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Home
Programs
Prevention Programs
Nurse-Family Partnership
Nurse-Family Partnership Referral Form
Community Education & Outreach
Register for Free Parent Enrichment Classes
Clases Para Padres Gratuitas
Parents as Teachers
Parents as Teachers Referral Form
Kelly Early Education Center
Intervention Programs
Foster Care & Adoption
Cuidado de Crianza Temporal
Supervised Visitation Services Program
Behavioral Health Treatment Programs
Behavioral Health Services
In-Home Services
Foundations of Infant and Early Childhood Mental Health Series
About
Executive Staff
Board of Directors & Foundation Trustees
Our Partners
History
Publications
Employment
Contact Us
Sign Up for Email Updates
News & Events
The Latest
For the Press
Sign Up for Email Updates
Thrift Store
Shopping
Make a Donation
Thrift Store Volunteering
How You Can Help
Donate Now
Donations & Volunteering
Planned Giving
DONATE
CONTACT US
EMPLOYMENT
Kelly Early Education Center Enrollment Packet
Step 1 of 2
50%
Child Information
First Child's Name
*
First
M.I.
Last
Entering Grade
Male
Female
Prefer not to specify
Birth Date
MM
DD
YYYY
Birth City/State
City
State
Social Security #
Existing medical conditions, medications and/or special attention your child may require:
Allergies:
May we take and maintain a photo of your child for security purposes?
Yes
No
Do you have a second child to register?
Yes
No
Child Information- Second Child
Second Child's Name
First
Last
Entering Grade
Male
Female
Prefer not to specify
Birth Date
MM
DD
YYYY
Birth City/State
City
State
Social Security #
Existing medical conditions, medications and/or special attention your child may require:
Allergies:
May we take and maintain a photo of your child for security purposes?
Yes
No
Do you have a third child to register?
Yes
No
Child Information- Third Child
Third Child's Name
First
Last
Entering Grade
Male
Female
Prefer not to specify
Birth Date
MM
DD
YYYY
Birth City/State
City
State
Social Security #
Existing medical conditions, medications and/or special attention your child may require:
Allergies:
May we take and maintain a photo of your child for security purposes?
Yes
No
Primary Guardian Information
Name(s) of person(s) with whom the child is living
1st Primary Guardian Name
First
M.I.
Last
Relationship to Child
Email
Work Phone
Cell Phone
Occupation
Employer
Work Address
Work Hours
Is there a 2nd primary guardian?
(person with whom the child is living)
Yes
No
2nd Primary Guardian
2nd Primary Guardian Name
First
M.I.
Last
Relationship to Child
Email
Work Phone
Cell Phone
Occupation
Employer
Work Address
Work Hours
Which guardian should be called first?
Home
Address
Street Address
Apt #
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
mailing address same as above
Mailing Address
Street Address
Apt #
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Prefered language for written communication:
Second Guardian Information
Non-primary custodial parent
Non-primary Guardian
First
M.I.
Last
Relationship to child
Email
Work Phone
Cell Phone
Home Phone
Additional Comments & Information
Emergency Contacts and Authorized Pickups
1st Contact/Pickup
First
Last
Relationship to child
Home Phone
Cell Phone
Specify which children may be picked up by this person
Able to pick up all children in the family
2nd Contact/Pickup
First
Last
Relationship to child
Home Phone
Cell Phone
Specify which children may be picked up by this person
Able to pick up all children in the family
3rd Contact/Pickup
First
Last
Relationship to child
Home Phone
Cell Phone
Specify which children may be picked up by this person
Able to pick up all children in the family
Additional Comments and Information
Is there any other information that would be helpful to our management and teaching staff?
