will be asked to complete surveys needed for our GP programs, general knowledge surveys (i.e., gardening, nutrition, etc.) and overall program satisfaction.*

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PUBERTY: Over the course of the summer, we intend on securing guest speakers to talk about puberty and the girls’ bodies. Some of the topics may include: • Menstrual cycle • Reproductive system • Personal hygiene (hair care, changes in perspiration, breast changes, choosing the right bra) • Feminine products (pads and tampons) • Sexual education (focus on abstinence, being biologically and emotionally unprepared for intercourse at this age, what is considered intercourse, sexually transmitted infections) • Peer pressure (“Not everyone is doing it!”) • Question and answer session. I agree that trained Girls Place staff and guest speakers can provide the above topics over the course of the 2018 Summer Day Camp program. Parents will be notified in advance on the weekly schedule when guest speakers are scheduled. I understand that any changes to the above will be made in writing to the program director.

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Transportation Agreement

Children will be transported to field trips and enrichment programs by the Girls Place bus and/or van. By initialing, you are giving your child permission to participate in Girls Place field trips. Girls Place does not provide transportation to or from the child's home.*

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I authorize the Girls Place after school program to arrange for transportation in case of an accident or acute illness of the participant. In the event it is not possible to receive instruction for the participant's care, consent is give to any licensed physician for treatment. I allow the physician to administer medication and to perform necessary treatment for the preservation of the participant's health and well-being. I understand that any cost incurred for treatment of sudden illness or accident shall be paid by me. The authorization and consent for treatment is given to Girls Place summer day camp program in conjunction with any authorized event.*

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Section 402.3125 (5), F.S. requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Childcare Facility" (CF/PI175-24). Section 65C-22.008(3)(c)(II)., F.A.C. requires that parents are notified in writing of the disciplinary practices used by the child care facility. Section 65C-22.008(3)(III), F.A.C. requires that parents are provided with the information detailing the causes, symptoms, and transmission of the influenza virus. The Parent Guide includes the department's brochure, CF/PI 175-70, June 2009, Influenza Virus, Guide to Parents. Your initials below indicate that you have received the above items and the information on this registration from is complete and accurate. If you wish to have any of this information, it is available to you upon request throughout the school year.*

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REGISTRATION

If space becomes available, once this form is completed and the $25 registration fee is paid, you will get a "SUCCESSFUL SUBMISSION" via email. It is critical that you type in your email correctly. Email will be our primary form of communication for the summer program. There are REQUIRED FIELDS in this form. If you do not complete a required field, it will be highlighted in red and will not be submitted until it is corrected.

Child Information

*All girls must be at least 5 years old to attend any Girls Place program.

Name*

First Last

Date of Birth*

mm/dd/yyyy

Current Grade Level*

Grade Level in AUGUST 2018*

School Attending in AUGUST 2018*

T-shirt Size

You will have the option to BUY summer day camp shirts for your child at the bottom of the form. Youth sizes (S-L) and adult sizes (S-XL) will be $5. We will not be supplying t-shirts this summer.

Race*

Date of last Tetanus immunization

mm/dd/yyyy

Present medical problems and chronic conditions (ex: epilepsy, asthma, etc.). Please enter N/A if your child does not have any medical problems.*

Allergies (drugs, insect bites, etc.). Please enter N/A if your child does not have any allergies.*

Medicines taken regularly (medication cannot be distributed by Girls Place staff without a signed medical form and the medication must be provided by the parents – including Tylenol, inhalers, etc.). Please enter N/A if your child does not have any medicines.*

Please list any special precautions, learning disabilities or any other important health related information regarding your child (i.e. dyslexia or autism). Please enter N/A if your child does not have any special precautions.*

First Aid

Antibiotic Cream
Bug Spray
Sunscreen
Hydrocortisone (itch) cream
Eye Drops
Spray Deodorant
Aloe

Please check all the items that trained Girls Place staff are authorized to use in caring for your child.

Other first aid authorized by parent/guardian

Please indicate what other treatment can be administered as needed.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Parent Information

Guardian #1 Name*

Prefix First Last

Relationship to the child

Email Address: MUST be checked regularly*

Place of Employment

Job Title

Office Phone

Cell Phone

Girls Place has permission to import this phone number to our Remind App. I understand that this will deliver text message reminders to my cell phone and will be a primary method of sending out important information.

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Guardian #2 Name

Prefix First Last

Relationship to the child

Email Address: MUST be checked regularly

Place of Employment

Job Title

Office Phone

Cell Phone

Girls Place has permission to import this phone number to our Remind App. I understand that this will deliver text message reminders to my cell phone and will be a primary method of sending out important information.

