Application for Enrollment

Federal and state laws prohibit discrimination because of sex, race, color, place of birth, national origin, religious creed, disability, or source of payment.

Child's Information

Child's Name: (first name & last name)

Address:

Telephone: 123-456-7890

Hours of Attendance:

Parent Information

Parent/Guardian Name: (first name & last name)

Occupation:

Place of Employment:

Daytime Telephone: 123-456-7890

Address: (Street, City, State, Zipcode)

Telephone: 123-456-7890

Parent/Guardian Name: (first name & last name)

Occupation:

Place of Employment:

Daytime Telephone: 123-456-7890

Address: (Street, City, State, Zipcode)

Telephone: 123-456-7890

Are there special custody/visitation arrangements that we should be aware of?:

Emergency Contacts

Emergency Contact 1: (first name & last name)

Telephone: 123-456-7890

Relationship to Child:

Emergency Contact 2: (first name & last name)

Telephone: 123-456-7890

Relationship to Child:

Household Composition

(Please list all living in household)

Child 1

Name: (first name & last name)

Relationship to Child:

Date of Birth: (mm/dd/yyyy)

Child 2

Name: (first name & last name)

Relationship to Child:

Date of Birth: (mm/dd/yyyy)

Child 3

Name: (first name & last name)

Relationship to Child:

Date of Birth: (mm/dd/yyyy)

Child 4

Name: (first name & last name)

Relationship to Child:

Date of Birth: (mm/dd/yyyy)

Health Information

Pediatrician's Name: (first name & last name)

Telephone: 123-456-7890

Address: (Street, City, State, Zipcode)

Allergies:

Does your child take a daily medication?

Yes

If yes, indicate medication and reason:

Does your child have any of the following health problems?

Urinary Infections

Colic

Diarrhea

Asthma

Ear Infections

Seizures

Constipation

Chicken Pox

Other

Please explain:

Is there any food your child can not eat for religious, medical, or personal reasons?:

Day Care History

Has your child had a group care experience before?

Yes

If yes, please list previous experiences.

Previous experience one

Where?:

Begin Date: (mm/dd/yyyy)

End Date: (mm/dd/yyyy)

Reason for leaving:

Previous experience two

Where?:

Begin Date: (mm/dd/yyyy)

End Date: (mm/dd/yyyy)

Reason for leaving:

What do you consider to be essential for high quality day care?

How did you hear about Kingsway Kids Center?