PHA Summer Program Registration

Welcome to the Somerville YMCA [email protected] Summer Program, STEAMing Ahead @ the Y!  STEAM stands for Science, Technology, Engineering, Arts, and Math programming and activities. This summer we will continue to focus on literacy, social/emotional learning and physical activity, but are also infusing STEAM into your children’s day!  We will also be using the Bellxcel Scholar Enrichment Curriculum for five weeks again this summer. This program was highly successful last summer in helping our children increase their Math and English Language Arts (ELA) scores.  Children who participate in high quality academically enriched programs during the summer months have more of a chance to stem any learning loss that may take place over the summer.   The program will be housed at the EC Campus as that is where the PHACS Summer Learning Program will also take place.  The program will be open from 7:45am-5:45pm, Monday-Friday, from June 26^th-August 11^th, 2023.  Drop-off will be between 7:45am-8:45am. 

Enclosed are the forms which are required for registration.  Please be sure to fill out every line.  If the answer is “none” or “no one”, please be sure to note that on the application. Please do not leave any spaces blank.

Below is the Registration Form. Thank you, We Look forward to a great summer at the [email protected]!

- Step 1 of 6

Child's Information

Child's Name *

First

Last

Date of Birth *

Home Address *

Address Line 1

Address Line 2

City

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

Zip Code

School *

School Address *

Current Teacher Name *

Grade Child will Enter September 2023 *

Is there a Physical Exam and Immunization Record at the Child's School? *YesNo

If child does not attend school in Massachusetts a physical and immunization record must be sent with this form

List any special limitations or concerns your child may have (Including dietary restrictions, allergies, chronic conditions) *

if none, write none

Height *

Weight *

Eye Color *

Hair Color *

Skin Color *

Sex *

Identifying Marks *

Other info?

Next

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Relationship to Child *

Address *

Address Line 1

Address Line 2

City

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

Zip Code

Parent/Guardian Email *

Home Phone *

Cell Phone *

Business Name

Business Address

Address Line 1

Address Line 2

City

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

Zip Code

Hours at Work

Second Parent/Guardian Authorized to pick up Child? *YesNo

Second Parent/Guardian Name *

First

Last

Relationship to Child *

Address *

Address Line 1

Address Line 2

City

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

Zip Code

Email *

Home Phone *

Cell Phone *

Business Name

Business Address

Address Line 1

Address Line 2

City

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

Zip Code

Business Phone

Hours at Work

Next

First Aid and Medical Care Authorization and Consent Form

Child's Name *

First

Last

Sessions *

• Session 1: June 26-30
• Session 2: July 3-7
• Session 3: July 10-14
• Session 4: July 17-21
• Session 5: July 24-July28
• Session 6: July 31-August 4
• Session 7: August 7-11

Date of Birth *

Age *

I understand the staff in the PHA Summer Program are trained in the basics of First Aid/CPR and I Authorize them to give my child First Aid/CPR when appropriate *

• I Agree

I understand that every effort will be made to contact me in the event of any emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to CHA Cambridge Hospital. *

• I Agree

Child's Physician's Name *

First

Last

Physician Address *

Address Line 1

Address Line 2

City

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

Zip Code

Physician Phone *

Child's Identifying Information

Height *

Weight *

Eye Color *

Hair Color *

Skin Color *

Sex *

Identifying Marks *

Child's Allergies *

If none, write none

Chronic Health Conditions *

If none, write none

Dietary Restrictions *

If none, write none

Health Insurance Coverage *

Policy Number *

Emergency Contacts

They are also authorize to pick up the child, write in order of contact

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

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

Zip Code

Phone

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

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

Zip Code

Phone

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

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

Zip Code

Phone

Next

Transportation Plan and Alternative Transportation Plan

My Child will Arrive at the Webster PHA Campus (No earlier than 7:45am and no later than 8:45am) *

• Supervised Arrival
• Unsupervised Arrival

The [email protected] is not responsible for unsupervised children until they arrive and again once they leave the program If Clarendon Towers MUST Reside in SHA Housing

My Child will depart from the Program (No later than 5:45pm) *

• Supervised Departure
• Unsupervised Departure

The [email protected] is not responsible for unsupervised children until they arrive and again once they leave the program If Clarendon Towers MUST Reside in SHA Housing

ALL children UNDER the age of 9 MUST be signed in/dropped off by a parent/legal guardian. Children ages 9+ may arrive and depart with written parental permission *

