SACC Summer Program Registration

Child's Information

Child's Name *

First

Last

Date of Birth *

Home Address *

Address Line 1

Address Line 2

City

State

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? *

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?

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Relationship to Child *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Email *

Home Phone *

Cell Phone *

Business Name

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Hours at Work

Second Parent/Guardian Authorized to pick up Child? *

First Aid and Medical Care Authorization and Consent Form

Child's Name *

First

Last

Sessions *

Session 4: July 17-21
Session 5: July 24-July28
Session 6: July 31-August 4
Session 7: August 7-11

Session 8 and 9 are full

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

State

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

State

Zip Code

Phone

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Name

First

Last

Relationship to Child

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Transportation Plan and Alternative Transportation Plan

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

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

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

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 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

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 *

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 *

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 *

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.

Session Sign-Up Summer 2023

The Daily schedule for the SACC Summer Program is from 7:45am- 5:45pm. Transportation is limited and will ONLY be provided to families that reside in a Somerville Housing Authority Unit at either Mystic, North St. or Clarendon Hill Towers. Children will be picked-up and dropped off at a central location within the housing authority. All other children must be dropped off and picked up daily at the Y. Parents must enter the building and sign in their child in at out on the 2nd floor. Children ages 9+, with parental/guardian written permission can walk to and from the Y. The YMCA 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 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

I understand I will be put on a waitlist *

Yes

Signature *

Currently you will be placed on a waitlist and if there is a space for your child you will be contacted

Child's Information

Parent/Guardian Information

First Aid and Medical Care Authorization and Consent Form

Child's Identifying Information

Emergency Contacts

Transportation Plan and Alternative Transportation Plan

Off-Site Activities Permission Form

Permission Form

Session Sign-Up Summer 2023

Contact Us

SACC Summer Program Registration

Currently you will be placed on a waitlist and if there is a space for your child you will be contacted

Child's Information

Parent/Guardian Information

First Aid and Medical Care Authorization and Consent Form

Child's Identifying Information

Emergency Contacts

Transportation Plan and Alternative Transportation Plan

Off-Site Activities Permission Form

Permission Form

Session Sign-Up Summer 2023

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