Los Altos Family YMCA

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* 1. My child is age:

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* 2. If available at Buffum, I would be interested in before school childcare (7:30am-10:00am).

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* 3. If available at Buffum, I would be interested in after school childcare (1:00pm-5:30pm).

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* 4. Does your family already have an established relationship and utilize resources through Harbor Regional Center or another 3rd party agency (CHS, Crystal Stairs, etc.)?

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* 5. My child is verbal. They are able to communicate their needs.

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* 6. My child is potty trained.
(This question is being asked to best plan to meet each child's need, not because potty training is a requirment.)

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* 7. If any, please briefly describe your child's behavior challenges.

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* 8. Any other questions or comments regarding the possiblity of the YMCA providing before and after school childcare on site at Buffum.

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* 9. Please provide some basic information about your family.

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