School-Age 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's First Name*

Child's Last Name*

Child's Gender*

Child's Birthdate*

School*

Parent/Guardian First Name*

Parent/Guardian Last Name*

Phone*

Email*

Address*

City*

State*

Zip*

Parent/Guardian Name 2 (optional)

Phone

Address

City

State

Zip

Are you a YMCA member?

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

a.m./p.m.
a.m.
p.m.
2nd Shift

Please select which days you would need care. (Check all that apply)

Monday
Tuesday
Wednesday
Thursday
Friday

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.

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

Please only hit the button once and wait 30 seconds for the page to load. Thank you.