Soc. Sec. #: Address:

City: State: Zip Code:

Home Phone: Cell Phone: Work Phone:

Employer: E-mail:

Soc. Sec. #: Address:

City: State: Zip Code:

Home Phone: Cell Phone: Work Phone:

Employer: E-mail:

If there is a separation or divorce custody issue of which we should be aware, please explain:

None DHS* Promise Jobs CCR&R Y Scholarship Other:____________________ *Please note that by selecting DHS option, you are responsible for any copays. If you DHS Childcare Assistance Application is denied or if you approval letter lapses, you are responsible for any fees that may be incurred. Therefore, you are must compete a payment method attached to this packet. Parent/Guardian Signature: Date:

Primary Payer: Relationship to Student:

Secondary Payer: Relationship to Student:

Child’s Name Name Used at Home: (Last) (First) (Middle)

Birth Date: Sex: Start Date:

Address: City: Zip Code:

Child Lives with:

CHILDCARE REGISTRATION 2019/2020

Y-Creative (Booth Location) Finley/DCY (North Grandview Ave) ▫Preschool Only ▫ Preschool Full Time School Age Child Care (SACC) School: _________________________ ▫Full Time Before School ▫ Full Time After School ▫ Full Time Before & After School

Enrollment Status: Y Member Non-Member Finley Employee Y Employee

If child should become sick/hurt, which guardian should we contact first:

Best Number to call:

Agency Assistance (attach documentation, such as current approval letter)

Marital Status: Married Divorced Separated Single Widowed

For office use only: _____ Registration Form _____ Child Immunization Form

_____ Emergency Contact Form

_____ Child Health Form Date Received

$25 Registration fee, per child, per year, due upon registration and submission of registration packet $_______

Staff Initials _______

MasterCard, VISA, Discover and AMEX.

Bank Name: Account Type (circle): Checking/Savings

Routing/Transit #: Acct #:

Parent/Guardian Signature: Date:

Parent/Guardian Printed Name: SSN: I have been informed of the current Dubuque Community YMCA/YWCA Child Care Handbook that is located at the Cool

School check-in.

Parent/Guardian Signature: Date:

-PAYMENT OPTION 1-

DUBUQUE COMMUNITY YMCA/YWCA

Child Care CREDIT CARD Authorization Form You must choose either option 1 or option 2

1. Credit/Debit Card (Auto draft every two weeks) I (we) authorize the Dubuque Community

YMCA/YWCA to withdrawal sufficient funds to pay my (our) childcare related fees that are due and payable. I (we)

authorize the Dubuque Community YMCA/YWCA to use their third party processing company to create, capture, and

transmit all credit card information. I (we) indemnify and hold harmless the Dubuque Community YMCA/YWCA from any

and all liability resulting from any and all transactions. All disputed will be directed to and addressed by and between the

Dubuque Community YMCA/YWCA and the below signed cardholder. The Dubuque Community YMCA/YWCA accepts

-PAYMENT OPTION 2-

DUBUQUE COMMUNITY YMCA/YWCA

Child Care ACH BANK DRAFT Authorization Form

You must choose either option 1 or option 2

2. ACH Bank Draft Authorization (Auto draft every two weeks) I (we) authorize the

Dubuque Community YMCA/YWCA, to initiate debit entries to my (our) Checking or Savings Account indicated below at

the depository financial institution indicted below. I (we) authorize the Dubuque Community YMCA/YWCA to withdrawal

sufficient funds to pay my (our) childcare related fees that are due and payable. I (we) authorize the Dubuque

Community YMCA/YWCA to use their third party processing party sender, to process all payments. I (we) acknowledge

that the origination of Automated Clearing House (ACH) transactions to my (our) account must comply with the

provisions of the United States Law. Please attach a voided check or deposit ticket

Card #: Exp. Date:

Cardholder Billing Address:

City, State, Zip:

________________________

First Name: ________________ Middle Initial: _____ Last Name: _______________ Phone: __________

Name on Bank Account: __________________________ Account Holder Phone: _______________

Declined Credit Card / Non-sufficient funds fee - $15.00

I understand that payment for service is due no less than one week in advance. I understand that service may be

suspended if I fail to keep my account current without making satisfactory payment arrangements. In addition, I

understand it is my responsibility to provide written notice at least one week in advance to stop service. If you stop

service and withdraw from the program, you will be responsible for paying an additional registration fee to return to care.

I understand that I will be charged for the schedule for which I have registered and that no refunds will be given unless

the change in schedule is pre-approved by the program director.

Please include photo copy of credit/debit card.

