KCA Daycare Registration Form

Information of Child
Child's Full Name

First NameLast Name
Child goes by:
Birth Date

MonthDayYear
Date
Age:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FemaleMale
Full dayHalf-day morningHalf-day afternoonOther
MondayTuesdayWednesdayThursdayFriday
YesNoCurrently Potty-Train-ING
Information of Parent/ Legal Guardian
Birth Father's Name:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Place of Work
Birth Mother's name:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Place of Work
Step Guardian Name:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Emergency Contact:
In the event of an emergency, and parents can not be contacted, who may be contacted:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child may be released to the following without permission from the parent or guardian:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parents Marital Status: (Options: Single, Married, Separated, Divorced)
If Divorced: List the person who has custody of the child: (Please include a copy of the Order of Custody with this application)
Medical Information
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred hospital
Insurance/health coverage
Miscellaneous Information:
Does the child have allergies? If yes, what kind:
Does your child have a sibling at KCA School?
If so ^, how many?
KCA Daycare has my permission to take and post pictures of my child on their social media pages:
Upload Updated Vaccination Schedule:

Cancelof
Other Files:

Cancelof
Should be Empty:

Information of Child

Information of Parent/ Legal Guardian

Medical Information

Miscellaneous Information: