Application for Childcare at KDCDC 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 $151.00Based on the age of your child and your annual income, your weekly fee will be $166.00Based on the age of your child and your annual income, your weekly fee will be $182.00Based on the age of your child and your annual income, your weekly fee will be $198.00Based on the age of your child and your annual income, your weekly fee will be $213.00Based on the age of your child and your annual income, your weekly fee will be $229.00Based on the age of your child and your annual income, your weekly fee will be $244.00Based on the age of your child and your annual income, your weekly fee will be $265.00Based on the age of your child and your annual income, your weekly fee will be $97.00Based on the age of your child and your annual income, your weekly fee will be $103.00Based on the age of your child and your annual income, your weekly fee will be $108.00Based on the age of your child and your annual income, your weekly fee will be $113.00Based on the age of your child and your annual income, your weekly fee will be $120.00Based on the age of your child and your annual income, your weekly fee will be $125.00Based on the age of your child and your annual income, your weekly fee will be $136.00Based on the age of your child and your annual income, your weekly fee will be $154.00Based on the age of your child and your annual income, your weekly fee will be $166.00Based on the age of your child and your annual income, your weekly fee will be $182.00Based on the age of your child and your annual income, your weekly fee will be $203.00Based on the age of your child and your annual income, your weekly fee will be $88.00Based on the age of your child and your annual income, your weekly fee will be $94.00Based on the age of your child and your annual income, your weekly fee will be $100.00Based on the age of your child and your annual income, your weekly fee will be $106.00Based on the age of your child and your annual income, your weekly fee will be $112.00Based on the age of your child and your annual income, your weekly fee will be $117.00Based on the age of your child and your annual income, your weekly fee will be $129.00Based on the age of your child and your annual income, your weekly fee will be $147.00Based on the age of your child and your annual income, your weekly fee will be $156.00Based on the age of your child and your annual income, your weekly fee will be $172.00Based on the age of your child and your annual income, your weekly fee will be $192.00Please select all that apply: (leave blank if none apply) Eligible for SNAP Eligible for D.H.S Child Care Certificate Eligible for TANF Signature* 40501