3 digit code:

_____ Permissions Page

THE FOLLOWING CHILDCARE PROGRAMS COMPLETE THIS FORM: Y CREATIVE, FINLEY/DCY, SCHOOL AGE CHILD CARE (SACC), COOL SCHOOL

PARENTAL EMERGENCY MEDICAL CONSENT This form must be presented upon admission for treatment

This form allows parents and guardians to authorize the provision of emergency treatment for below named child who becomes ill or injured while under program authority when parents or guardians cannot be reached.

In the event reasonable attempts to contact have been unsuccessful, I hereby give consent for the administration of any treatment deemed necessary by the doctor or dentist listed below, or if unavailable, another licensed physician or dentist.

I agree to pay all costs and fees as secured or authorized under this consent.

CHILD’S NAME: BIRTH DATE: PARENT(S)/GUARDIAN(S) WITH WHOM THE CHILD RESIDES

1. NAME RELATIONSHIP TO CHILD

ADDRESS EMPLOYER

HOME NUMBER CELL NUMBER WORK NUMBER

2. NAME RELATIONSHIP TO CHILD

ADDRESS EMPLOYER

HOME NUMBER CELL NUMBER WORK NUMBER EMERGENCY CONTACT PERSON(S)

1. NAME RELATIONSHIP TO CHILD

HOME NUMBER CELL NUMBER WORK NUMBER

2. NAME RELATIONSHIP TO CHILD

HOME NUMBER CELL NUMBER WORK NUMBER

3. NAME RELATIONSHIP TO CHILD

HOME NUMBER CELL NUMBER WORK NUMBER PERSONS AUTHORIZED TO PICK UP CHILD ADDRESS PHONE NUMBER 1. 2. 3.

Are there any custody or restraining orders for person(s) who may attempt to pick up or have contact with the child while in care at the center?

Name Name

PHYSICIAN NAME DENTIST NAME

PHONE NUMBER PHONE NUMBER

ADDRESS ADDRESS

HOSPITAL PREFERENCE

KNOWN ALLERGIES DATE OF LAST TETANUS

PRESENT MEDICATION

INSURANCE COMPANY POLICY HOLDER ID

This consent will be in effect for one year beginning (date)

SIGNATURE OF PARENT OR GUARDIAN DATE

SIGNATURE OF PARENT OR GUARDIAN DATE

THE FOLLOWING CHILDCARE PROGRAMS COMPLETE THIS FORM: Y CREATIVE, FINLEY/DCY, SCHOOL AGE CHILD CARE (SACC), COOL SCHOOL

Parent’s/Guardian’s Permission Page

Name of Child ____________________________ Date of Birth _______________

GENERAL WALK (Y Creative and Finley/DCY)□ Yes, I give permission for my child to take a short educational walk, weather permitting around the

block or to a nearby park. I understand additional staff, emergency information, and first aid bag

will accompany the group.

□ No, my child may not leave the Center Grounds during Childcare/Preschool.

POOL (Y Creative and Finley/DCY)□ Yes, I give permission for my child to participate in swimming at the Dubuque Community Y small

pool during Childcare/Preschool Swims. I understand that each child will be provided with a safety

floatation belt, additional staff in the water, and lifeguard on duty.

□ No, my child may not participate in swimming activities. Rather, my child will be offered alternative

activities in the classroom.

SUNSCREEN

As the parent of the above child, I recognize that too much sunlight my increase my child’s risk f getting

skin cancer someday. Therefore I give my permission for staff at the Dubuque Community Y Childcare to

apply Banana Boat Sports Performance Sunscreen, SPF 50, to my child, as specified below, when he/she

will be playing outside, especially during the months of March through October and between the times of

10am and 4pm. I understand that sunscreen may be applied to exposed skin, including but not limited to

the face, tops of the ears, nose and bare shoulders, arms, and legs. I have checked all the applicable

information regarding the type and use of sunscreen for my child:

□ I do not know of any allergies my child has to sunscreen.

□ Staff may use the Y sunscreen provided following the directions or recommendations printed on the

bottle.

□ My Child is allergic to some sunscreens. Please use only the following brand(s) and type (s) of sunscreen. ________________________________________

□ For medical or other reasons, please do not apply sunscreen to the following areas of my child’s body: ____________________________________________

PICTURE RELEASE

□ I do___/do not___give consent to have my child photographed or videotaped for use by the center

in newspapers, publicity, advertisement, or for educational purposes.

