Basic Information

Name of Child
Child Home Address
Select School Your Child Attends

About Your Child

Does your child have any special needs, medical concerns, allergies, or physical limitations? Please share any information about your child that would be helpful to our staff:
Parent/Guardian 1:
Parent 1 Address
Parent/Guardian 2
Parent 2 Address
Select Desired School Age Child Care Program. Check all that apply. (All programs held at Great South Bay YMCA 200 West Main St. Bay Shore)
6:45am-9:00am
3:00pm-6:30pm
6:45am-9:00am and 3:00pm-6:30pm
BEFORE SCHOOL PROGRAM: Select days of the week to attend. Check all that apply:
AFTER SCHOOL PROGRAM: Select days of the week to attend. Check all that apply.
Parental Agreement

No refund or credit for days absent or missed. Suspension from this program is at the discretion of the YMCA of Long Island. If your child is not picked up by the program end time, there will be a $25 charge for the first five minutes and then $1 every minute you are late. Written notice is required for all withdrawals or changes at least 15 days prior to the change. There is a $10 fee for all withdrawals and changes. I give permission for my child to participate in all SACC activities planned for the days he/she attends. I understand that I must have a Medical Consent Form signed by a Parent or Guardian on file at the YMCA before the first day my child begins the SACC program. I also give permission for my child's photograph for be taken to use in YMCA marketing materials. 

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