Child Care Interest Form

Child Care Interest Form

Kaiden's Korner Childcare Services
Parent Contact Information
Parent Name*

First NameLast Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information About Your Child/Children
Child 1 Name*

First NameLast Name
Child’s Age*
Birth Date*

MonthDayYear
FemaleMale
Child 2 Name

First NameLast Name
Child’s age*
Birth Date

MonthDayYear
FemaleMale
Child 3 Name

First NameLast Name
Child’s age
Birth Date

MonthDayYear
FemaleMale
Full TimePart TimeOther
MondayTuesdayWednesdayThursdayFridaySaturday
Before schoolAfter school
If answered Yes to Before/After Care. What school does your child attend?
Do you require non-traditional hours? (Any Hours after 6pm)
If yes, What Hours are needed?
Has your child attended a childcare center before? If so, where?*
Place of Work (Information used only in case of an emergency; Does not get reported to ELRC or any other agencies)*
Private Pay (Cash, Debit/Credit Card)CCIS/ELRC
Please list any of the following: Current medications, medication allergies, food allergies, chronic health concerns, or anything else you would like us to know!
How did you hear about us?*
If referred by a parent; please type their name below!
Desired Start Date: *

MonthDayYear
Date
Phone Consultation (Required Before Tour)All families must complete a phone consultation before a tour can be scheduled.
Please select a day/time for a phone consultation. This is required before any in-person tour is conducted *
WHATS NEXT???

1. After the submission of this form, you will be contacted via phone for a phone consultation on the date/time you selected above!

2. After your phone consult and you like what you hear, you will be invited to tour the facility, and to complete the required paperwork!

Please make sure the email address and phone number you documented is the best means of contact for you!
Should be Empty:

Child Care Interest Form

Parent Contact Information

Information About Your Child/Children

Phone Consultation (Required Before Tour)All families must complete a phone consultation before a tour can be scheduled.