Parent/Guardian full name (print) ____________________________

Parent/Guardian signature: Date _____________

THE FOLLOWING CHILDCARE PROGRAMS COMPLETE THIS FORM: Y CREATIVE, FINLEY/DCY

Infant, Toddler, Preschool Age – Child Health Form

1 Iowa Child Care Regulations require an admission physical exam report within the previous year and annually. The American Academy of Pediatrics has recommendations for frequency of childhood preventative pediatric health care (Bright Futures 2015) https://www.aap.org/en-us/Documents/periodicity_schedule.pdf

3

HEALTH PROFESSIONAL COMPLETE THIS PAGE

Child’s Name: _____________________________

Birthdate: _____________ Age today: ________

Date of Exam: _____________

Height/Length: ____________ Weight:___________

BMI– starting at age 24 mo. ____________

Head Circumference- age 2 yr. and under: _____________

Blood Pressure-start @ age 3 yr:____________ Hgb or Hct- @ 12 mo: _____________ Lead Risk Assessment:_________________

Blood Lead Level: date__________ results _____________

Sensory Screening:

Vison Assessment: ______________________________

Vision Acuity: Right eye ________ Left eye _________

Hearing Assessment: Right ear ______ Left ear ________

Tympanometry (may attach results)

Developmental Screening/Surveillance:(n = normal limits) otherwise describe Developmental screening results:

Autism screening results:

Psychosocial/behavioral results

Developmental Referral Made Today: Yes No

Exam Results: (n = normal limits) otherwise describe

HEENT

Oral/Teeth

Date of Dental exam ____________

Oral Health/Dental Referral Made Today: Yes No

Heart

Lungs

Stomach/Abdomen

Genitalia

Extremities, Joints, Muscles, Spine

Skin, Lymph Nodes

Neurological

Allergies

Environmental: Medication: Food: Insects: Other:

Immunization: Please attach: Iowa Department of Public Health

Certificate of Immunization Iowa Department of Public Health

Certificate of Immunization Exemption Medical Iowa Department of Public Health

Certificate of Immunization Exemption Religious.

TB testing completed (only for high-risk child)

Medication: Health professional authorizes the child may receive the following medications while at the child care facility: (include over-the-counter and prescribed)

Medication Name Dosage Diaper crème: Fever or Pain reliever: Sunscreen: Other

Other Medication should be listed with written instructions for use in child care. Medication forms available at www.idph.iowa.gov/hcci/products

Referrals made: Referred to hawk-i today 1-800-257-8563 Other: _________________________________

Health Provider Assessment Statement:

The child may participate in developmentally ap-propriate early care/learning with NO health-related restrictions.

The child may participate in developmentally ap-propriate early care/learning with restrictions (seecomments).

The child has a special needs care plan Type of plan __________________________ (please attach)

May use stamp

Signature ____________________________________ Circle the Provider Credential Type: MD DO PA ARNP

Address: Telephone:

Health Care Provider comments:

THE FOLLOWING CHILDCARE PROGRAMS COMPLETE THIS FORM (2 PAGES): Y CREATIVE, FINLEY/DCY

2

PARENT/GUARDIAN COMPLETE THIS PAGE Child’s Name: ___________________________

Tell us about your child's health. Place an X in the box if the sentence applies to your child. Check all that apply to your child. This will help your health care provider plan your child’s physical exam.

Growth

I am concerned about my child's growth.

Appetite

I am concerned about my child's eating/ feeding habits or appetite.

Rest - I am concerned about the amount of sleep

my child needs.

Illness/Surgery/Injury - My child had a serious illness, injury, or surgery..

Physical Activity - My child must restrict physical activity.

Development and Learning

I am concerned about my child’s behavior, development, or learning.

Allergies-My child has allergies. (Medicine,food, dust, mold, pollen, insects, animals, etc.).

Special Needs Care Plan – My child has a special needs care plan (IEP, IFSP, Asthma Action Plan, Food Allergy Action Plan, etc.). Please discuss with your health care provider.

Body Health - My child has problems with Skin, birthmarks, Mongolian spots, hair, fin-

gernails or toenails. Map and describe color/shape of skin markings

birthmarks, scars, moles

Eyes \ vision, glasses Ears \ hearing, hearing aides or device, ear- aches, tubes in ears

Nose problems, nosebleeds, runny nose Mouth, teething, gums, tongue, sores in mouth or on lips, mouth-breathing, snoring

Frequent sore throats or tonsillitis Breathing problems, asthma, cough, croup

Heart, heart murmur Stomach aches, upset stomach, spitting-up Using toilet, toilet training, urinating Bones, muscles, movement, pain when moving, uses assistive equipment.

Nervous system, headaches, seizures, or nervous habits (like twitches) Needs special equipment.