• I understand

Parents/Guardians are responsible for walking their children into the program to sign them in. Parents will bring their children into the school building to drop them off to the designated room/staff

• I understand

List names of Parents/Guardians Authorized to pick up child *

I give my permission for my child to be released from the program at the end of the day as stated above and/or I give my permission to the following people to receive my child at the end of the day. (If no one is authorized, please indicate below by checking "NO ONE"). *

• The Following People are Authorized
• No One

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

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

Zip Code

Phone

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

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

Zip Code

Phone

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

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

Zip Code

Phone

Next

Off-Site Activities Permission Form

Child's Name *

First

Last

I give permission for my child to participate in all of the activities located at the following off-site facilities: *

• I give permission

• Beaver Brook • Blue Hills Reservation • Capitol Theatre • Central Hill Park • Community Growing Center • Conway Park • Corbett-McKenna Park • Cranes beach • Cummings School Playground • Danehy Park • Davis Square • Dilboy Field • Esplanade Association • Farrington Nature Linc • Foss Park Pool and Field • Latta Brothers Memorial Pool • Franklin Park Zoo • George’s Island • Gore Street Park • Hoyt-Sullivan Park • Funworld • Kennedy Pool • Argenziano/Lincoln Park Playground, field and splash park • Lynn Woods • Coco Keys • Science Museum • Nahant Beach • North Point Park • Nunziato Field • Children’s Museum • Perry Park • Plymouth Plantation • Aquarium • Prospect Hill Park • Roger Williams Park Zoo • Singing Beach • Chunk’s • Somerville YMCA • Southwick Zoo • Spectacle Island • Stage Fort Park • Stone Zoo • Trum Field • War Memorial pool • PHA EC/Webster location for children attending UE/Franklin campus • Wingaersheek Beach • Winter Hill Community School Playground • Somerville YMCA Pool and Gym

Permission Form

Name *

First

Last

Media Permission *YesNo

I give permission for my child’s name, photograph, video or likeness, to be used by the Somerville YMCA for public relations purposes, publications or reports.

YMCA Swimming Pool Permission *YesNo

I give permission for my child to use the Somerville YMCA swimming pool. Note: all children in camp must wear a bathing cap in YMCA pool. Foss Park DCR Pool may also be utilized during programming time as well as local beaches.

Sunscreen Permission *YesNo

I will provide my child with sunscreen. If my child arrives at the YMCA without sunscreen, on that day, I give the Somerville YMCA permission to provide sunscreen (Sunscreen SPF30) to my child.

Next

Session Sign-Up Summer 2023

The Daily schedule for the [email protected] Summer Program is from 7:45am- 5:45pm. Parents must enter the building and sign in their child in at out inside the Webster Campus.  Children ages 9+, with parental/guardian written permission can walk to and from the program.  The [email protected] is not responsible for unsupervised children until they arrive at the program and again once they leave the program.

 

Please indicate which sessions you child will attend by selecting each desired Session week.  All sessions are from 7:45am-5:45pm and the cost is $250.00 per session.  A $25 per week non-refundable deposit applied to your child’s ledger is due upon registration to ensure your child’s place in the program.  All payments for the sessions are due in full by the Friday prior to the session.  No child will be allowed into the program if payment has not been made. Payments will be billed through Procare, upon registering and acceptance into program if you do not have a Procare account with the Somerville YMCA/[email protected] one will be created for your child and you will be invited to put your billing information in.

I have a Voucher/Scholarship *

• Yes
• No

Checkboxes *

• Session 1: June 26-30
• Session 2: July 3-7
• Session 3: July 10-14
• Session 4: July 17-21
• Session 5: July 24-28
• Session 6: July 31-August 4
• Session 7: August 7-11

Sessions Wanted- $25 Deposit Per Session (Full Price is $250/Week Billed through Procare) *

• Session 1: June 26-30
• Session 2: July 3-7
• Session 3: July 10-14
• Session 4: July 17-21
• Session 5: July 24-28
• Session 6: July 31- August 4
• Session 7: August 7-11

Credit/Debit Card Information *

Card Number

MM123456789101112Expiration

/

YY2324252627282930313233

Security Code

Billing Address *

Address Line 1

Address Line 2

City

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

Zip Code

Total

$ 0.00

Signature *

Clear Signature

Submit