Guardian’s Name:
_______________________________________
(Last)
(First)
(M.I.)
Address: _____________________________________________________________
Coalition For Kids, Inc. Summer Enrollment Form
City ____________________ State: ____ Zip _________ County _______________
Mailing Address (if different): _____________________________________________
Phone (Home) __________________________ (Cell) __________________________
Child’s Name___________________________________________________________
(Last)
(First)
(M.I.)
Email Address: _________________________________________________________
Gender: ( )Male ( )Female Race:______________
Father’s Name: _____________________Phone: (1) ___________ (2) ____________
Date of Birth:____/____/_____
Social Security #_____-_____-_______ School: ________________________________
Address: ____________________________________ Phone: ____________________
Authorized Pick-Up ( ) Yes ( ) No
Mother’s Name: __________________Phone: (1) ____________ (2) _____________
Authorized Pick-Up ( ) Yes ( ) No
Grade Entering Fall 2016: __________
T-Shirt Size: ____________________
Stepfather’s Name: __________________Phone: (1) ___________ (2) ____________
Authorized Pick-Up ( ) Yes ( ) No
Stepmother’s Name: __________________Phone: (1) ___________ (2) ___________
Authorized Pick-Up ( ) Yes ( ) No
Mother’s Employer: _____________________________ Hours: _________________
Days at Work: ( )M ( )T ( )W ( )Th ( ) F Address: ______________________________
Father’s Employer: ______________________________ Hours: _________________
Days at Work: ( )M ( )T ( )W ( )Th ( ) F Address: ______________________________
1. Does your child qualify for a lunch program? ( )Free ( )Reduced ( )Neither
2. A copy of my child’s immunizations and health records stating that they are up-todate are currently on file at their school. ( )Yes ( )No
3. Are you eligible for DHS Families First Child Care Certificate? ( ) Yes ( ) No ( ) Maybe
Program Enrolled: Summer ( )
Date Enrolled in Program: ____/____/_____
Siblings attending Coalition For Kids, Inc. Program:
Custody ( ) Mother ( ) Father ( ) Joint ( ) Other Resides with _____________________
Custodial Family Income: $0-24,999 ____
$24,500-39,999 ____
1.Name:________________________ School:_______________________ Grade:_____
$40,000-& Over ____
Do not release this child to __________________________ (see court papers on file)
If parents cannot be reached call:
1. Name: __________________________________Authorized Pick-Up ( ) Yes ( ) No
Address: _____________________ City ___________ State ______ Zip ___________
Phone (H) _________________(C) _________________ Relation_________________
2.Name:________________________ School:_______________________ Grade:_____
3.Name:________________________ School:_______________________ Grade:_____
4.Name:________________________ School:_______________________ Grade:_____
I have been informed of the Coalition For Kids Inc. policy regarding pick-up times, fees,
late pick-up fees, extended care hours, transportation and emergencies and fully
understand and agree to these policies. Initial: _____
2. Name: __________________________________Authorized Pick-Up ( ) Yes ( ) No
Address: _____________________ City ___________ State ______ Zip ___________
Phone (H) _________________(C) _________________ Relation_________________
3. Name: __________________________________Authorized Pick-Up ( ) Yes ( ) No
_________________________________________________________________________
For Official Use Only:
Address: _____________________ City ___________ State ______ Zip ___________
Site(s) Placement: ___________________________
(Kid City)
Phone (H) _________________(C) _________________ Relation_________________
Start Date: ____/____/_____ Exit Date: ____/____/______