Medication - My child takes medication. (List the name of medication, time medication taken, and the reason medication prescribed).

Parent/Guardian questions or comments for the health care provider:

List equipment:

Please describe:

Please describe:

Please describe:

Please describe:

THE FOLLOWING CHILDCARE PROGRAMS COMPLETE THIS FORM: Y CREATIVE, FINLEY/DCY

I certify that the above named applicant has a record of age-appropriate immunizations that meet the requirement for licensed child care or school enrollment.

Iowa Department of Public HealthCertificate of Immunization

First: Middle: Date of Birth:Name Last:

Address: Phone:Parent/Guardian:

Signature: Date:Physician, Physician Assistant, Nurse, or Certified Medical Assistant

A representative of the local Board of Health or Iowa Department of Public Health may review this certificate for survey purposes.

If applicant has ahistory of naturaldisease write"Immune to Varicella"

MMR

Measles,Mumps,Rubella

DTaP/DTP/DT/Td/Tdap

IPV/OPV

Hepatitis B

Varicella

PCV/PPSV

Date Given Doctor / Clinic / SourceDate GivenVaccine

MCV/MPSV/Mening B

Hepatitis A

Rotavirus

HPV

Other

Diphtheria,Tetanus,Pertussis

Polio

Haemophilusinfluenzae

Meningococcal

Pneumococcal

Chicken Pox

Vaccine Doctor / Clinic / Source

VirusPapillomaHuman

Hibtype b

January 2013

THE FOLLOWING CHILDCARE PROGRAMS COMPLETE THIS FORM: Y CREATIVE, FINLEY/DCY

SCHOOL-AGE ASSESSMENT & HEALTH FORM

& IMMUNIZATION DECLARATION

1. HEALTH STATEMENT - To be completed by parent.

Child’s Full Name Birth Date

1. Significant illnesses and surgeries child has had (give age at time):

2. Any special health-related needs of child (allergies, medications, injuries, etc.):

2. PHYSICAL ASSESSMENT

1. Is there any defect of vision, hearing or speech of which the child care program should be aware, or

could compensate by appropriate action?

2. Is this child subject to any conditions which limit classroom activities or physical education?

3. Is this child subject to any condition which may result in an emergency situation?

4. Is this child subject to any mental or physical condition for which he/she should remain under periodic

medical observation?

5. Other information you would like to share:

Parent’s Signature Date

FOR CENTERS SERVING SCHOOL-AGE CHILDREN OPERATING IN THE SAME SCHOOL

FACILITY IN WHICH THE CHILD ATTENDS SCHOOL:

My signature below certifies that immunization information concerning my child has been provided

and is available in the school file.

THE FOLLOW CHILDCARE PROGRAMS COMPLETE THIS FORM: SCHOOL AGE CHILD CARE (SACC) ONLY

CACFP (Food Program) Enrollment Sheets…

*This paperwork is for our program to be reimbursement from the state for the snacks we

serve.

Iowa Eligibility Application (page 1)

Everyone must sign the bottom of this page

You only need to complete the top potion if you think your family will qualify for

free/reduce meals

Iowa Child and Adult Care Food Program Child Care Enrollment (page 2)

This page must be completed by ALL families

THE FOLLOWING CHILDCARE PROGRAMS COMPLETE THESE FORMS: Y CREATIVE, FINLEY/DCY, SCHOOL AGE CHILD CARE, COOL SCHOOL

Iowa Child and Adult Care Food Program Child Care Enrollment Form

May 2018

Times of Care Regular Days of Care Meals Served During Care Ethnicity/Race*

Last Name, First Name Birthdate Arrival Departure M T W Th F S S B AM Sn

Lu PM Sn

D E Sn

Ethnicity Race

*Ethnicity (Select one and enter in the chart above): H=Hispanic or Latino or N=Not Hispanic or Latino*Race (Select one or more and enter in the chart above): W=White, B=Black or African American, I=American Indian or Alaska Native, A=Asian, and P=Native Hawaiian or Other Pacific Islander Thisinformation is requested by the Federal Government in order to monitor compliance with Civil Rights law. You are not required to furnish this information, but are encouraged to do so. The lawrequires that organizations may not discriminate on the basis of this information nor on whether you choose to furnish it. However, if you choose not to furnish it, the center’s Program representative isrequired to note race/ethnicity on the basis of visual observation.

