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Includes emergency first aid and CPR consent under 102 CMR 7.09(3), emergency contact entries, health insurance data, signature and date lines, and a transportation plan authorization referencing 7.09(3) and 7.12(1). Provides program days selection and monthly rate tables for member and non-member options.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/pvcicssaccenrollmentform-20232024/287968/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/pvcicssaccenrollmentform-20232024/287968.png","ImageObject",442,249,{"name":88,"@type":89},"Finn","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What child information and required attachments are requested on the enrollment form?","Question",{"text":108,"@type":109},"The form collects the child’s name, age/grade, birthdate, gender, pronouns, ethnicity, medications, and allergies/special diets. It requests that an Individual Health Care Plan (IHCP) be attached when applicable, along with properly labeled medications for director review.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What emergency authorization does the consent form provide?",{"text":113,"@type":109},"It authorizes trained staff to give basic first aid and/or CPR when appropriate. It also states that every effort will be made to contact the parent/guardian, and if they cannot be reached, the program may transport the child to the nearest medical care facility and secure necessary medical treatment.",{"name":115,"@type":106,"acceptedAnswer":116},"How are program days selected and how do monthly rates work?",{"text":117,"@type":109},"Families check the days they plan to attend (Tues/Thurs, Mon/Wed/Fri, or Monday-Friday). Monthly rates are provided by grade band and differ for member versus non-member, with scheduled time ranges listed for kindergarten/1st and 2nd–5th grades.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287968,1790099024,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},34359740700684,"https://ap-avatar.wpscdn.com/avatar/1f400023980c374ae676?_k=1777273430885731487","SCHOOL AGE CHILD CARE ENROLLMENT FORM: 2023/2024 PIONEER VALLEY CHINESE IMMERSION CHARTER SCHOOL (Please print clearly and fill in ALL information)  \nCHILD INFORMATION:  \nOffice use only:  \n  Date   Initial  \n  FA   Voucher  \n  Entered into ME   Registered in CORE   Copied for Site  \nMember Non-Member  \n\n| Child’s Name: | Age: | Grade: |  | Birthdate: | Gender: | Pronouns: |\n| --- | --- | --- | --- | --- | --- | --- |\n| Ethnicity: |  |  | Medications: |  |  |  |\n| Allergies/Special Diets or Restrictions:\u003Cbr>* *Please attach Individual Health Care Plan (Required by the EEC for students with Epi-Pens and/or Inhalers)** Children cannot start care until the IHCP and properly labeled medications are submitted to Director. |  |  |  |  |  |  |\n\nDATE OF ADMISSION:  \nPIONEER VALLEY CHINESE IMMERSION CHARTER SCHOOL ENROLLMENT FORM  \nPARENT/GUARDIAN INFORMATION:  \n\n| Parent/Caregiver Name:\u003Cbr>Relationship to child: |  | Parent/Caregiver Name:\u003Cbr>Relationship to child: |  |\n| --- | --- | --- | --- |\n| Home Address: |  | Home Address: |  |\n| Business Name: | Business Address: | Business Name: | Business Address: |\n| Primary Phone Number: |  | Primary Phone Number: |  |\n| Secondary Phone Number: |  | Secondary Phone Number: |  |\n| Email: |  | Email: |  |\n| Name of HRYMCA Member: |  |  |  |\n\nMEDICAL INFORMATION:  \nPhysician/Clinic:  \nAddress: Phone:  \nHospital Preference:  \nDentist Name:  \nAddress: Phone:  \nIndividual Education Plan (IEP) or Special Needs Accommodation? YES NO If yes, please attach  \nI certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning screening in accordance with public health requirements are on file at my child's school. Parent/Guardian initials:    \nAdditional information we should know about your child:  \n\n|  |\n| --- |\n|  |\n\nParent/Guardian Signature   Date    \nHampshire Regional YMCA School Year 2023-2024 Registration  \nChild’s Name:   Parent/Guardian:   Address:   School:   Grade:    \nPlease check the days you plan to attend:  \n\n|  | Tuesdays/Thursdays | Mondays/Wednesdays/Fridays | Monday-Friday |\n| --- | --- | --- | --- |\n| KINDERGARTEN/1ST GRADE\u003Cbr>3:30 pm-5:30pm |  |  |  |\n| 2ND GRADE-5TH GRADE 4:00pm-5:30pm |  |  |  |\n\nSchool Year 2023-20234Rates: (Monthly rates)  \n\n| PROGRAM DAYS: | 2 DAY: Tues/Thurs  | 3 DAY:Mon/Wed/Fri | 5 DAY:Mon-Fri  |\n| --- | --- | --- | --- |\n|  |  |  |  |\n| KINDERGARDEN/1ST GRADE | MEMBER:\u003Cbr>$ 109.00\u003Cbr>NON-MEMBER:\u003Cbr>$ 125.00 | MEMBER:\u003Cbr>$ 162.00\u003Cbr>NON-MEMBER:\u003Cbr>$ 186.00 | MEMBER:\u003Cbr>$278.00\u003Cbr>NON-MEMBER:\u003Cbr>$ 320.00 |\n| 2nd GRADE-5th GRADE | MEMBER:\u003Cbr>$82.00\u003Cbr>NON-MEMBER:\u003Cbr>$ 94.00 | MEMBER:\u003Cbr>$ 121.00\u003Cbr>NON-MEMBER:\u003Cbr>$ 139.00 | MEMBER:\u003Cbr>$ 208.00\u003Cbr>NON-MEMBER:\u003Cbr>$239.00 |\n\nPayment Options  \nPlease Choose:  Bank Draft   Credit Card Draft  \nWe offer a 5% discount for a second child enrolled in the program  \nPlease note that the enrollment process can take up to one week, please plan accordingly We will process your enrollment when we receive a completed Enrollment Form along with the first month’s payment.  \nAre you applying for Financial Aid?   YES  NO Have a SEVENHILLS Voucher?  YES   NO  \nMonthly Payment   Total Due   \nBe advised all payments are due by the 1st of the month for the current month’s program. Payments made after the 1st will incura $10 late fee. If payment is not received before the 5th of the month your child will be suspended from the program until all payments are made. If you cancel your SACC enrollment PRIOR to the first day of the current school year start date, you will be  \ncharged a $50.00 administration fee.  \nGROUP CHILD CARE AND SCHOOL AGE CHILD CARE  \nFIRST AID AND EMERGENCY MEDICAL CARE  \nCONSENT FORM  \n102 CMR 7.09(3)  \n**In the event of an emergency, this form will go with your child to the hospital, please fill out completely and clearly**  \nChild's Name:   Date of Birth:    \nI authorize staff in the child care program who are trained in the basics of","cbCaidJfL9DVKlf9","https://ap.wps.com/l/cbCaidJfL9DVKlf9","pdf",575685,8,"English","# Child Information\n## Parent/Guardian Information\n## Medical Information\n## Emergency Consent and First Aid\n## Transportation Plan and Authorization\n## Program Days and Rates\n## Payment Options","[{\"question\":\"What child information and required attachments are requested on the enrollment form?\",\"answer\":\"The form collects the child’s name, age/grade, birthdate, gender, pronouns, ethnicity, medications, and allergies/special diets. It requests that an Individual Health Care Plan (IHCP) be attached when applicable, along with properly labeled medications for director review.\"},{\"question\":\"What emergency authorization does the consent form provide?\",\"answer\":\"It authorizes trained staff to give basic first aid and/or CPR when appropriate. It also states that every effort will be made to contact the parent/guardian, and if they cannot be reached, the program may transport the child to the nearest medical care facility and secure necessary medical treatment.\"},{\"question\":\"How are program days selected and how do monthly rates work?\",\"answer\":\"Families check the days they plan to attend (Tues/Thurs, Mon/Wed/Fri, or Monday-Friday). Monthly rates are provided by grade band and differ for member versus non-member, with scheduled time ranges listed for kindergarten/1st and 2nd–5th grades.\"}]","PVCICS+SACC+Enrollment+Form - 2023/2024 | PDF",1789632932]