CAPC Intake

To start the intake process, please complete the intake form below.

One of our Site Coordinators will follow up with you to ensure we connect you with the appropriate programs and services to meet the needs of your family and to determine eligibility.

Choose your location(Required)

Previous participant?(Required)

Parent / Guardian information

Parent Name(Required)

Email address(Required)

Phone(Required)

Child #1 Information

Childs Name(Required)

Child's date of birth(Required)

Child #2 Information

Child #2 Name

Child #2 date of birth

Child #3 Information

Child #3 Name

Child #3 date of birth

Please share any other information you would like us to know:

Please share how you heard about YCD: