K-12 Latchkey Enrollment Form

K - 12 Latchkey Enrollment Form

The Romine Group is offering a before and after school latchkey program to all K - 12th grade students at Trillium Academy.

Latchkey is available Monday thru Friday before school from 6:30 AM to 7:30 AM and after school from 3:30 PM to 6:00 PM in Room 408, which is in the RTI/Special Ed wing and will be ran by Ms. Cheryl Swarts, who can be reached between 8:00 am & 1:30 pm at This email address is being protected from spambots. You need JavaScript enabled to view it. and between 2:00 and 2:45 at 734-281- 7706.

Parents may register their children at school by filling out the required forms and paying the non-refundable family registration fee of $10 along with pre-paying the first 2 weeks, based on the amount of hours needed times the hourly rate.

Fee Policy

• Non-refundable family registration fee - $10.00 per year

• Morning Flat Fee - $7.00/student (that attend less than 5 days)
$13.00/family (that attend less than 5 days)

• Special Morning Offer - $45.00/family that attend all 5 days.

• Afternoon Fee - $7.00/student for 1 hour* (3:30 - 4:30 or when student arrives from an after school activity)
$10.00/student for 2 hours* (3:30 - 5:30)
$12.00/student for 2 1/2 hours* (3:30 - 6:00) *rounded to next hour

• Special Afternoon Offer - $45.00/student that attend all 5 days and stay until 6:00 pm.

• 1/2 Day Offer - $15.00/family (from 11:50 - 3:30)
* after 3:30 regular rates will go into effect.

• Registration fee and pre-payment of 2 weeks is due before student can attend latchkey.

*Make check or money order (NO CASH) out to: THE ROMINE GROUP

• If payment is not received by the first day of school, your child will not be allowed to attend latchkey until pre-payment is received. *There will be no exceptions.

• Failure to make bi-weekly pre-payment will result in dismal from latchkey until payment is made.

• Snack is not provided by The Romine Group & therefore must be provided by the parent.


Program Philosophy
Trillium Academy’s latchkey will provide a safe place where students will be able to go, before or after school, that will allow students to interact with other students in a positive atmosphere, but also have the support they need to continue in their education.

Daily Schedule
 Morning - Unfinished homework, games, sleep (for those tired)
• 3:30 − 4:00 − Snack
• 4:00 − 5:00 − Homework
• 5:00 − 6:00 − Play Time
*includes: reading, crafts, games, going to playground (weather permitted), playing in gym (when accessible)

Health Care Policy
 All students are required to wash their hands, especially after using the bathroom.
 All bodily fluids will be handled with gloves and than placed in a bag that will be labeled and given to the janitor for dispense.
 All toys and desks will be sanitized with a bleach/water solution, which will
also control any infections that can be passed through hands.
 The room will be sprayed with Lysol to prevent any air-borne diseases from being passed.

Emergency Procedures
 In case of a fire, all students will line up orderly, evacuate the building & go to a safe place on the schools premises.
 In case of a tornado, all students will line up orderly and go to the designated hall for safety.
 Should a student become ill while in latchkey, their parent will be notified and depending on the type of illness, may be placed in another room so not to spread to other students.
 Should a student be injured, their parent will be immediately notified and proper attention will be given to the student. Also, a written report will be filled out and given to the parent as well as a copy to be kept on file.
• Should a student be seriously injured, 911 will be called right away and the child’s parent will be immediately notified thereafter.

Disciplinary Rules
 There is NO SWEARING allowed in Latchkey, if so, it will result in a next day suspension.
*This applies to any words that start with the letter A, B, D, F, H and S. It also includes JESUS CHRIST and GOD D .
 Every child and parent is expected to display self-control, positive behavior & to show respect towards each other.
 No child will be allowed to verbally (e.g. name calling) or physically attack (e.g. hitting) another child or adult (including a sibling).
 Corporal punishment will not be administered by any staff member towards any of the students.
 All students are required to stay in the room unless given permission to leave.
 Problems that cause physical or mental injury will result:
1. A Caution Card which the parent must sign.
2. Upon receipt of the third caution card, the child will be suspended from the Latchkey program. In order to re-enter the program, the parent and the Program Supervisor must meet and devise an action plan for the child’s behavior. If a behavior incident occurs again, the child will not be permitted to return to the program.
3. At the Directors discretion, any behavior problem which warrants severity will result in dismissal from program.

I have read and discussed the Latchkey rules with my child.

Parent/Guardian Signature Date

TRILLIUM ACADEMY LATCHKEY PROGRAM

Health Statement

 This acknowledges that my child

Date of birth

who attends the school-age child care program at Trillium Academy is in good health and his/her immunizations are current. I understand that I assume responsibility for my child’s health while he/she is at Latchkey.


Please list any special health problems:

 

 

Please list any allergies:

 

 

Parent/Guardian Signature Date


TRILLIUM ACADEMY LATCHKEY PROGRAM

Food Form Agreement

When a child attends an after school program, it is very important to provide that child with a healthy snack. The children are in school all day and are hungry by days end. Remind your child to save their snack for Latchkey so they will have something to hold them over until they get home. Please read and sign below.

