KIDZ City Daycare Enrollment Application

By submitting this application you are requesting that your child be considered for enrollment into KIDZ City Daycare. A non-refundable enrollment fee is required at time of confirmed enrollment date. (Fee is waived for Waiting List but will be due at time of confirmed enrollment.)

$50.00 - single child, $75.00 - multiple children per family * Fee will not be applied to tuition payments

Child & Family Information

Mother/Guardian Full Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

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Occupation

Employed By:

Work Phone

(###)

###

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Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Hours

Marital Status

Father/Guardian Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Occupation

Employed By:

Work Phone

(###)

###

####

Work Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Hours

Marital Status

Childs Full Name

First Name

Last Name

Name Child Prefers to be Called:

Childs Age

Child's Birthday

YYYY

Gender

Has Your Child been in Childcare in the Past?

Health

*Please provide a copy of your child’s current Immunization record or Exemption waiver at time of confirmed enrollment date. (Please be aware that exemption waivers are to be updated every 6 mos. or before expiration.) It is the responsibility of parent/guardian to provide updated changes to medical information and notify KIDZ City Daycare immediately of any medical conditions that may affect other children and staff. List any existing medical conditions, medication and/or special attention your child may require.

Allergies

Medications

Existing Illness (if any, please explain)

Serious Injury or Illness in Past 12 Months (if any, please explain)

Physician's Name

First Name

Last Name

Physician's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician's Phone

(###)

###

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Hospital

Hospital Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Hospital Phone

(###)

###

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Toileting

Does Your Child Need Assistance with Toileting?

Does Your Child Communicate the Need to Go?

What Are Your Ideas About Toilet Training?

How Can We Best Help?

Behavior

Does Your Child Have Any Special Fears?

How Does Your Child Communicate His/Her Needs?

Are There Any Special Words That Your Child Uses That Might Not Be Recognized?

Are There Any Behavioral Concerns That We Need to be Aware of, I.E. Tantrums, Hitting, Biting?

How Do You Tell Your Child to Stop Unacceptable Behavior?

What Best Helps to Calm your Child Down if Upset?

Does Your Child Have Any Special Naptime Routines?

Eating

Does Your Child Feed His/Her Self?

Does Your Child Use Utensils or Fingers?

What Are Your Child's Favorite Foods?

Are They Willing to Try Different Foods?

(Infant) Formula or Nursing

(Infant) If Nursing, Will Your Child Take a Bottle?

Activities

What Activities Does Your Child Like to do When Playing Alone?

How Well Does Your Child Play With Other Children?

What is Your Child's Favorite Toy?

List Siblings Names & Ages

Names of Any Siblings Enrolled at KCD

Additional Comments & Information

Are There Any Concerns You Have About Placing Your Child in KIDZ City Daycare?

Is There Any Other Information That Would be Helpful to our Management and Teaching Staff?

Tuition/Payment Information

*Be mindful that state child care assistance funding cannot be accepted- All tuition is private pay only

Tuition Payment Schedule

Tuition Payment schedule Weekly (online Billing system) (Late payment/pick up fees additional)

Full Time: 5 Days Per Week @ $195.00

Who is Responsible for Payment of Tuition & Fees?

Parents/Guardians 100%

Mother/Guardian 100%

Mother/Guardian 50%

Father/Guardian 100%

Father/Guardian 50%

If Tuition is the Responsibility of an Adult Other Than the Parents, List Name Below:

If Other Than Above, Please Explain:

Signature

I understand that all the above information will only be used to asses my child for enrollment in KIDZ City Daycare and does not guarantee that a position is available at time of submission. All information will be kept confidential.

Date Submitted

YYYY