Colonie Youth Center, Inc.
21 Aviation Rd., Albany, NY 12205
2017-18 School-Age Childcare Application (North Colonie)
- Please review the
before submitting this application.
- One child per form
- enter "n/a" in required fields where no information is available
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COLONIE YOUTH CENTER - 2017/18 School-Age Childcare Application
Child's Legal Name
Date of Birth
Grade (Sept. 2017)
Parent/Guardian #1 (primary account-holder)
--> Children will not be released to anyone except parents/guardians, emergency contacts & authorized pick-ups.<--
Emergency Contact Information
Emergency Contact #1
Emergency Contact #2
Authorized Pick-Up Information (in addition to Emergency Contacts)
Authorized Pick-Up #1
Authorized Pick-Up #2
IN CASE OF EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO CONTACT THE PARENTS OR GUARDIANS OF THE CHILD. IN THE EVENT THE PARENT/GUARDIAN CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY A CYC STAFF MEMBER TO HOSPITALIZE AND/OR SECURE TREATMENT FOR MY CHILD AS NAMED ABOVE.
Does your child have any disabilities, allergies, medical conditions, prescriptions, special concerns or is your child receiving services from the school that impacts your child’s participation in the CYC School-Age Childcare Program?
If yes, specify and explain
IMPORTANT NOTE: Only emergency medications (epi-pens, inhalers, nebulizers, and diphenhydramine i.e. Benadryl when prescribed with an epi-pen only) will be administered. A Medical Consent Form will be provided to the parent/guardian. The form must be completed and signed by the parent/guardian and the child’s physician granting permission and written instruction regarding medication administration. Medication held at the program site must be in its original packaging. The parent/guardian must transport the medication from site to the Vacation Camp or bring additional medication to the camp. Staff will not transport medication from one program to another.
CYC has permission to use photographs of my child for promotional purposes. *Please note your child’s name will not be published with the photo.
Please do not publish photographs of my child.
Do you have a legal document (court order, restraining order, etc.) that impacts your child’s participation in the CYC School-Age Childcare Program in areas such as pick-up rights and financial responsibilities?
Yes (please submit a copy to the administrative office)
Parental Agreement. By submitting this form, you acknowledge and agree to the following:
- I have read and understand the policies and procedures as contained in the CYC School-Age Childcare Parent Handbook. - I agree to abide by the policies and procedures as contained in the CYC School-Age Childcare Parent Handbook. - I agree to notify the CYC Administrative Office if my child is going to be absent from the after-school program. - I agree to give the CYC Administrative Office two weeks advance written notice if I choose to remove my child from the program. - I agree to keep the information on this application updated as needed. - I agree to pay the fees as outlined on the Registration and Fees Sheet. - I understand that if the childcare account is delinquent at any time, my child may be terminated from the program.
Full Name (First/Last)