Childcare Enrollment | YMCA of Auburn-Lewiston

Childcare Enrollment

YMCA of Auburn-Lewiston | Early Childhood Education
Now enrolling infants to age 5. For more information about childcare programs at the YMCA of Auburn-Lewiston, or to book a tour of our facilities, please visit alymca.org/childcare.
- Child's Name
  
  First NameLast Name
- Child's DOB
  
  MonthDayYear
  Date of Birth
- Child M/F
- Child's Age
- Household Address
  
  Street Number & Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Our family receives mail at:
- Mailing Address (if different than household)
  
  Street Number & Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian 1 Name
  
  Parent 1 First NameParent 1 Last Name
- P1 DOB
  
  MonthDayYear
  Parent 1 Date of Birth
- P1 M/F
- P1 Email
  Parent 1 Email Address
- P1 License No
  Parent 1 Driver's License Number
- P1 License State
  Parent 1 Driver's License State of Issue
- P1 Primary Phone
  Parent 1 Preferred Phone NumberFormat: (000) 000-0000.
- Primary Phone Type
- P1 Secondary Phone
  Parent 1 Backup Phone NumberFormat: (000) 000-0000.
- Secondary Phone Type
- P1 Employer Name
  Parent 1 Place of Work
- Parent/Guardian 2 Name
  
  Parent 2 First NameParent 2 Last Name
- P2 DOB
  
  MonthDayYear
  Parent 2 Date of Birth
- P2 M/F
- P2 Email
  Parent 2 Email Address
- P2 License No
  Parent 2 Driver's License Number
- P2 License State
  Parent 2 Driver's License State of Issue
- P2 Primary Phone
  Parent 2 Preferred Phone NumberFormat: (000) 000-0000.
- Primary Phone Type
- P2 Secondary Phone
  Parent 2 Backup Phone NumberFormat: (000) 000-0000.
- Secondary Phone Type
- P2 Employer Name
  Parent 2 Place of Work
- Contacts listed in this section will serve as authorized for pickup of your child, and persons to contact if a parent cannot be reached. MUST BE SOMONE OTHER THAN PARENTS, MUST HAVE AT LEAST TWO (2).
- Authorized Pickup / Emergency Contact (Person 1)
  
  Full Name
  
  Relationship to child
  
  Phone NumberDate of Birth
  
  What your child calls them
- Authorized Pickup / Emergency Contact (Person 2)
  
  Full Name
  
  Relationship to child
  
  Phone NumberDate of Birth
  
  What your child calls them
- Authorized Pickup / Emergency Contact (Person 3)
  
  Full Name
  
  Relationship to child
  
  Phone NumberDate of Birth
  
  What your child calls them
- Child's Doctor
  
  Doctor Name
  
  Doctor Address
  
  Doctor Phone NumberState / Province
  
  Zip Code
- Child's Dentist
  
  Dentist Name
  
  Dentist Address
  
  Dentist Phone NumberState / Province
  
  Zip Code
- Please list any known MEDICAL CONDITIONS your child has or has had in the past:
  List child's medical conditions
- Medications taken on a regular basis:
  List child's medications
- Food or drinks your child should not have:
  List food/drink to avoid
- Allergy 1
  
  Allergy
  
  Reaction / Severity
  
  Care RequiredState / Province
  
  Zip Code
- Allergy 2
  
  Allergy
  
  Reaction / Severity
  
  Care RequiredState / Province
  
  Zip Code
- Hospital Preference
- Insurance Policy Name
  Must be filled in to bill for care received
- Insurance Policy Number
  Must be filled in to bill for care received
- It's important that you read in full and understand the following:
  
  Illness & Health Policy
  
  Checking "I agree" will serve as a placeholder for your digital signature.
- My childcare payments will be
- It's important that you read in full and understand the following:
  
  EFT Authorization & Financial Agreement
  
  Checking "I agree" will serve as a placeholder for your digital signature.
- It's important that you read in full and understand the following:
  
  Photo and Video/Audio Recording Release
  
  Checking "I agree" will serve as a placeholder for your digital signature.
- Do you consent to the Photo and Video/Audio Recording Release?
- It's important that you read in full and understand the following:
  
  Release and Waiver of Liability
  
  Checking "I agree" will serve as a placeholder for your digital signature.
- It's important that you read in full and understand the following:
  
  Family Handbook
  
  Checking "I agree" will serve as a placeholder for your digital signature.
- Anything else you would like the YMCA to be aware of that would help to better serve your child and family?
- I certify that all information provided is true and accurate. I will notify the YMCA of Auburn-Lewiston Welcome Center of any changes to the information provided immediately should they occur.
- Parent/Guardian 1 Signature
- Parent/Guardian 2 Signature
- Date
  
  MonthDayYear
  MM-DD-YYYY
- Note: The Y conducts regular sex offender screenings on all members, participants, and guests. If a sex offender match occurs the Y reserves the right to cancel membership, end program participation, and remove visitation access.
- Verify you are human
- Should be Empty: