YMCA of Greater Erie

If you have any questions, please reach out to [email protected]

Child's Name*
First Last
Child's Birthdate*
MM slash DD slash YYYY
Child's Gender*
Race*
- Asian
- African American
- Caucasian
- Hispanic (Chicano/Latino)
- American Indian
- Multiracial
For clerical use only, will not effect services offered.
Primary Caregiver Name*
First Last
Relationship*
Email*
Home Address*
Street Address Address Line 2 City State ZIP Code
School District*
ITCS Site*
Authorization*
I agree to following:
I authorize and request the ITCS program disclose to the ELRC, all information contained in the form to verify my child’s enrollment in ITCS and the Child Care Works Program
Signature