Please check appropriate program (above) that you are requesting for your child. The Merrick Before & After School Program is located at Birch, Chatterton and Norman J. Levy Lakeside Elementary School.

Days your child will be attending the program:
Mornings: Mon Tues Wed Thursday Fri
Afternoons: Mon Tues Wed Thursday Fri

Your Childs grade in September: School:

Childs Address:

MOTHER'S NAME:

Business/Work phone: Home phone: Cell phone

FATHER'S NAME:

Business/Work phone: Home phone: Cell phone:

Father's E-mail address: Mother's E-mail address:

Emergency Names/Telephone Numbers of persons authorized to pick up your child (ren) from the After School Program. Must have all three. Can not be parent/guardian.

Name: Phone Number:

Name: Phone Number:

Name: Phone Number:

The After School Program closes at 6 p.m. All activities in the program end at 5:45 p.m. If you will be delayed due to traffic, transportation delays, inclement weather or an emergency, please have an authorized person from the emergency list pick up your child(ren) by 6 p.m. If it is someone other than a person on the emergency list, please call our program office (516)379-4245 to indicate the name of the person picking up the child(ren). They will need to provide identification when picking up. Children who are not picked up by 6 p.m. by a parent or authorized person will be supervised by staff. However, a late fee will be charged and added to the next month's tuition bill. The late fee ($10.00 for every 15 minutes late/or part thereof) must be paid with the next month's tuition.

Children who are not picked up by 6 p.m. by you or a person authorized by you will be properly supervised until they are picked up. However, a late fee will be charged to you and added to your next months regular tuition bill. The late fee, ($10.00 for every 15 minutes late/or part thereof) must be paid along with your regular tuition fee.

We must know in advance, if someone other than the authorized person on your Emergency list has been given permission by you to pick up your child. Please call our office before the 6 p.m. dismissal time with the name of the person that you have authorized to pick up your child. That person will be required to present a photo identification (e.g. drivers license) to our staff before your child will be released. Please note that your child will not be released to a person who is not authorized to pick up your child.

Childs Health/Medical Information

Certified staff in our program may administer emergency care through the use of epinephrine auto-injector devices (epi pen) when necessary to prevent anaphylaxis. In the case of medication(s) that need to be given on on-going basis, the authorization and consent forms need to be completed by a licensed authorized prescriber and submitted to our office. An individual Health Care Plan will be developed and signed off by the childs parent. Medication may be administered only upon written permission of a parent and accompanied by written instructions of a health care provider. Medication will only be given during an emergency by staff who are trained.

1. Is your child allergic to any food or medication? If yes, please describe:
   
2. Does your child require an epi pen for this allergy?
   
3. Does your child suffer from any recurrent illness or disorder? If yes, please describe:
   
4. Will your child require any medication before dismissal to the After School Program? If yes, please describe:
   
5. Please inform us of any other pertinent medical information regarding your child that will be helpful to our staff in understanding and caring for your child in B/ASP

Pediatrician's Name: Telephone: .

1. I understand that the Merrick Before/After School Program is open according to the official school calendar of the Merrick UFSD and is closed during official school holidays and summer vacation. We are closed whenever MUFSD schools are closed.
2. I understand that I am responsible for payment of a monthly tuition fee made payable to the: Merrick Before/After School Program (B/ASP). I also understand that I am required to prepay each months tuition payment for the entire 10 month school year. Thus, I will submit my tuition payment one month prior to my childs actual participation in the Before and/or After School Program. Prepayment will be due in our office on or before the 15th of each month. Returned checks are subject to a $ 15.00 fee payable to the Merrick Before/After School Program.
3. I understand that in the event of continued late payment of tuition fees, or non-payment of tuition fees exceeding 15 days, that my child may be removed from the program and placed on a wait-list until payment is brought up to date.
4. The children are placed in groups according to OCFS regulations. No child in the program is provided with a one to one staff member.
5. I understand that if my child displays untoward behavior in his/her group that affects the health and safety of other children and/or staff in the program, that my child may be removed from the program. Parents will be given the opportunity to meet with the Program Director in order to discuss and remedy their childs unsatisfactory behavior.
6. I understand that in the event of an accident or illness concerning my child whenever he/she is under the supervision of Before/After School staff, that I will be notified immediately by telephone.
7. I understand that if my child is involved in an accident requiring immediate medical attention, that the Merrick B/ASP will obtain emergency health care (911 ambulance). My signature below, authorizes/gives written consent to the Merrick Before/After School Program to obtain emergency health care for my child. In an emergency, our program Supervisor will arrange for transportation (ambulance) of your child to a local hospital and you will be notified immediately by telephone.
8. I understand that if my child is enrolled in the Before School Program, that each morning that he/she attends the BSP. I will come into the building and sign a daily attendance sheet and for my childs safety, I will not leave my child outside the school building. I also understand that if the MUFSD Superintendent announces a late (10 a.m.) school opening due to snow or ice or inclement weather, that the Before School Program will be closed.
9. If the MUFSD Superintendent announces no after school activities, we request that you arrange to have your child picked up no later than 4 pm for the safety of the children and the staff.
10. I will call the Merrick Before/After School Program Office at 379 4245 or email merrickbasp@gmail.com to inform them of my childs absence from the After School Program on or before the actual date of absence. I will also call the program office to inform them if someone other than the names listed on the emergency list on the front page will pick up my child.
11. I understand that if my child is absent from a regularly scheduled morning (BSP) and/or afternoon session (ASP), that I will still be charged for tuition for that missed session. Parents will not be allowed to use make-up days to replace a missed session.

By submitting this application, I hereby agree to abide by The Merrick Before/After School Progam Policies and Rules listed above