Civitan Childcare Application
Apply for Civitan Children services here.
Date
*
-
Month
-
Day
Year
Date
Parent Name 1
*
First Name
Last Name
Parent Name 2
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you a KCARC Employee?
*
Yes
No
Child's Information
Child 1 Name
*
First Name
Last Name
Child 1 Birth Date or Due Date
*
-
Month
-
Day
Year
Date
+ Add another child
Child 2 Name
First Name
Last Name
Child 2 Birth Date or Due Date
-
Month
-
Day
Year
Date
+ Add another child
Child 3 Name
First Name
Last Name
Child 3 Birth Date or Due Date
-
Month
-
Day
Year
Date
Does your child have any special needs?
*
Yes
No
If yes, please describe:
Does your child have behavior concerns?
*
Yes
No
If yes, please describe:
Is your child currently on Medicaid?
*
Yes
No
Are you receiving any services through a medicaid waiver?
*
Yes
No
Does your child have any allergies?
*
Yes
No
If yes, please list
Where has your child attended child care before?
Child Care Center
Family
In-Home
Other
Reason for leaving previous child care?
Date you would like your child to start?
*
-
Month
-
Day
Year
Date
Do you have vouchers?
*
Yes
No
Will you be applying for vouchers?
*
Yes
No
How did you hear about us?
*
Website
Referral Agency
Referred by a person
Printed Media
Facebook
Instagram
Radio Advertisement
Yard Sign
Fliers
Other
If answer is referred by a person, referral agency or other please specify.
Submit
Should be Empty: