Summer Break 2021 Waiting List

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This form is for Summer Break Care only. We will contact you either via phone or email to let you know that we have let you in from the waiting list.

What is your name? *

What is your email address? *

What is your phone number? *

Has this child(ren) attended SAC in the past? *

Yes

What is the child's name? *

What is the child's birthday? *

What grade is this child currently in? *

Pre-K

Kindergarten

1st

2nd

3rd

4th

5th

6th

7th

8th

What days/ weeks will this child need? *

Everyday

Wk 1 (6/1-6/4)

Wk 2 (6/7/-6/11)

Wk 3 (6/14-6/14)

Wk 4 (6/21-6/25)

Wk 5 (6/28-7/2) Closed 7/2

Wk 6 (7/6-7/9) Closed 7/6

Wk 7 (7/12-7/16)

Wk 8 (7/19-7/23)

Other:

Required

Parent Authorizations *

I authorize SAC to apply bug spray to my child

I authorize SAC to apply sunscreen to my child

I authorize SAC to use my child's photo on SAC's social media, website or the local newspaper.

Required

Does your child have any know allergies? *

Do you need staff to administer any regular medication? *

Yes, on regular (daily) basis.

Yes, but only as needed basis.

What school does this child attend? *

I authorize the child care personnel to arrange emergency medical care for my child in the event that I can not be reached. *

Yes

I give permission for my child to travel by Putnam County School bus with the Putnam County SAC Program on the the following field trips. *

Clyde York 4-H Pool, Friday June 11th.

Clyde York 4-H Pool, Friday June 18th.

Clyde York 4-H Pool, Friday June 25th.

Clyde York 4-H Pool, Friday July 9th.

Required

Do you have another child to add? *

Yes

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