Fillable HHS/ED Childrens Center Waiting List Form

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HHS/ED Childrens Center Waiting List Form

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The HHS/ED Childrens Center Waiting List Form form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 56 other fields

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File type: PDF

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Today’s Date: ________________
HHS/ED Children’s Center Waiting List Form
Part I Participant Information
Child’s Full Name (First, Middle, Last)
Nickname
Birth Date (Month/Day/Year)
Expected DOB
Sex
Street Address
City
State
Zip
Home Phone:
Desired Start Date:
Part II Parent / Guardian Information
Parent/Guardian #1 Name (First, Last)
Employer Info. (Company Name)
Email
Home Phone
Cell Phone
Work Phone
Parent / Guardian #2 Name (First, Last)
Employer Info. (Company Name)
Email
Home Phone
Cell Phone
Work Phone
Part III Notes
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Part IV (FOR OFFICE USE ONLY) Priority:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Date and method of Contact:
Offer Date: ________________ Offer Date: ________________ Offer Date: ________________
Part IV (FOR OFFICE USE ONLY) Payment Information
PLEASE COMPLETE PAYMENT AUTHORIZATION BELOW
(Please Check Method of Payment)
CREDIT CARD AUTHORIZATION
I authorize the YMCA to charge my credit card for the waiting list fee
__________________________________________________ ___________ AMEX MC VISA DISCOVER
NAME AS IT APPEARS ON CARD CARD ISSUER
_____________________________________________________ ____________________ ________________________________________________
CREDIT CARD NUMBER EXP. DATE SIGNATURE OF CARD HOLDER
BILLING ADDRESS OF CARDHOLDER: ___________________________________________________________________________________________________
CITY: ___________________________________________________ STATE: _______________ ZIP: _________________
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HHSED Childrens Center Waiting List Form

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Completed 10 August 2021

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