Infants only (0 to 12 months): I am not enrolling an infant (skip this section)As a participant in a USDA Child Nutrition Program, our center offers meals to children of all ages; you are not required to provide infant food or formula. Infant feeding is based on Academy of Pediatrics nutrition guidelines. Infant foods served are appropriate for the age and developmental readiness of your infant. Mark (X) to indicate your choice(s) below:

I will provide breastmilk for my infant. Yes No Center formula may be used to supplement feedings if necessary: Yes No

I would like to breastfeed on site, if this option is available1. Yes No If yes, time(s)

I will provide formula for my infant. Name of formula (must be iron-fortified and manufactured in the USA): I accept the center’s formula for my infant. Name of iron-fortified formula: I will submit a Diet Modification Request Form for non-reimbursable formula. Name of formula: I accept the center’s solid foods (appropriately textured) to be served to my infant as s/he is ready for them, and after I have discussed it with the caregiver. I will provide solid foods for my infant2. The center may supplement with additional solid foods when my infant needs them: Yes No

Parent Signature Date:_

Parent Signature Date:_ (Make any needed changes above, sign and date)

Parent Signature Date:_ (Make any needed changes above, sign and date) 1Ask your center if you can breastfeed on-site. 2The parent may provide no more than one required meal component in order for the center to claim reimbursement for the meal. DHS licensed centers must follow CACFP infant meal pattern requirements regardless of who supplies the food. Your center can provide a copy of the CACFP infant meal pattern and a list of reimbursable foods upon request.

This institution is an equal opportunity provider.

Your child is enrolled in a center that participates in the Child and Adult Care Food Program (CACFP). By participating in this Program, the center follows federal meal pattern requirements and receives reimbursement to assist with food costs. The CACFP requires parents to provide specific enrollment information on an annual basis. This form will be placed in center files and treated as confidential information. Complete one form for all of your children who are enrolled at the center.

Purpose: The attached Iowa Eligibility Application is used to determine eligibility for free and reduced price meal reimbursement. The instructions for completion are on the back of this letter.

Dear Parent or Guardian:

This center participates in the Child and Adult Care Food Program (CACFP) administered by the United States Department of Agriculture (USDA). Participants are not charged separately for meals. However, by participating in this Program, the center receives partial reimbursement for nutritious meals served to children. The amount of reimbursement the center receives is determined by the information you provide. Providing information can help your center purchase nutritious food. Higher reimbursement will be given to the center for meals served to enrolled children from families whose income is at or below the level shown in the chart below. Please read the instructions on the back, complete, sign and return the attached income application as soon as possible. An application that does not contain all required information cannot be used by the center. If required information is missing, free or reduced-price meal benefits will be denied. Call your center if you need help with the form. The information reported on this form will be filed and treated as confidential. A foster child who is the legal responsibility of a welfare agency or court may be certified as eligible for free meals regardless of your household income. See instructions on the back for more information. If you do not qualify now to receive free or reduced price meals, you may apply for benefits at any time during the year. If you have a decrease in household income, have an increase in family size, or have enrolled children that become eligible for food assistance or FIP, you may fill out an application at that time.

Income Eligibility Guidelines for Reduced Price Meals Effective 7-1-2019 to 6-30-2020

Household Size

Reduced Price Meals

Yearly Monthly Twice per

Month Every Two

Weeks Weekly

1 $23,107 $1,926 $ 963 $ 889 $ 445 2 $31,284 $2,607 $1,304 $1,204 $ 602 3 $39,461 $3,289 $1,645 $1,518 $ 759 4 $47,638 $3,970 $1,985 $1,833 $ 917 5 $55,815 $4,652 $2,326 $2,147 $1,074 6 $63,992 $5,333 $2,667 $2,462 $1,231 7 $72,169 $6,015 $3,008 $2,776 $1,388 8 $80,346 $6,696 $3,348 $3,091 $1,546

For each additional family member add: +$8,177 + $682 + $341 + $315 + $158

Privacy Act Statement: This explains how we will use the information you give us.

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. The last four digits of the social security number of the adult household member who signs the application must be listed. The social security information is not required when you apply on behalf of a foster child or if you list a Food Assistance number, or Family Investment Program number, or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the CACFP. We may share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. USDA Nondiscrimination Statement In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or

(3) email: program.intake@usda.gov.

Iowa CACFP Child Care Center Parent/Guardian Letter - Non-pricing (front) 7/2019

Instructions for Completing Iowa Eligibility Application Complete both sides of an application for each household.

All applicants should complete Part 1. This application may be used to apply for benefits in school meals or milk programs, child care centers and home based care for children. Check all boxes that apply to your family. You may make copies of a completed application for each program in which your child participates. FIP OR FOOD ASSISTANCE HOUSEHOLD MEMBER, including child(ren) in Head Start or Even Start, follow these instructions. Part 3. List one FIP or Food Assistance Case Number per household in the area provided. Use the Case Number listed in the DHS Notice of Decision. Eligibility based on Head Start or Even Start is available only if your child is enrolled in Head Start and documentation from the Head Start agency is provided. NOTE: Medicaid, Title XIX and EBT card numbers are not acceptable. Part 4. List the name, date of birth, grade (if applicable), name of school/Head Start/child care center attended for each child in your household. Provide ethnic and racial information if you choose, but the school/Head Start/child care will make the determination of your child’s ethnic and racial status if you do not complete this section. Part 5. Skip this section. Part 6. Read the certification and complete this section.

FOSTER CHILD IN HOUSEHOLD, follow these instructions. A foster child is a child who is living with a household but who remains the legal responsibility of the welfare agency or court. Foster children can be included as household members or included on a separate application. Part 4. List the child’s name, date of birth, grade (if applicable), name of school/Head Start/child care center attended. Check the box for foster child. Provide ethnic and racial information if you choose, but the school/Head Start/child care will make the determination of your foster child’s ethnic and racial status if you do not fill this section. Part 5. Complete this section only if the foster child receives money for personal use or has other regular personal income. If the foster child has no income, check the box indicating no income. DO NOT include the stipend received by the foster family to provide care to the foster child. Part 6. Read the certification and complete this section.

ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions for reporting income. Part 4. List the name, date of birth, grade (if applicable), name of school/Head Start/child care center/home attended for each child in your household. Provide ethnic and racial information if you choose, but the school/Head Start/child care will make the determination of each child’s ethnic and racial status if you do not complete this section. Part 5. Follow these instructions to report total household income from last month.

Name: List the last and first names of each person living in your household, related or not (such as grandparents, other relatives, or friends); include yourself and all children living with you. The household decides whether to include the foster child on their household application with non-foster children. Attach another sheet of paper if needed.

Age: List the age of each household member. Check if No Income: Put a mark in the box if the household member does not have an income. Gross Income last month and how it was received: Report the amount of income received in the appropriate Gross Income

column (weekly, every 2 weeks, twice monthly, or monthly). List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. If you have a household member for whom last month’s income was higher or lower than usual, list that person’s expected average income. If the household includes the foster child, they must report any personal income received by the foster child on the foster parent’s household application.

Other Monthly Payments or Income: Money is reported in this section if it is regularly received. List the amount each person received last month from welfare, child support, alimony, adoption subsidies, pensions, retirement, Social Security, Supplemental Security Income (SSI), and Veteran’s benefits (VA benefits). In the All Other Income column, include Worker’s Compensation, unemployment, strike benefits, regular contributions from people who do not live in your household, cash withdrawn from savings, investments or trusts, interest and ANY OTHER INCOME. Use the Self-Employment Income Worksheet on the back of the application to calculate net income for self-owned businesses, farm, or rental income and report in the All Other Income column. Do not report: Scholarships, educational benefits, lump sum payments, combat pay, Deployment Extension Incentive Pay (DEIP) or children’s incidental income from occasional activities such as babysitting, shoveling snow, or cutting grass. If you are in the Military Housing Privatization Initiative or get combat pay do not include these allowances.

Social Security Number: If the application is being made on the basis of income, the adult signing the form must provide the last 4 digits of his or her Social Security number or mark the "I do not have a Social Security number" box. If you do not provide your Social Security information or mark the box, your application cannot be processed.

Part 6. Read the certification and complete this section.

HOMELESS, MIGRANT OR RUNAWAY, follow these instructions. Part 2. For children attending school, check if any child is Homeless, Migrant, or a Runaway and call your child’s school. Part 4. List the name, date of birth, grade (if applicable), name of school/Head Start/child care center attended for each child in your household. Provide ethnic and racial information if you choose, but the school/Head Start/child care will make the determination of your child’s ethnic and racial status if you do not complete this section. Part 5. Skip this section. Part 6. Read the certification and complete this section.

Page 1 of 2 Iowa Eligibility Application FFY 19-20

Complete one application per household. Fiscal Year 2019-2020

Part 1. Check all applicable boxes:

school meals special milk (restrictions apply)

children in child care center Tier I home provider (HP) Head Start/Even Start

children in child care home(HP)Provider name:

Part 2. Check if any child is Homeless, Migrant, or a Runaway and call your child’s school. Run away Migrant Homeless

Part 3. FIP or Food Assistance Eligible: Enter the FIP or Food Assistance Case Number for ANY household member as listed in the Notice of Decision (10 digits, include zeros). NOTE: Medicaid, Title XIX and EBT card numbers are not acceptable. Skip part 5.

