2025 Vistancia Elementary AMPM Registration

VISTANCIA ELEMENTARY 2025-26 AMPM REGISTRATION

(Before starting this form, please have a copy of your child's immunization records available to upload or to take a picture. Previous year's submissions are NOT on file and a new copy is REQUIRED to complete this request)

The City of Peoria AMPM before and after school program is currently taking Registrations for the 2025-26 school year, This program is licensed through the Department of Health Services, and is available from 6:00AM until school starts and from school dismissal until 6:00PM. Due to the ongoing impatCOVID19 pandemic, program times, days, hours and options may be subject to change immediately to align with state and local health and safety guidelines and with the Peoria Unified School District. Currently, the 2025-26 AMPM program is scheduled for July 31, 2025- May 21, 2026. Please note that this date is also subject to change.

All payments for the program will be automatically charged every Monday at the start of each week based on the scheduled attendance you select. No credit back for sick/missed days. An automatic payment method is REQUIRED and must be posted on your recreation account within 24 hours after submitting this form. Directions on how to add your finance information is noted at the bottom of this form and will be available on the AM/PM website at www.peoriaaz.gov/ampm. Administration business hours are Monday through Thursday, 7:00AM to 6:00PM, except holidays.

Program capacity at each school is dependent on staffing capacity.

YesNo

AMPM Site:*

Drop in schedule is not available.

No credit back for sick/missed days, early pick-ups or suspensions.

Please choose/confirm your attendance options below:

(You must choose your attendance options. Drop in is not available at this time)

AM OnlyPM OnlyFULL TIME ($95/week if attending AM and PM every day)Do not need Mondays

AM OnlyPM OnlyFULL TIME ($95/week if attending AM and PM every day)Do not need Tuesdays

AM OnlyPM OnlyFULL TIME ($95/week if attending AM and PM every day)Do not need Wednesdays

AM OnlyPM OnlyFULL TIME ($95/week if attending AM and PM every day)Do not need Thursdays

AM OnlyPM OnlyFULL TIME ($95/week if attending AM and PM every day)Do not need Fridays

Before starting this portion of the form, please have a copy of your child's immunization records available to upload (PDF attachment or you can take a picture). Previous year's submission is NOT on file and a new copy is REQUIRED to complete this registraiton.

Child's Name*

First NameLast Name

Child's Date of Birth:*

Date

First day child will start the program:*

Date

malefemale

Address*

Street Address

Apt # (if aapplicable)

CityState / Province

Postal / Zip Code

Mother or Guardian Name If none, type N/A*

First NameLast Name

Address (if none for mother, type N/A in all required fields)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Guardian Telephone Number:*

If none for mother type N/A

Guardian Email*

example@example.com

Father or Guardian Name (If none, please type N/A)*

First NameLast Name

Address (if none for father, type N/A in all required fields)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Guardian Phone Number:

Email Address:*

If none for father type N/A

I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted: (Pursuant to R9-5-304.B, at least two contact persons are required other than mother and father and cannot duplicate.

First Contact Name (first and last name, other than mother or father):*

First Contact Telephone Number:*

Second Contact Name (first and last name, other than mother or father):*

Second Contact Telephone Number:*

Third Contact Name (first and last name, other than mother or father):

Third Contact Telephone Number:

Fourth Contact Name (first and last name, other than mother or father):

Fourth Contact Telephone Number:

If Medical care is necessary, call:

*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.

Health Care Provider Name: (not insurance company)*

Health Care Contact Telephone Number:*

In case of injury or sudden illness,

I request that this individual be called first (first and last name):*

The following individual(s) may NOT remove my child from the facility:

Name(s):

NoYes

Telephone Authorization Code (optional):

For information regarding current immunization requirements go to: www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630.

Copy of current official documented immunization record attachedReligious Beliefs exemption form signed by parent/guardian attachedMedical Exemption form signed by physician and parent/guardian attachedSigned Laboratory Proof of Immunity form attached

NoYes

If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:

NoYes

If yes, list precautions:

NoYes

If yes, specify procedure:

NoYes

If yes, list precautions:

Additional comments:

Other special instructions:

This Emergency Information and Immunization Record Information is accurate and complete and was provided by:

Parent/Guardian PRINTED Name:*

Signature: (use your mouse or finger to sign)*

DATE Submitted:

DateHourMinutesAM/PM Option

Upload from my computerTake a picture from my phone or tablet

Upload shot records or any necessary custody papers from your computer. Document MUST be an immunization record of the child listed n this registration. *

Browse Files

--OR--- Take photo of shot records or any necessary custody papers from your phone or tablet. Picture MUST be the immunization record of the child listed in this registration.*

Does your child receive DES childcare assistance? If yes, it is the parent/guardian's responsibility to ensure the billing department has received your DES authorization PRIOR to registering for the AMPM Program. Your account will be charged full fees until DES approval has been received by the billing department. Child must be must be approved at the AMPM site chosen. Please call 623-773-7505 or 623-773-7139 to verify DES approval has been received.*

YES, my child receives DES subsidiesNo, my child does not receive DES susidies

Does your child need any special accommodations? Modification services for participants that need additional support and guidance is available for those that qualify. Applications and supported documentation will be reviewed within 48 hours of receipt and are not guaranteed. For more information, please contact leslie.king@peoriaaz.gov or call 623-773-7108.
Modification Form

I do not need modification services.Yes, my child needs an accommodation. I will complete and submit the modification form and provide supporting documentation.

About Me Questionnaire

This confidential information will be used to help your child care provider support the growth and development of your child while creating a safe, stable and healthy environment for all children. By providing complete information about your child, you will be assisting us in creating a positive experience for your child while in our care. Confidentiality is a vital component in the child care setting. Therefore, we will only share this questionnaire with the child care director, owner and your child's primary teacher unless approved by a parent/guardian.

Instructions: A parent/guardian must complete the Best of Care form, and it must be on file at the program on/or before your child’s first day of attendance. Additionally, the questionnaire should be updated when significant changes occur in the child's care or annually.

In order to better service citizens who require modification, Please complete the Inclusion Service Form. This needs to be 1-2 weeks prior to the first day of attendance.

City of Peoria Youth Program Leadership may reach out to you prior to admission to follow up on response provided below.

What is your preferred method of communication?

YesNo

If yes, what type of setting (s) was your child in? (family child care, group care, etc)

What did you most like about your child's previous child care setting?

What did you like the least?

What is important to you about your child's care?

Who is important to your child?

AloneOther Children

YesNo

If yes, what?

What is your child's current sleep schedule?

YesNo

What is your child's mood like upon awakening?

What does your child like?

What does your child dislike?

Special things you say or do to comfort your child are:

How do you know when your child is:

Happy:

Sad:

Mad:

Tired:

Other:

How does your child react when:

Something unexpected happens:

Something happens they don't like:

They are scared:

Other:

YesNo

If "Yes", please explain:

YesNo

If "Yes", please explain:

Is there anything else you would like to share about your child to help us create a positive environment and relationship with your child?

YesNo

If yes, please list the Case Manager's name and contact information:

I (as parent/guardian) decline to complete the About Me Questionnaire. (type initials ONLY if you wish to decline - otherwise, leave blank)

YesNo

Yes, I understand

I have read and agree to abide by the City of Peoria Waiver

Yes, I agree

I have read and agree to abide by the AMPM Parent Handbook

Yes, I agree

City of Peoria AMPM Youth Program Waiver
Release, and Assumption of Risk Form

On behalf of myself, my household members, and as parent and lawful guardian of my minor child, I hereby give permission for my child to receive childcare services at the City of Peoria AMPM program. My child and I are familiar with, and knowingly and voluntarily accept, any and all risks associated with childcare on a school campus. I acknowledge that my child’s participation in this program is voluntary and is not part of any regular school curriculum. I specifically assume all risks and hazards associated with my child’s participation in the City of Peoria AMPM program. I understand that my child will be associating with staff and other children and may be exposed to viruses and diseases, through my child’s participation in the City of Peoria AMPM program. I understand and voluntarily assume the risk that my child may acquire a virus or disease and subsequently be transmitted from my child to me, my family, and members of my household. I certify that my child is in good health, has no fever, and has no current issues that make it unsafe for my child to participate in the City of Peoria AMPM program, which will not have a medical professional on-site. I will notify the school and not send my child to the City of Peoria AMPM program if my child develops a fever or illness. To the fullest extent permitted by law, I hereby agree to waive, release, and discharge any and all claims, causes of action, damages, and rights of any kind, including serious injury or death, against: the City of Peoria, the school where my child attends, the Peoria Unified School District, its insurers, the district’s governing board, and all of their respective employees, agents, representatives, and volunteers (the “Released Parties”) arising from or relating in any way to my child’s participation in the City of Peoria AMPM program.

Parent/Guardian Signature*

To Add your Finance Information: Be sure you are using a desktop or laptop computer and Google Chrome as your internet browser. After you click on SUBMIT below, you MUST log into your City of Peoria Recreation account and input your required finance information. To do this, you will log into your recreation account, click the primary account holder (parent or guardian only, NOT the child), then scroll down and look for the FINANCE INFO line. Click on the NEW button. After the screen opens, be sure you check the box next to the Default button at the top left. Complete the information and click Save.

Failure to submit your financial information within 24 hours WILL result in the removal from the AMPM Program.

What are the LAST FOUR numbers of the debit/credit card or checking account number that you will be using for this program? (This must match the finance information you enter on your Peoria Recreation account)*

This will be used to make sure staff sets up the CORRECT finance information for your payments. If the information listed here does not match the finance information you list on your Peoria Recreation account, THIS REGISTRATION WILL NOT BE PROCESSED. An entry here does NOT qualify as providing financial information You MUST log into your secure Peoria Recreation account to set up your default payment type.

Health Care Provider

Immunization Information

Medical Information