YMCA of Greater Erie

Child's Name*

First Last

Date of Birth*

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Gender

Male
Female

Gender*

School District of Residence

School Currently Attending

Grade / Classroom

Select Preferred Childcare Program Location*

Race*

For clerical use only, will not effect services offered.

Ethnicity*

Hispanic or Latino
Non Hispanic or Latino

For clerical use only, will not effect services offered.

Parent Information

Do you have a COURT ORDER stating visitation or custody arrangements of parent/guardian?*

Yes
No

Regulations require a COURT ORDER to be ON FILE at the facility should there by any restrictions regarding visitation or custody.

Primary Parent or Guardian*

First Last

Home Phone

Cell Phone*

Permission for Text Communications*

Carrier

Address*

Street Address City State ZIP Code

Email address*

Primary Parent or Guardian Status

I do not have employment or attend school outside the home

Employer / School

Employer / School Phone (include extension)

Employer / School Address

Street Address City State ZIP Code

Sole Guardian

I am the sole guardian for the child

Secondary Parent or Guardian

Home Phone

Cell Phone

Permission for Text Communications

Carrier

Address

Street Address City State ZIP Code

Email address

Secondary Guardian Status

I do not have employment or attend school outside the home

Employer / School

Employer / School Phone (include extension)

Employer / School Address

Street Address City State ZIP Code

Child's Medical Information

Name of Child's Physician / Medical Care Provider*

Phone*

Address*

Street Address City State ZIP Code

Medications*

Medications (If you selected Yes above)

Allergies*

Allergies (If you selected Yes above)

Medical or Dietary Information Necessary in Emergency Situation*

Medical or Dietary Information Necessary in Emergency Situation

(If you selected Yes above)

Special Disabilities*

Special Disabilities (If you selected Yes above)

Other information necessary for the care of your child*

Other information on special needs of child*

Other information on special needs of child

(If you selected Yes above)

Please check any applicable*

A child who was referred from an appropriately credentialed health or mental health practitioner; a child who is receiving mental health services.
IEP: A child who is currently enrolled in the Preschool Early Intervention program with an active IEP (or Family Plan IFSP)
Concerns Regarding Child’s Physical Development or Existing Medical Condition (Currently Not Receiving Early Intervention Services)
Concerns Regarding Child’s Speech or Language Development (Currently Not Receiving Early Intervention Services)
Concerns Regarding Child’s Social, Emotional, or Behavioral Development (Currently Not Receiving Early Intervention Services)
Other – Concern, Allergy or Diagnosis not listed above that I would like to discuss further during the pre-enrollment interview.
No Concerns

If your child has a current IEP, IFSP or Evaluation, a copy must be submitted prior to enrollment. This will provide us with the information to ensure that your child is supported in our program. Enrollment cannot be processed until this is submitted.

Health Insurance Coverage or MA benefits*

Policy Numbers*

*Enrollment will not be processed without a valid number.

Parental Consent

Obtaining Emergency Medical Care*

Minor First Aid Procedures*

Transportation by the Facility*

Walking and Trips*

Swimming and/or Wading*

Consent to be Photographed for Promotion*

Consent to be Videotaped for Promotion*

Signature*

By signing here I consent to all items listed above

Authorized Pick-up People

Person(s) to Whom the Child May Be Released / Emergency Contact Information

Name*

First Last

Address*

Street Address City State ZIP Code

Phone*

Emergency Contact?*

Yes
No

Relationship*

Additional Contacts

I have additional names to enter

Name

First Last

Address

Street Address City State ZIP Code

Phone

Emergency Contact?

Yes
No

Relationship

Name

First Last

Address

Street Address City State ZIP Code

Phone

Emergency Contact?

Yes
No

Relationship

Name

First Last

Address

Street Address City State ZIP Code

Phone

Emergency Contact?

Yes
No

Relationship

Parent Handbook*

I acknowledgement the following:

I have received and reviewed the Parent Handbook and that by enrolling my child in the YMCA of Greater Erie Childcare Programs I am agreeing to all policies and procedures detailed within.

Signature of Parent or Guardian

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Date

How did you hear about us?

Any changes to information can be submitted on our Change of Information Update Form located on our website.

Childcare Application (1 of 3)

Parent Information

Child's Medical Information

Parental Consent

Authorized Pick-up People