Child Care Enrollment Interest Form
Thank you for your interest in our West Licking County Family YMCA Child Care Center. Please note that completion of this form does NOT confirm your child's enrollment. We will be in contact with you. Infant/Toddler care will be available in 2024, Preschool ages 3 and up are available now.
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Degree of Relationship
*
Ex: Mother
Child's Information
Note: If you have multiple children to enroll, additional children can be added in the next section.
Child's Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Additional Children to enroll
Child #2
First Name
Last Name
Child #2 Birth date
-
Month
-
Day
Year
Date
Child #3
First Name
Last Name
Child #3 Birth Date
-
Month
-
Day
Year
Date
Child's Age
*
6 weeks-12 months
12 months-18 months
18 months-3 year
3 years
4 years
5 years
6 years
Additional Information
Are you currently on PFCC (Title 20) Benefits?
*
Yes
No
I don't know
Additional notes/questions/other important infomration
Submit
Should be Empty: