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

Other
Parent/Guardian #2 Name

PrefixFirst NameLast NameSuffix
Parent/Guardian #2 Date of Birth

MonthDayYear
Parent/Guardian #2 Role

Other
Child's Name

First NameMiddle NameLast NameSuffix
Child's Date of Birth

MonthDayYear
Pediatrician's Name

PrefixFirst NameLast NameSuffix
Applying for
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?
Would you like to sign up for SMS texting to your ALTERNATE phone 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)?
Do you currently live with a friend or another family member or in temporary housing?
Estimated monthly income
No $ sign
Income from (check all that apply).

Other
Agree to receive text messages
By checking this box, you agree to receive conversational text messages from Kids Central, Inc. Message frequency may vary. On average, 1-2 messages per month. Message and data rates may apply. Reply HELP for help, STOP to opt out.
- Message frequency may vary. On average, 1-2 messages per month.
- Message and data rates may apply.
- Reply HELP for assistance.
- Reply STOP to opt out at any time.
Privacy Policy: https://kidscentralinc.com/privacy-policy
Terms and Conditions: https://kidscentralinc.com/terms-and-conditions
Should be Empty: