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Enrollment Form
Kingdom Business Learning Center Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state child care licensing regulations.
Child's Information
Name
*
First Name
Last Name
M.I.
Male or female?
Female
Male
Age
*
Date of Birth
*
Grade Level (2024/25)
2nd Child's Information
Name
First Name
Last Name
M.I.
Male or female?
Female
Male
Age
Date of Birth
Grade Level (2024/25)
3rd Child's Information
Name
First Name
Last Name
M.I.
Male or female?
Female
Male
Age
Date of Birth
Grade Level (2024/25)
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Services Needed:
*
Homeschool Tutorial Program
Saturday Camp
Tutoring Services
Reading & Math Summer Program
Courses
*
Kindergarten Program
1st grade Program
2nd grade Program
3rd grade Program
4th grade Program
5th grade Program
Weekly Schedule (list days and times)
Parent's Information
Name
*
First Name
Last Name
Relationship to child
*
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Employer
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
2nd Parent's Information
Name
First Name
Last Name
Relationship to child
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Employer
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact & Release Information
Please notify Ms. Smith if an Emergency Release Contact will pick up your child on a given day. [For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pick up. The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization.
Person #1
*
First Name
Last Name
Relationship to child
*
Primary phone number
*
Secondary phone number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person #2
*
First Name
Last Name
Relationship to child
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person #3
First Name
Last Name
Relationship to child
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MEDICAL INFORMATION
Height
Weight
Hair Color
Eye Color
Primary Physician's Name
First Name
Last Name
Primary Physician's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred hospital
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
*
Additional Medical Policies
Prior to enrollment, I must provide the center with updated medical and immunization information for my child. This information is to be kept current and updated in accordance with state child care regulations.
*
Initial
I agree to provide information to the child care center about my child’s conditions, illnesses, allergies or other needs.
*
Initial
If my child becomes ill with a reportable contagious disease, I understand that he/she will not be able to return until I bring in a physician’s note stating that he/she is no longer contagious.
*
Initial
In case of a medical emergency, the staff will attempt to contact me, those listed in the Child Emergency Contact and Release, and lastly my physician.
*
Initial
In case of a medical emergency, I agree that my child may receive first aid and/or CPR.
*
Initial
In case of a medical emergency, I permit the transportation of my child to a local hospital or other urgent care facility, if necessary by paramedics or other emergency personnel.
*
Initial
In case of a medical emergency, I will be responsible for the emergency medical expenses.
*
Initial
In case of an accidental ingestion of a poisonous substance, I consent to my child being treated as directed by the Poison Control Center.
*
Initial
Media Release
Occasionally, photos will be taken of the children during sessions for use on our website and/or newsletters. Please indicate that you authorize the use and reproduction of photographs of your child in conjunction with the program.
*
Initial
Handbook Acknowledgment
-I understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them. -I understand that it is my responsibility to go directly to management with any questions I may have regarding the policies and procedures and information contained in this Enrollment Agreement. -Information contained in the Family Handbook may be subject to change.
*
Initial
Date of Application
*
-
Month
-
Day
Year
Date
Signature
*
To the best of my knowledge the information contained above is accurate. I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement.
Submit
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