KCI Online Interest Form

KCI Online Interest Form

This interest form is for parents and guardians to fill out. Once you do, we will be in touch to help you enroll your child at Kids Central Inc. We can’t wait to welcome you to our family!
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
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Would you like to sign up for SMS texting to your PRIMARY phone number?*

YesNo
Would you like to sign up for SMS texting to your ALTERNATE phone number?*

YesNo
Agree to receive text messages

I agree to receive text messages from Kids Central Inc. to the phone numbers indicated above.
We may text you to help with the enrollment process and to allow communications between teachers and parents and guardians. You may opt out at any time by replying STOP. Standard SMS texting rates apply. You can view our full privacy policy at: https://kidscentralinc.com/privacy-policy/
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
Should be Empty: