K4J Student Enrollment Form
Please fill out this form and click submit.
Child's Full Name
*
Child's Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Parent's Phone
*
Parent's Email
*
This address will receive a confirmation email
Child's Date of Birth
*
Gender of Child
*
Please select all that apply.
Male
Female
Preferred Enrollment Date
*
Attendance Information
Programming enrolling for
*
Please select all that apply.
Infant
Toddler
Preschool
School Age
What days will your child be attending?
*
Please select all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
Time your child will be in attendance
*
Parent/Guardian Information
The child's primary residence
*
Please select all that apply.
With Mother
With Father
Both
Other
Enrolling Parent/Guardian Name
*
Relationship to child
*
Home address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Employer/Place of work
*
Employer/Work Address
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Cell/Home Phone
*
Work Phone
Email Address
*
This address will receive a confirmation email
Marital Status
*
Please select one option.
Single
Married
Divorced
Widowed
Additional Parent/Guardian Information
Parent/Guardian Name
Relationship to the child
*
Home Address
*
Employer/Place of Work
Employer/Work Address
Cell/Home Phone
*
Work Phone
Email Address
*
Marital Status
*
Please select one option.
Married
Single
Divorced
If divorced/separated, who has legal custody? (legal documentation required)
May the non-custodial parent pick up the child? (legal documentation required)
Please select one option.
Yes
No
Emergency Information
In the event that I cannot be reached to make arrangements, I hearby give my consent to Kids 4 Jesus to contact Doctor (please add Name, Phone Number, Address, City).
*
Phone
*
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Emergency Contacts (Other Than Parents)
Emergency Contact #1 Name
*
Relationship to child
*
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Best Contact Phone Number
*
Emergency Contact #2 Name
*
Relationship to child
*
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Best Contact Phone Number
*
Authorized Pick Up List
The child(ren) will only be released to the people on this application (including emergency contacts).
Name
*
Relationship to child(ren)
*
Name
Relationship to child(ren)
Name
Relationship to child(ren)
*
Name
Relationship to child(ren)
*
Name
Relationship to child(ren)
*
About Your Child
Current health status of child
*
Please select one option.
Good
Fair
Poor
Select Option
Good
Fair
Poor
Allergies or special needs?
*
Allergic reactions that occur
*
If allergic reaction does occur, what procedures need to take place?
*
Is your child potty trained?
*
Please select one option.
Yes
No
How does your child indicate he/she needs to use the restroom?
*
What are some of your child's favorite toys, games, and activities?
*
What expectations do you have for your child care provider?
*
Does your child have a special toy or blanket to sleep with?
*
Infant Eating & Sleeping Schedule
Feeding
Please select one option.
Breast Milk
Formula (to be supplied by the parent/guardian)
Select Option
Breast Milk
Formula (to be supplied by the parent/guardian)
Submit
Description
Please fill out this form and click submit.
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