Child’s Name

I agree to provide my child, who attends the latchkey program at Trillium Academy, with a healthy snack every day they are in attendance of the after school program.

Parent/Guardian Signature Date

Outdoor Playground Area Permission Slip
Dear Parent or Guardian,

This letter is to inform you that the playground area, that is adjacent to the school, was not inspected in order to obtain a license for latchkey. According to the Child Care Center Rules (R440.5117 (14)),
“If children who attend the school during the day use a school playground, it is reasonable to allow school-age children attending a before or after school child care program at the same location to use the same playground.”

Therefore, in order for your child to be able to play on the playground, your permission will be needed.

I give me child
permission to play on the playground, even though it is not licensed for Trillium Academy Latchkey to use it. But because it is on the school grounds of Trillium Academy, where my child attends school, and according to the rule stated above, I feel it is safe for my child to play on the playground.

Parent/Guardian Signature Date


PARENT NOTIFICATION OF THE LICENSING NOTEBOOK
Child Care Organizations Act, 1973 Public Act 116
Michigan Department of Human Services


All child care centers must maintain a licensing notebook which includes all licensing inspection reports, special investigation reports and all related corrective action plans (CAP). The notebook must include all reports issued and CAPs developed on and after May 27, 2010until the license is closed.

• The center maintains a licensing notebook of all licensing inspection reports, special investigation reports and all related corrective action plans.

• The notebook will be available to parents for review during regular business hours.

• Licensing inspection and special investigation reports from at least the past two years are available on the Bureau of Children and Adult Licensing website at www.michigan.gov/michildcare .


I have read the above statement issued by _
Name of Child Care Center


Child(ren)'s Name(s) _

 

Parent Name _ Parent Signature -------------------Date _

 

Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you arc invited to make your needs known to a DHS office in your area.

CHILD INFORMATION RECORD
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.

FOR PROVIDER Date of Admission
USE ONLY: Date of Discharge
Name of Child (Last, First, Middle Initial) Child’s Date of Birth
Address (Number, Street, Building/Apartment Number City State Zip Code
Father/Legal Guardian’s Name Home Phone ( ) Mother/Legal Guardian’s Name Home Phone ( )
Home Address (if not child’s address Cell Phone ( ) Home Address (if not child’s address Cell Phone ( )
City State Zip Code City State Zip Code
Email Address (optional) Email Address (optional)
Employer Name Work Phone ( ) Employer Name Work Phone ( )
Name of Child Physician or Health Clinic Physician’s or Health Clinic’s Phone Number ( )
Hospital Preferred for Emergency Treatment (optional)
Allergies, Special Needs and Special Instructions (Attach additional sheets, if necessary

Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency along with their numbers - home, work and cell, to whom the child can be released. (If more individuals, attach additional sheets.)
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Release of Child Only: List all individuals, other than the parents/legal guardians, along with their numbers - home, work and cell, to whom the child may be released. (If more individuals, attach additional sheets.)
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )


I give permission to to secure emergency medical and/or emergency surgical
(Provider’s Name)

treatment for the above named minor child while in care.
Signature of Parent or Guardian Date Signed

Date Card Reviewed Parent or Legal Guardian Initials Date Card Reviewed Parent or Legal Guardian Initials Date Card Reviewed Parent or Legal Guardian Initials Date Card Reviewed Parent or Legal Guardian Initials

Update in November Update in January Update in March Update in May

CHILD INFORMATION RECORD
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.

FOR PROVIDER Date of Admission
USE ONLY: Date of Discharge
Name of Child (Last, First, Middle Initial) Child’s Date of Birth
Address (Number, Street, Building/Apartment Number City State Zip Code
Father/Legal Guardian’s Name Home Phone ( ) Mother/Legal Guardian’s Name Home Phone ( )
Home Address (if not child’s address Cell Phone ( ) Home Address (if not child’s address Cell Phone ( )
City State Zip Code City State Zip Code
Email Address (optional) Email Address (optional)
Employer Name Work Phone ( ) Employer Name Work Phone ( )
Name of Child Physician or Health Clinic Physician’s or Health Clinic’s Phone Number ( )
Hospital Preferred for Emergency Treatment (optional)
Allergies, Special Needs and Special Instructions (Attach additional sheets, if necessary

Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency along with their numbers - home, work and cell, to whom the child can be released. (If more individuals, attach additional sheets.)
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Release of Child Only: List all individuals, other than the parents/legal guardians, along with their numbers - home, work and cell, to whom the child may be released. (If more individuals, attach additional sheets.)
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )
Home Phone ( ) Work Phone ( ) Cell Phone ( )


I give permission to to secure emergency medical and/or emergency surgical
(Provider’s Name)

treatment for the above named minor child while in care.
Signature of Parent or Guardian Date Signed

Date Card Reviewed Parent or Legal Guardian Initials Date Card Reviewed Parent or Legal Guardian Initials Date Card Reviewed Parent or Legal Guardian Initials Date Card Reviewed Parent or Legal Guardian Initials

Update in November Update in January Update in March Update in May

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