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Emergency Contact

This MUST be someone other than a guardian!

Emergency Contact's Name*

First Last

Relationship to Child (NOT guardian)*

Home Phone

Cell Phone*

Work Phone

2nd Emergency Contact's Name*

First Last

Relationship to Child (NOT guardian)*

Home Phone

Cell Phone*

Work Phone

Pick Up Limitations

Please list ALL individuals authorized to pick up your child from Girls Place. This includes guardians and emergency contacts. If an individual is not listed on this registration, they will not be able to pick up your child.

AUTHORIZED PICK UP: Please list FIRST NAME, LAST NAME, and RELATIONSHIP of those people who CAN pick up your child.*

Please note that, for girls who have attended one of our programs before, our system will be CHANGED to reflect the names indicated above.

Please list FIRST and LAST names of those people who CANNOT pick up your child under any circumstances.

Please note that, for girls who have attended one of our programs before, our system will be CHANGED to reflect the names indicated above.

Attendance

Please check the weeks you would like your child(ren) to attend. Due to limited enrollment, you must pre-register for all weeks you wish your daughter to attend. By checking a week, you are not committed to paying for that week, but you are asked to notify staff at least one week in advance if your child will not be attending.

Please check each week you plan on having your child attend. You are required to pay for each week in advance. Failure to pay in time results in losing your child's space in the program.*

Demographics

The following is optional and ONLY used to assist us in obtaining funding and various grants. THIS INFORMATION WILL BE HELD CONFIDENTIAL.

Child resides with (check all that apply):

Mother
Father
Stepfather
Stepmother
Grandparent
Aunt/Uncle
Foster Parent
Other

If other, please identify:

Who is the head of household?

Mother
Father
Stepfather
Stepmother
Grandparent
Aunt/Uncle
Foster Parent
Other

If other, please identify:

Annual Family Income*

Please remember that this information is held confidential and is merely used for reporting purposes and securing additional grants.

Total # of adults (18 and older) in household

Total # of children (0-17 years old) in household

Additional Medical Information

If any information does not apply to your child, please put "N/A"

Doctor*

Doctor Address*

Doctor Telephone*

Dentist

Medical Insurance Company Name*

Policy #

Preferred hospital in case of an emergency*

My daughter qualifies for free or reduced lunch at school:*

Free
Reduced
Does not qualify
Unknown

How did you hear about Girls Place?

If other, please identify:

Siblings

NOTE: A separate REGISTRATION FORM must be completed for each child.

Please list siblings that will also be registering summer day camp.

This information will be used for billing purposes.

Questionnaire: (Please complete in an effort to provide the most positive experience for your children)

Summer Learning

Please list any subjects (reading, math, etc.) or skills (organization, responsibility, etc.) that your child may need to work on this summer. If you are registering additional children, please identify the child and the subject or skill.

Does your child have an IEP or 504 for school?*

Individual Education Plan (IEP)
504 Plan
None of the above

Please describe the support received with the IEP or 504 Plan.

Does your child have access to a computer and the internet at home?*

Computer only
Computer and internet
None

What types of community service activities (if any) would you like your child to be involved in this summer?

What additional activities or programs should the Girls Place staff consider that would be of interest to you or your child?

What is Gainesville missing for your girls and your family?

What physical, educational, social, or life skills would you like your child to gain while in the summer camp program? What sports would you be interested in seeing at Girls Place?

What do you expect your child to gain from the programs offered at Girls Place?

Below, please give us any input that you would like to share about Girls Place or the summer camp program.

For returning families, please share how Girls Place has benefited you and your family. What would your child's life be like without Girls Place?

Signature

I have read and fully understand the contents of this application. I have completed the application to the best of my knowledge and ability. I understand that if any information listed in this application changes, I will notify GIRLS PLACE immediately. The child/children listed above has/have my permission to participate in the activities sponsored by GIRLS PLACE as noted on the program schedules. In the case of an emergency an alternate person will be called if the parent(s) can not be reached by phone. The undersigned, individually and as parent or guardian of the participant, hereby authorize GIRLS PLACE to carry out any measures deemed necessary should an emergency occur, including at the expense of the undersigned, appropriate medical treatment for the participant, and hereby releases the GIRLS PLACE, its employees and agents, from any liability or claims arising out of the participant's engagement in the above described events.

Please type your full name into the box below to serve as your digital signature for this form:*

Type full name here

Date*