Enrollment Form | kiddiekingdom

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Child's name

Gender

Birthday

Month

Day

Year

Parent/Guardian #1

Relationship To Child

Phone

Address

Email

Employer

Work Phone

Parent/Guardian #2

Relationship To Child

Phone

Address

Email

Employer

Work Phone

Emergency Contact Name

Relationship To Child

Emergency Contact Number

Service Needed

Schedule Needed

Full-time

Part-time

Days Needed

Monday

Tuesday

Wednesday

Thursday

Friday

Time

:HoursMinutes

Start Date

Month

Day

Year

Authorized Pickup Names & Phone Numbers

I give Kiddie Kingdom Daycare permission to:

Photograph my child for daycare activities/ social media

Apply Sunscreen

Apply Off

Seek emergency medical treatment if necessary

Participate in outdoor activities

Child's Physician

Physician's Phone Number

Allergies

Medical Conditions

Current Medications

Immunization Records

Birth Certificates

I certify that all information provided is accurate and complete. I understand that enrollment is subject to availability and completion of all required paperwork.

Signature

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Date

Month

Day

Year

Submit

Providing nurturing childcare and early learning experiences for children in Northwest Indiana.

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