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Apply for Child Care

Important Note: In order to be eligible for placement in classrooms for ages 3 and up,
your child must be fully potty-trained.

Before filling out this form, please double check that you are applying to King’s Daughters Child Development Center located at 590 N Dupont Ave. Madison, TN 37115

Child Care Needed By:
MM slash DD slash YYYY
Child's Information
How many children would you like to apply?
- 1
- 2
- 3
- 4
Child's Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Is child a Dual Language Learner?*
- Yes
- No
Languages spoken*
Does child have any diagnosed special needs?*
Child's Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Is child a Dual Language Learner?*
- Yes
- No
Languages spoken*
Does child have any diagnosed special needs?*
Child's Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Is child a Dual Language Learner?*
- Yes
- No
Languages spoken*
Does child have any diagnosed special needs?*
Child's Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Is child a Dual Language Learner?*
- Yes
- No
Languages spoken*
Does child have any diagnosed special needs?*
Parent/Care Giver's Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone (Home)*
Phone (Cell)*
Email*

Please put an email address that you check regularly and would be best to reach you.
Employed*
- Yes
- No
Is there another parent/care giver?*
- Yes
- No
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone (Home)*
Phone (Cell)*
Email*

Please put an email address that you check regularly and would be best to reach you.
Employed*
- Yes
- No
Annual Household Income $*
Based on the age of your child and your annual income, your weekly fee will be $130.00.
Based on the age of your child and your annual income, your weekly fee will be $140.00.
Based on the age of your child and your annual income, your weekly fee will be $151.00
Based on the age of your child and your annual income, your weekly fee will be $166.00
Based on the age of your child and your annual income, your weekly fee will be $182.00
Based on the age of your child and your annual income, your weekly fee will be $198.00
Based on the age of your child and your annual income, your weekly fee will be $213.00
Based on the age of your child and your annual income, your weekly fee will be $229.00
Based on the age of your child and your annual income, your weekly fee will be $244.00
Based on the age of your child and your annual income, your weekly fee will be $265.00
Based on the age of your child and your annual income, your weekly fee will be $97.00
Based on the age of your child and your annual income, your weekly fee will be $103.00
Based on the age of your child and your annual income, your weekly fee will be $108.00
Based on the age of your child and your annual income, your weekly fee will be $113.00
Based on the age of your child and your annual income, your weekly fee will be $120.00
Based on the age of your child and your annual income, your weekly fee will be $125.00
Based on the age of your child and your annual income, your weekly fee will be $136.00
Based on the age of your child and your annual income, your weekly fee will be $154.00
Based on the age of your child and your annual income, your weekly fee will be $166.00
Based on the age of your child and your annual income, your weekly fee will be $182.00
Based on the age of your child and your annual income, your weekly fee will be $203.00
Based on the age of your child and your annual income, your weekly fee will be $88.00
Based on the age of your child and your annual income, your weekly fee will be $94.00
Based on the age of your child and your annual income, your weekly fee will be $100.00
Based on the age of your child and your annual income, your weekly fee will be $106.00
Based on the age of your child and your annual income, your weekly fee will be $112.00
Based on the age of your child and your annual income, your weekly fee will be $117.00
Based on the age of your child and your annual income, your weekly fee will be $129.00
Based on the age of your child and your annual income, your weekly fee will be $147.00
Based on the age of your child and your annual income, your weekly fee will be $156.00
Based on the age of your child and your annual income, your weekly fee will be $172.00
Based on the age of your child and your annual income, your weekly fee will be $192.00
Please select all that apply: (leave blank if none apply)
- Eligible for SNAP
- Eligible for D.H.S Child Care Certificate
- Eligible for TANF
Signature*

322

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King’s Daughters Child Development Center | 590 N Dupont Ave., Madison, TN 37115 |

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