Name of household member with Case Number __________________________ List Case Number ___-___-___-___-___-___-___-___-___-___ Part 4. Children enrolled: REQUIRED OF ALL APPLICANTS.

List name(s) of all enrolled child(ren) in your household. Ethnicity: H=Hispanic or Latino

N=Not Hispanic or Latino Race: A = Asian B = Black or African American

I = American Indian or Alaska Native W=White If ethnicity & race are not completed, the form will be completed based on visual observation

Last Name First Name Middle Name or Initial

Check box for

FOSTER child

Date of Birth

Grade OPTIONAL

Name of School/Head Start/ Child Care Center/Home

ETHNICITY RACE

1.

2.

3.

4.

5.

Part 5. Total Household Gross Income: DO NOT COMPLETE PART 5 IF YOU LISTED A FIP OR FOOD ASSISTANCE NUMBER IN PART 3. Report the gross income received by EACH household member one time in the correct column: weekly, every 2 weeks, twice a month or monthly. Gross income is the amount earned before taxes and other deductions, not take-home pay. Report all other monthly income received. Self- employed persons, see the worksheet on reverse side of this application.

List the names of everyone living in your household, including the children listed in Part 4. Attach a separate page if more space is needed. For FOSTER children, include only

money available for child’s personal use or child’s own income.

Gross Income: Report income by how often the household member is paid.

Other Monthly Payments or Income Received.

Gross amount earned weekly

Gross amount earned every

2 weeks

Gross amount earned twice

a month

Gross amount earned monthly

Welfare, child

support, alimony, adoption subsidies

Pension, retirement,

social security, SSI, VA benefits

All other income

Last Name First Name Age Check if

NO Income

1.

2.

3.

4.

5.

Last four digits of my Social Security Number: X XX - X X - ___ ___ ___ ___ I do not have a Social Security Number. If Part 5 is completed, the adult signing the form must provide the last 4 digits of his or her Social Security Number or mark the "I do not have a Social Security Number" box. For further information refer to the Privacy Act Statement in the parent letter.

Part 6. Certification and Signature. REQUIRED OF ALL APPLICANTS. I certify (promise) that all information on this application is true and that all income is reported if required. I understand that I will receive benefits from Federal funds based on the information I give. I understand that officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal/milk benefits, and I may be prosecuted. Email of Adult Completing Form_______________________________________________

______________________________________________ _________________________________________________ ___________________ Signature of Adult Completing Form Printed Name of Adult Completing Form Date Signed

_____________________________________________ _____________ _______ _____________ ____________ __________ Address of Adult Completing Form Town ZIP Code Work Phone Home Phone Cell Phone Part 7. DO NOT WRITE BELOW THIS LINE. FOR ADMINISTRATIVE USE ONLY.

Income conversion factors for annual income: weekly X 52; two weeks X 26; twice a month X 24; monthly X 12 Household Income: $ ___________ Weekly Every 2 Weeks Twice Monthly Monthly Annually Household Size _______

Application Approved: Income Foster Child (free) FIP/Food Assistance CACFP HP ONLY: Head Start DOCUMENTATION REQUIRED Homeless/Migrant/Runaway

(Schools only) Tier 1 Area (Provider’s ownchildren)

Eligibility Determination: Free Meals Reduced Price Meals Free Milk Tier 1 Income (All children)Application Denied: Incomplete Over income limits Tier 1 Child (Tier 2 mixed)

_____________________________________________________________________________________ __________________ Determining Official Signature Effective Date

Self-Employment Income Worksheet: This worksheet will help you calculate the amount to report if you farm, are self employed, or have income from other sources.

Persons who are engaged in farming or who operate other types of private businesses may experience variations in cash flow or monthly income throughout the year. These persons may use their income tax records from the preceding calendar year as a basis for applying for the free and reduced price meals. The income to be reported is income derived from the business venture less operating costs incurred in the generation of that income. Deductions for personal expenses such as medical expenses and other non-business deductions are not allowed in reducing gross business income. If you have additional income from other kinds of employment, this income must be treated as separate and apart from the income generated from your business venture. USDA DOES NOT recognize income the same way as IRS. USDA does not permit a loss from a business venture to off-set earnings from wages or salary. Though your business may have suffered a net operational loss, for purposes of this application, it is not possible to have a negative income. The least self employed income possible is zero (no income). For example, if you operated a business at a net loss but held another job where you received wages, your income for purposes of applying for free or reduced price meals would be the income from your wages only. The loss from the business cannot be deducted from the amount of the income earned in the other job. A prior year loss from farming or other private business operation cannot be used to reduce the current year net income for determining free and reduced price eligibility. Wages paid to a spouse or other family member in the operation of a farm or private business must be shown as household income in Part 5 of the application.

Income from private business operations is to be taken from your most recent U.S. Individual Income Tax Return - Form 1040 (including Schedule 1). Use the lines from the 1040, Schedule 1 identified below: Line 12 - Business income or (loss) $ Line 13 - Capital gain or (loss) $ Line 14 - Other gains or (losses) $ Line 17 - Rental real estate, royalties, partnerships, S corporations, trusts, etc. $ Line 18 - Farm income or (loss) $ Total $ The least income possible is zero (a negative number cannot be reported) Total ÷12* = ______________________ *Enter amount in the “Other Monthly Payments or Income Received” column in Part 5 on the front of the Iowa Eligibility Application.

DCY CHILDCARE WEEKLY SERVICE RATES

DUBUQUE COMMUNITY YMCA/YWCA

DUBUQUE COMMUNITY YMCA/YWCA 35 N. BOOTH ST., DUBUQUE, IA www.DubuqueY.org 563.556.3371

• Y MEMBER $185 • COMMUNITY $205

INFANT CHILDCARE

6 weeks - 18 months

• Y MEMBER $149 • COMMUNITY $169

TODDLER CHILDCARE

18 months - 36 months

• Y MEMBER $144 • COMMUNITY $164

PRESCHOOL CHILDCARE 3 - 5 years of age

•Y MEMBER $104 •COMMUNITY $124

*V4 - PRESCHOOL CHILDCARE

Fulltime - 12 free hours 4-5 years

•OPTION 1: 8:00AM - 11:00AM •OPTION 2: 12:30PM - 3:30PM

*V4 - PRESCHOOL Preschool Only - 12 free hours

4-5 years

MUST HAVE A HOUSEHOLD MEMBERSHIP TO RECEIVE MEMBER RATE ALL RATES ARE FULL TIME FOR THE WEEK; HOLIDAY WEEKS ARE PRORATED REGISTRATION FEE IS $25 PER CHILD PER YEAR (NON-REFUNDABLE) BREAKFAST/LUNCH/SNACK INCLUDED *V4 (Statewide Voluntary Preschool Program) – 12 FREE HOURS PRESCHOOL (Mon. – Thurs.)

10 hours provided by the State of Iowa. 2 hours provided by DCY. Some restrictions apply.

V4 PRESCHOOL ONLY: AM SESSION INCLUDES BREAKFAST & PM SESSION INCLUDES SNACK

SCHOOL-AGE CHILD CARE (SACC) MONTHLY SERVICE RATES DUBUQUE COMMUNITY YMCA/YWCA

MUST MAINTAIN A Y MEMBERSHIP FOR ENTIRE SCHOOL YEAR TO RECEIVE MEMBER RATE

ALL RATES ARE FULL TIME FOR THE MONTH REGISTRATION FEE IS $25 PER CHILD PER SCHOOL YEAR (NON-REFUNDABLE) MORNING SNACK AND AFTERNOON SNACK PROVIDED

FREE CHILDCARE FOR SACC PARTICIPANTS DUE TO IMCLEMENT WEATHER* * When school is cancelled, alternate care is available from 6 a.m. to 6 p.m. at the Y located at 35 N. Booth St. for children who are enrolled in the before or after school program. When you receive the announcement that school is cancelled, please call (563)556-3371 to make arrangements to attend. THIS IS ONLY AVAILABLE FOR ALL DAY CANCELLATION. (The Y does not have transportation; parents are required to get students to the Dubuque Community YMCA/YWCA.)

DUBUQUE COMMUNITY YMCA/YWCA 35 N. BOOTH ST., DUBUQUE, IA www.DubuqueY.org 563.556.3371

BRYANT ELEMENTARY

CARVER ELEMENTARY

EISENHOWER ELEMENTARY

EPWORTH ELEMENTARY

HOOVER ELEMENTARY

IRVING ELEMENTARY

JOHN KENNEDY ELEMENTARY

SAGEVILLE ELEMENTARY

TABLE MOUND ELEMENTARY

FULL TIME BEFORE SCHOOL ONLY

Y MEMBER $199 COMMUNITY $220

FULL TIME BEFORE & AFTER

Y MEMBER $239 COMMUNITY $260

FULL TIME AFTER SCHOOL ONLY

Y MEMBER $199

COMMUNITY $220