Click to Return to Kingdom Kids Home Page
 

Kingdom Kids
 

KINGDOM KIDS DEVELOPMENT LEARNING CENTER
Child Enrollment Form
 

Please fill out the form completely.

Entrance Date: month, day, year
Withdrawal Date month, day, year
Child’s Full Name
Child's Sex    Male           Female
Age     Birthdate:  mo, day, yr
Home Address  

Street Address

City

State

    Zip Code 

Home Phone

 Please include area code
Father’s Name
Home address if different from above:

Street Address

City

State

    Zip Code 

Home Phone

 Please include area code
Place of Employment
Address of Employment
  City   
  State         Zip
Business Phone Number
   
Mother’s Name
Home address if different from child's above:

Street Address

City

State

    Zip Code 

Home Phone

 Please include area code
Place of Employment
Address of Employment
  City  
  State       Zip
Business Phone Number
Child’s Living Arrangements:
 

  Both Parents   Mother     Father    Other
Child’s Living Guardian(s):  
  Both Parents    Mother    Father     Other
The child may be released to the person (s) signing this agreement or to the following:
Name Address (Street, City, State, and Zip)
Persons to contact in the case of an emergency when parents cannot be reached:
Name Phone
Medical
Name of public or private school child attends, if any:
 
Child’s Physician or Clinic’s Name (Child’s Primary Health Source)
 
Telephone Number
List any special needs your child has:
The following special accommodation(s) may be required to most effectively meet my child’s needs while at the center:
My child is currently on medication(s) prescribed for long- term continuous use and/ or has the following pre-existing illness, allergies, or health concerns:
Please Enter a 5-digit pin that will act as your electronic signature Full Name: 

PIN Number

           


 

Our Mission  :  Operation  :  Curriculum  :  Our Facility  :  Staff  :  Application
Parents Handbook  :  Home

Home    Church    Pastor    Worship    Ministries  BGBC Online

Seek, Save, Support, Shape, & Serve

Beulah Grove Baptist Church
1434 Poplar Street
Augusta, Georgia  30901
Office:  706.724.1086
Fax:  706. 724.6999
webadministrator@beulahgrove.org