SACC 2023-2024 Registration

As we are currently full, This is not a guaranteed spot, you will be placed on the waitlist. If you get a spot you will be contacted by our registrar.

Dear Y Families:

The School Age Child Care (SACC) Program is currently accepting children for the 2023-2024 school year.  For more information and online registration, please visit our website at www.somervilleymca.com.

Once your application has been reviewed and processed a member of the Child Care Administration team will contact you regarding deposits, payment options and required orientation. Registration is on a first come, first served basis with priority given to families seeking full time (5 day) care. Please note that weekly payments are due in advance by Fridays for the following week of care.

Please feel free to contact the SACC team with any questions you may have.

Matthew O’Donnell – Director of Out-of-School Time

[email protected]

617-625-5050 x118

Janet Alvarez-SACC Site Coordinator

[email protected]

617-625-5050 x127

For Voucher, and billing questions

Francesca Ciccone-Child Care Registrar & Billing/Intake Coordinator

[email protected]   

617-625-5050 x111                   

We look forward to having your family as a part of the YMCA SACC Program!

Thank you,

Tania Buck, VP of Child Development and Education

[email protected]

617-625-5050 x128

- Step 1 of 6

Child's Information

Child's Name *

First

Last

Date of Birth *

Home 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

School *

School Address *

Teacher Name *

Grade for 23-24 School Year *

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

--- Select state ---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

--- Select state ---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

--- Select state ---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

--- Select state ---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

Date of Birth *

Age *

I understand the staff in the SACC 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

--- Select state ---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

--- Select state ---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

--- Select state ---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

--- Select state ---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 YMCA Program by: *

• YMCA Bus, Van or staff supervised walk
• Other (Please Specify Below)

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

Other Arrival: *

My Child will depart from the Program by: (No later than 6pm) *

• Supervised Departure
• Unsupervised Departure
• Y Transportation- Mystic
• Y Transportation- North Street
• Y Transportation- Clarendon Towers

If you would like Y Transportation please also select Supervised or Unsupervised The YMCA 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 Unsupervised with written parental permission *

• 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

--- Select state ---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

--- Select state ---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

--- Select state ---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

Aquarium (Boston) Beaver Brook Blue Hills Reservation Central Hill Park Candia Springs Mass Audobon Society( Ipswich) Chunkys Community Growing Center/Garden Wingaersheek Beach Conway Park Corbett-McKenna Park Children’s Museum-Boston Danehy Park Dilboy Field Draw Seven Park East Boston Park Ecotarium Esplanade Association Farrington Nature Linc Farm Foss Park/DCR Pool Franklin Park Zoo Fun World Georges Island Hampton Beach Hampton Beach State Park Hopkington State Park Hoyt-Sullivan Park Honey Pot Hill Orchards Latta Brothers Memorial Pool Lincoln Park/Argenziano Park and Field Lynch Park & Beach Lynn Woods Nahant Beach North Point Park Nunziato Field Oxford Street Park, Cambridge Perry Park Pine Banks Park, Malden Powderhouse Park Prospect Hill Park Salem Willows Salisbury State Park Reservation Scussett Beach Singing Beach Skyline Park, Arlington Somerville High School Somerville Capitol Theatre Stone Zoo Stage Fort Park Trum Field Wingaersheek Beach Winter Hill Community School Playground Waterpark of New England Woburn Bowladrome

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.

Permission to Speak *YesNo

I authorize the YMCA SACC Directors to speak with my child’s pediatrician, nurse, therapist, school teacher/principal/guidance counselor/school adjustment counselor, the Department of Children & Families, social worker, psychiatrist, or psychologist. I will be informed by the Directors should any of these people need to be contacted prior to doing so.

Individualized Education Program *YesNo

I authorize the Directors to have a copy of my child’s IEP in order to better support him/her in the program.

Permission to use Hand Sanitizer *YesNo

I give permission for my child to use hand sanitizer (at least 60% alcohol) in the program

Next

Sign-up

The program per diem cost is:

 Full days are charged at $50.00 and regular afterschool days are $30.00 per day.

Vacation Program and Summer Program weeks are $250.00 per week.

Priority is given to families requesting 5 days. Tuition is subject to change with a

 60 day written notice.

*The first day of school for SPS 1-12^th grades is 8/30/23

**The first day of school for SPS Kindergarten is 9/6/23

***The first day of school for PHACS is 9/5/23 for all grades

*A deposit of one week’s tuition in addition to the payment for the first week of care, is due in advance in order to secure a spot for your child. Weekly Payments are due no later than Fridays for the following week of care. Families who are two weeks or more behind in payments risk termination from the program.  Please see Parent Handbook for the complete financial policy information.

 

I understand that a 2 Week Notice is required should I want to remove my child from the program *

• I understand

I have a Voucher/Scholarship *

• Yes
• No

Days Wanted *

• Mondays
• Tuesdays
• Wednesdays
• Thursdays
• Fridays

Signature *

Clear Signature

Submit