Kingdom Builders King's Kids
Kingdom Builders King's Kids
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KINGDOME BUILDERS KINGâS KIDS â Child Care Application Form
KINGDOME BUILDERS KINGâS KIDS â Child Care Application Form
Child Information
Full Name:
Date of Birth:
Address:
Allergies or Medical Conditions:
Parent/Guardian Information
Full Name:
Relationship to Child:
Phone Number:
Email Address:
Emergency Contact Information
Full Name:
Relationship to Child:
Phone Number:
Authorized Pick-Up Persons
Full Name:
Relationship to Child:
Phone Number:
Medical Information
Physician's Name:
Physician's Contact Information:
Health Insurance Information:
Immunization Records:
Special Medical Needs or Instructions:
Consent and Agreements
Consent for Emergency Medical Treatment:
Yes
No
Consent for Participation in Activities:
Yes
No
Agreement to Follow Facility Policies and Procedures:
Yes
No
Additional Information
Signatures
Parent/Guardian Signature:
Date:
Submit Application