Childcare Request Form

Child Information
Child's Gender
Is your child school age?
If your child's school is not listed, please enter it in the box above
Child Care Details
Please check the type of care your child will need
Do you need full time or part time care
Please select days needed
Parent / Guardian #1
Additional Information
Are you a YMCA member?
Special Instructions / Requests
Financial Assistance
Greene County Department of Job and Family Services
541 Ledbetter Rd, Xenia, OH 45385
(937) 562-6000

Montgomery County Department of Job and Family Services
1111 S Edwin C Moses Blvd, Dayton, OH 45417
(937) 496-6720

Preble County Department of Job and Family Services
101 East Main Street, Eaton, Ohio 45320
(937)456-8143 

Warren County Department of Job and Family Services
416 South East Street, Lebanon, OH 45036
(513) 695-1420

What is Title 20?
https://jfs.ohio.gov/cdc/Page4.stm

Child Care in Ohio
http://jfs.ohio.gov/cdc/page2.stm

Application for Child Care Benefits
http://www.odjfs.state.oh.us/forms/file.asp?id=121&type=application/pdf

Form Submission

* - required field.

By clicking submit, I understand that I am not registered for YMCA child care until my child’s designated paperwork is completed; that I have spoken to a YMCA Child Care representative and confirmed my child’s enrollment AND have attended a child care orientation.

You will receive a call within 24 hours from a child care representative to confirm your enrollment. If you need additional assistance, please call 937-610-9622 ext. 1033.

4 + 2 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.