School Age Child Care Inquiry Form

This is not a registration or enrollment form, but an inquiry about YMCA School Age programs.

For Ages 5 - 12 years old
Child Information
Child Name*

First NameLast Name
Child's Gender*

FemaleMale
Birth Date*

MonthDayYear
Location
Please choose which school your child attends*
Parent/Guardian 1 Information
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian 2 Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Click to copy guardian 1 address to guardian 2 if the same

Yes
Address

Street Address

Street Address Line 2

CityState

Zip Code
Additional Information
Are you a YMCA member?*

YesNo
Please check the type of care your child will need (Check all that apply)*

A.M/P.M.A.M.P.M.
Please select which days you would need care. (Check all that apply)*

MondayTuesdayWednesdayThursdayFriday
My child's fee will be paid by:*
How did you hear about YMCA/JCC child care?
Special needs or requests
You will be contacted by a child care representative within 12 hours of submission. If you need additional assistance, please call 419.474.3995.
Should be Empty:

Child Information