Language
English (US)
KCI Online Enrollment Application
For parents and guardians
Parent/Guardian #1 Name
*
Prefix
First Name
Last Name
Suffix
Parent/Guardian #1 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Parent/Guardian #1 Role
Mom
Dad
Guardian
Step-parent
Grandparent
Foster
Parent/Guardian #2 Name
Prefix
First Name
Last Name
Suffix
Parent/Guardian #2 Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Parent/Guardian #2 Role
Mom
Dad
Guardian
Step-parent
Grandparent
Foster
Child's Name
*
First Name
Middle Name
Last Name
Suffix
Child's Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Pediatrician's Name
Prefix
First Name
Last Name
Suffix
Applying for
Home Base
Center Base
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
example@example.com
Does anyone in the household receive any of the following (check all that apply)?
TANF
WIC
SNAP
SSI
MEDICAID
Do you currently live with a friend or another family member or in temporary housing?
Yes
No
Estimated monthly income
No $ sign
Income from (check all that apply).
Employment
Child support
Unemployment benefits
No income
Submit
Should be Empty: