Summer 2022 Child Admission Paperwork
Please complete all required fields to register your child for Summer SACC!
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Email *
Which summer program is your child enrolled in? *
Required
Child's Name (#1) *
Birthday *
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Age *
Gender *
Incoming Grade *
Home Address *
Child's Name (#2)
Birthday  2
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Age 2
Gender 2
Clear selection
Incoming Grade 2
Home Address
Child's Name (#3)
Birthday 3
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Age 3
Gender 3
Clear selection
Incoming Grade 3
Home Address
EMERGENCY CALL LIST! In case of emergency or when you cannot be reached, we will call someone else to report the emergency and decide on an appropriate course of action. Please list four (4) persons to call, in order of preference. DO NOT LIST YOURSELF OR YOUR SPOUSE (if listed above as parent) Example: Name (Phone #) *
CHILD RELEASE! Please list the names of all people that are authorized to remove your child from the program other than parents/guardians. *
Marital Status (Parent/Guardian 1) *
Marital Status (Parent/Guardian 2) *
CUSTODY & FINANCIAL ARRANGEMENTS/AGREEMENTS!  Please indicate financial arrangements (e.g. who will be paying what for your child/ren's care). Please indicate if you receive money through any State or Federal program that we will have to work with.  If you have documentation, please email to director@windhamraymondsacc.com *
Parent/Guardian 1 Name *
Home Address *
Place of Employment, Address & Phone Number *
Best Email Address *
Home/Cell Number *
Parent/Guardian 2 Name *
Home Address *
Place of Employment, Address & Phone Number *
Best Email Address *
Home/Cell Number *
RELEASE FOR PERMISSION TO USE LIKENESS: You must check at least one, no more than two – please read carefully. We take a lot of photographs at Windham S.A.C.C. Most are for our own use and enjoyment. We do, however, sometimes use photos in our brochures or in other publications or promotions. Please complete below. *
Required
WALKING FIELD TRIP PERMISSION FORM: I give permission for my child to take occasional walking field trips accompanied by a S.A.C.C./Café Teen staff member while in attendance at the program. *
RELEASE TO COMMUNICATE WITH SCHOOL PERSONNEL: From time to time we find it useful to speak with classroom teachers and other personnel from the school attended by your child. With your permission, we will carry out such communication only for the benefit of your child. (For instance, if we are trying to find ideas to help your child improve his/her behavior.) Any information obtained in the course of this communication will be treated as strictly confidential. *
WINDHAM RAYMOND S.A.C.C. PROGRAM POLICY AND PROCEDURE AGREEMENT: I/We have read, understand and agree with the policies and procedures of Windham/Raymond S.A.C.C. as outlined in the Program Handbook. (sign & date below) *
Two Week Notice - All Programs: I understand that I must give Windham/Raymond S.A.C.C. a two week written notice when I withdraw my child/children from the program. I understand that if I fail to give a two week written notice, I am obligated to pay two weeks worth of tuition past the last day of my child's attendance. (sign & date below) *
READ AND SIGN: I certify that all the answers and statements contained in the Admission Information Sheet are true to the best of my knowledge and belief. I also affirm that I have read and understand the Windham/Raymond School Age Child Care Program policies as outlined herein and in the program handbook. (sign & date below) *
Windham/Raymond School Age Child Care Facebook Photo Permission: Please check one of the boxes below. Children’s names will not be used with their pictures. We only allow access to the site by current and formerSACC/Café Teen enrolled families. *
Required
Windham/Raymond School Age Child Care Facebook Photo Permission: (sign & date below) *
Windham/Raymond School Age Child Care Full Day Payment & Sign up Policy: This includes all in-service, holidays and vacations that SACC is open.  All scheduled full days for SACC will be held in Windham at a site to be determined on an annual basis. There are deadlines in place to sign up for a space at a full day. If a child is not signed up to either attend or not attend, by the deadline, the parent/legal guardian will be charged the full day rate for attendance. If a child is not signed up, but attends on any full day, there will be a $10charge in addition to the regular full day fee for the day. Families will be contacted initially through email and follow up will take place at centers. I understand the above policy and agree to abide by the terms of sign up or pay the fees associated with not signing up or dropping my child in. All Children are required to bring a lunch with them for full day care. Any children that do not bring a lunch will be provided with a basic lunch and the family will be charged $10 to cover the cost to the program. (Sign & Date Below) *
EMERGENCY MEDICAL AND DENTAL CONSENT
We hereby give consent to W/R SACC employees to arrange for emergency medical or dental care treatment necessary to preserve the health of our child/ren. We acknowledge that we are responsible for all charges in connection with the care and treatment rendered to our child during that period. (sign & date below) *
Child/ren's Physican, Address & Phone Number *
Name of Insurance Company *
Group Number *
Family Dentist, Address, & Phone Number *
Name of Insurance *
Group Number *
Date of Last Tetanus (Child #1) *
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Date of Last Tetanus (Child #2)
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Date of Last Tetanus (Child #3)
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ALL ABOUT YOUR CHILD (#1)
What special interests and talents and skills does your child have? *
How would you best describe your child in a group setting? *
Required
Is your child generally: *
Required
Please list other behavior characteristics of your child: *
Is there any social or emotional adjustment information we should know about your child? *
Does your child exhibit specific fears? *
Does your child have any allergies? Please explain. *
Is your child taking any medications or using any medical devices? *
Required
Please list and explain all medications: *
Are there any activities your child should not participate in? *
Are there any foods your child may not eat? *
Please tell us any other pertinent information that you feel we should know about your child in order to help us make this experience happy, healthy, and enriching. *
ALL ABOUT YOUR CHILD (#2)
What special interests and talents and skills does your child have?  2
How would you best describe your child in a group setting? 2
Is your child generally: 2
Please list other behavior characteristics of your child: 2
Is there any social or emotional adjustment information we should know about your child? 2
Does your child exhibit specific fears? 2
Does your child have any allergies? Please explain. 2
Is your child taking any medications or using any medical devices? 2
Please list and explain all medications: 2
Are there any activities your child should not participate in? 2
Are there any foods your child may not eat? 2
Please tell us any other pertinent information that you feel we should know about your child in order to help us make this experience happy, healthy, and enriching. 2
ALL ABOUT YOUR CHILD (#3)
What special interests and talents and skills does your child have? 3
How would you best describe your child in a group setting? 3
Is your child generally: 3
Please list other behavior characteristics of your child: 3
Is there any social or emotional adjustment information we should know about your child? 3
Does your child exhibit specific fears? 3
Does your child have any allergies? Please explain. 3
Is your child taking any medications or using any medical devices? 3
Please list and explain all medications: 3
Are there any activities your child should not participate in? 3
Are there any foods your child may not eat? 3
Please tell us any other pertinent information that you feel we should know about your child in order to help us make this experience happy, healthy, and enriching. 3
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