KCI Online Enrollment Application

KCI Online Enrollment Application

For parents and guardians
Parent/Guardian #1 Name*

PrefixFirst NameLast NameSuffix
Parent/Guardian #1 Date of Birth *

MonthDayYear
Parent/Guardian #1 Role

MomDadGuardianStep-parentGrandparentFosterOther
Parent/Guardian #2 Name

PrefixFirst NameLast NameSuffix
Parent/Guardian #2 Date of Birth

MonthDayYear
Parent/Guardian #2 Role

MomDadGuardianStep-parentGrandparentFosterOther
Child's Name*

First NameMiddle NameLast NameSuffix
Child's Date of Birth*

MonthDayYear
Pediatrician's Name

PrefixFirst NameLast NameSuffix
Applying for

Home BaseCenter Base
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email
example@example.com
Do you have Facebook? Can we contact you via messenger?
Does anyone in the household receive any of the following (check all that apply)?

TANFWICSNAPSSIMEDICAID
Do you currently live with a friend or another family member or in temporary housing?

YesNo
Estimated monthly income
No $ sign
Income from (check all that apply).

EmploymentChild supportUnemployment benefitsNo incomeOther
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