YMCA Preschool Interest Form
Please note that completion of this form does NOT confirm your child's enrollment.  Our YMCA Child Care Enrollment Team will be in contact with you if and when there is availability for your child.
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Email *
Child's First Name *
Child's Middle Name *
Child's Last Name *
Child's Birthdate *
MM
/
DD
/
YYYY
Child's Age *
Required
Preferred Program Schedule *
Required
Preferred Location *
Perfered Program(s)  *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Phone Number *
Street Address *
Street Address Line 2
City *
State *
Zip Code *
County *
Child's Assigned School District 
Does your child have an Individualized Education Plan (IEP)?
Clear selection
Is your child up tp date on their immunizations?
Children must be immunized according to the State of Ohio’s recommended immunization schedule, or following a physician's recommended guidelines in order to enroll.
Is your child toilet trained? *
Required
Are you currently on PFCC (Title XX) Benefits? *
Please check any applicable option(s) that relate to my preschool age child or family situation:
Estimated Annual Household Income (Used for grant eligibility)
Number of people living in your household? *
What is your preferred method of communication?  *
Required
Additional Notes
A copy of your responses will be emailed to the address you provided.
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