YMCA Preschool Interest Form
Student Name
*
First Name
Middle Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Preferred Program
*
Half Day AM
Half Day PM
Full Day (8:30am-3:30pm)
Extended Full Day
Preferred Location
Far East (Canal Winchester/Pickerington)
West Side
North Side
Hilliard
Airport area/ Gahanna
Preferred Y program or branch location:
Preferred Start Date:
Primary Adult
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
School District
Assigned Home school district
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have PFCC (Title 20)
*
Please Select
Yes
No
Does your child have an Individualized Education Plan (IEP)?
Estimated Annual Household Income
Number of people in your Household
Additional Notes
Clear Fields
Submit Application
Should be Empty: