School Age Child Care Inquiry Form — YMCA of Greater Toledo

This is not a registration or enrollment form, but an inquiry about YMCA School Age programs.

For Ages 5 - 12 years old

Child Information

Child Name *

First name

Last name

Child's Gender *

Female Male

Birth Date *

Location

Please choose which school your child attends *

Parent/Guardian 1 Information

Parent/Guardian Name *

First name

Last name

Email *

example@example.com

Phone Number *

Address *

Street address

Street address line 2

City

State

ZIP

Parent/Guardian 2 Information

Name

First name

Last name

Email

example@example.com

Phone Number

Click to copy guardian 1 address to guardian 2 if the same

Yes

Address

Street address

Street address line 2

City

State

ZIP

Additional Information

Are you a YMCA member? *

Yes No

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

A.M/P.M. A.M. P.M.

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.