Interest Form Information for Infant, Toddler & Preschool
Please note that completion of this form does NOT confirm your child's enrollment. Our Director will be in contact with you if and when there is availability for your child.
Date of Requested Start Date (Our wait lists can last upwards of 6 months to a year for some age groups and locations)
/
Month
/
Day
Year
Date Picker Icon
Select which programs your are interested in.
*
Half Day AM Preschool Only (Garver & North YMCA)
Half Day PM Preschool Only (Garver & North YMCA)
Full Day Preschool Only (8:30am-3:30pm North & Hilltop YMCA)
Extended Full Day Infant, Toddler, Preschool (YMCA Early Learning Center - Johnstown Rd)
Extended Full Day Infant, Toddler, Preschool (YMCA Early Learning Center - West Broad)
Extended Full Day Infant, Toddler, Preschool (YMCA Logan County Early Learning Center)
Preferred Location(s)
*
Far East (Canal Winchester/Pickerington)
West Side
North Side
Hilliard
Airport Area/ Gahanna
Logan County (Bellefontaine)
Requested Class (Choose One)
*
Infant Class (6wks-18mths)
Toddler Class (18mths-3yrs)
Preschool Class (3-5 yrs)
School District
Assigned Home school district
Student Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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Current Date
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Month
-
Day
Year
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Days
Age
Do you have more than one child that you would like to enroll?
*
Please Select
Yes
No
Student Name #2
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Days
Age
Student #2 Requested Class (Choose One)
Infant Class (6wks-18mths)
Toddler Class (18mths-3yrs)
Preschool Class (3-5 yrs)
Student Name #3
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Days
Age
Student #3 Requested Class (Choose One)
Infant Class (6wks-18mths)
Toddler Class (18mths-3yrs)
Preschool Class (3-5 yrs)
Parent/Guardian #1
*
First Name
Last Name
Parent/Guardian #2
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
Cell Phone Number
*
Home Phone Number
Work Phone Number
Do you have PFCC (Title 20)
*
Yes
No
Does your child(ren) currently have an Individualized Education Plan (IEP)?
Estimated Annual Household Income
Number of people in your Household
Does your child have previous group experience? Please describe:
Other important info:
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