Kid Connect Registration

Mother/Guardian Contact
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Place of Employment
Work Phone
Please enter a valid phone number.
Marital Status

MarriedEngagedSeperatedDivorcedSingle
Do you have custody of your child?

YesNo
Are you allowed to pick up the child?

YesNo

Father/Guardian Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Place of Employment
Work Number
Please enter a valid phone number.
Marital Status

MarriedEngagedSeparatedDivorcedSingle
Do you have custody of your child?

YesNo
Are you allowed to pick up the child?

YesNo

Approved Pick Up List

Please attach a copy of all parties' driver's licenses that will be picking up the child.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation to Child
Driver's License Upload

Please upload a picture of the front and back of this person's DL. If unavailable, bring a copy with you to your next visit.
Cancelof
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation to Child
Driver's License Upload

Please upload a picture of the front and back of this person's DL. If unavailable, bring a copy with you to your next visit.
Cancelof
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation to Child
Driver's License Upload

Please upload a picture of the front and back of this person's DL. If unavailable, bring a copy with you to your next visit.
Cancelof

Emergency Information
Physician Name*
Physician phone*
Please enter a valid phone number.
Preferred Hospital for Emergencies
Insurance Company*
Policy Number*
Policy Holder*

First NameLast Name
In the event of an emergency, if you need someone to pick up your child who is not on the list, they will be asked to answer a security questions. In the space below, write down your security question and answer.*

Emergency Contact Information
Contact #1

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #2

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My Products

Registration FeeA non-refundable $115 registration fee is required to secure your child's enrollment at Kid Connect. This fee guarantees your child's spot in our program.

$115.00

Supply FeeA non-refundable $50 supply fee is required at registration to cover the cost of classroom materials and resources.

$50.00

Total

$0.00

Credit Card

Final Question: Where would like us to send a completed copy of your registration documents?
Email*
example@example.com
Should be Empty:

Preschool Registration

Credit Card