PHA Summer Program Registration

PHA Summer 2024 Registration

Program Dates: June 24th – August 9th

Program Time: 7:45am-5:45pm Drop off: 7:45am-8:45am

Program Cost: $300 per Week. A $50/week per child NON-REFUNDABLE Deposit is REQUIRED to Register

Please fill out the Following Registration PDF (It is form fillable so it can be downloaded and filled in on your device or you can download, print it, fill it out and scan and email it back or bring it in) 

Please Email completed PDFs to Francesca Ciccone- fciccone@somervilleymca.org

PHA Summer Registration PDF

You Must also Fill out the Form on this page to pay your deposit or confirm you have a voucher.

Parent/Guardian Name *

First

Last

Email *

Do you have a Voucher? *

• Yes
• No

How Many Children do you have attending the Program *

• 1
• 2
• 3
• 4

How many weeks attending and Deposit Amount *One - $50.00Two - $100.00Three - $150.00Four - $200.00Five - $250.00Six - $300.00Seven - $350.00

How many weeks attending and Deposit Amount *One - $100.00Two - $200.00Three - $300.00Four - $400.00Five - $500.00Six - $600.00Seven - $700.00

How many weeks attending and Deposit Amount *One - $150.00Two - $300.00Three - $450.00Four - $600.00Five - $750.00Six - $900.00Seven - $1,050.00

How many weeks attending and Deposit Amount *One - $200.00Two - $400.00Three - $600.00Four - $800.00Five - $1,000.00Six - $1,200.00Seven - $1,400.00

Card Info *

Card Number

MM123456789101112Expiration

/

YY2425262728293031323334

Security Code

Billing Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Signature *

Clear Signature

I acknowledge that this Deposit is Non-Refundable.

Total

$0.00

Submit