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Online Registration for
2024-2025
school year
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Indicates required field
For which session are you registering your child?
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Please select
AM Session (for students 3+ years old on/before Sep. 1, 2024)
PM Session (for students 4+ years old on/before Sep. 1, 2024)
Child's Name
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First
Last
Child's Date of Birth (MM/DD/YYYY)
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Gender
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Please select
Male
Female
Place of Birth (City, State or Country)
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Current Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Parent / Guardian 1 Name
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First
Last
[object Object]
Parent / Guardian 1 Phone:
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Parent / Guardian 1 Email
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Parent / Guardian 1 Occupation
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Work Phone (if applicable)
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Parent / Guardian 1 Address (if different)
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Line 1
Line 2
City
State
Zip Code
Country
Parent / Guardian 2 Name
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First
Last
Parent / Guardian 2 Phone
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Parent / Guardian 2 Email
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Parent / Guardian 2 Occupation
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Work Phone (if applicable)
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Parent / Guardian 2 Address (if different)
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Line 1
Line 2
City
State
Zip Code
Country
Is child adopted?
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Yes
No
If yes (adopted), at what age was adoption?
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If yes (adopted), is child aware of adoption?
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Yes
No
Please describe any custody arrangements, if applicable, regarding the child's visitation with a parent/guardian:
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Please list siblings and ages (e.g. siblings name, age):
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Please list other members living in the household (e.g. person's name, age, relationship to child):
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What are your child's favorite activities?
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Describe any fears or anxieties your child may experience:
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What behavior management practices are used for your child?
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How does your child respond to these measures of correction and discipline?
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Please list any organizations, if applicable, where your child has attended daycare or preschool:
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What learning experiences and objectives are important to you for your child's education at Kiddie Kampus?
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Please describe any concerns you may have about your child's development:
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Please describe any stressful experiences, if applicable, which may affect your child's behavior (i.e. divorce, death in the family, past abuse, etc):
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Please describe any symptoms of illness your child frequently experiences:
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Please list any allergies that affect your child:
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If your child has allergies, describe reaction symtoms:
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List any food/drink items (non-allergy related) you wish for your child to NOT have:
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Pick-Up Preferences
Who do you anticipate being the primary person who would be picking up your child?
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First
Last
[object Object]
Phone Number
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Relation to child
*
Please list (up to) 4 other individuals who may be permitted to pick up your child from school:
Individual 1 Name
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First
Last
Individual 1 Phone
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Relation to child
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Individual 2 Name
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First
Last
Individual 2 Phone
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Relation to child
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Individual 3 Name
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First
Last
Individual 3 Phone
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Relation to child
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Individual 4 Name
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First
Last
Individual 4 Phone
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Relation to child
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Emergency Contact Info
Please list (up to) 4 other individuals we may contact in case of an emergency. (
We will always attempt to contact you first
)
Emergency Contact (EC) 1 Name
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First
Last
EC 1 Phone
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Relation to child
*
EC 2 Name
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First
Last
EC 2 Phone
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Relation to child
*
EC 3 Name
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First
Last
EC 3 Phone
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Relation to child
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EC 4 Name
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First
Last
EC 4 Phone
*
Relation to child
*
Your Child's Physician / Pediatrician (Name):
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First
Last
Physician / Pediatrician Phone
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Hospital Preference
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Medical Response Agreement:
I hereby give my permission for Kiddie Kampus staff members to obtain the services of the doctor listed above (or another if your child’s primary care physician cannot be reached), EMT unit, or hospital in case the child suffers a serious illness or accident and requires medical attention.
Please indicate your agreement to the Medical Response statement above:
*
Please select
YES, I agree to the Medical Response Statement
NO, I do not agree to the Medical Response Statement
Media Release Agreement:
I grant permission to Kiddie Kampus, Pierce Church, and its children’s ministry, employees, and volunteers to take photographs, video, and/or electronic images of any member of my family in the children’s ministry environment. I authorize the aforementioned entities to copyright, use, and publish (i.e. Facebook) the photographs, video, and/or electronic images in print and/or electronically—with or without our names—for any lawful purpose to highlight and promote Kiddie Kampus, Pierce Church, and its children’s ministry.
Please indicate your agreement to the Media Release statement above:
*
Please select
YES, I agree to the Media Release Statement
NO, I do not agree to the Media Release Statement
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