Child Care Interest Form

Which Location? (Only choose 1) *

Watertown Area YMCA - Early Education Center

YMCA at Pabst Farms - Child Care Center

Summit Elementary 4K Half Day

Child's Name *

Member of the YMCA? *

Yes

No

Has the child been born yet? *

Yes

No

Child Due Date * +

Child Date of Birth * +

Current Age of Child *

Which days are you interested in? *

	Yes	No
Monday	Yes	No
Tuesday	Yes	No
Wednesday	Yes	No
Thursday	Yes	No
Friday	Yes	No

Anticipate Due Date (If Applicable) +

Parent/Guardian Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Email Address 2

Parent/Guardian Employer *

I understand that being placed on the waiting list does not guarantee a space for my child. The Center will not give numbers or time frames of when a space will open. The only way to guarantee a space for my child is to respond to the email indicating a vacancy. Upon confirmation of an available space, complete all required paperwork and pay the $75 per family registration fee *

Yes

Signature *

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