Kaleidoscope Play and Learn Interest Form
Caregiver Information
Caregiver's First Name
Caregiver's Last Name
Phone number
Email
County
ZIP Code
Ethnicity
Please select...
Hispanic or Latino
Non-Hispanic or Latino
Do not wish to respond
Race
Please select...
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
White
Multiracial or Mixed Race
Other Race
Do not wish to respond
Ethnicity and Race data is collected for our funders.
Child Information
Please complete for all children birth-5 years in the home:
How many children 5 and under will be attending?
Please select...
1
2
3
Child #1
Child's First Name
Child's Last Name
Are you the primary caregiver for this child?
Yes
No
Child's Gender
Male
Female
Prefer to not answer
Child's Date of Birth
Child's Age
Relationship to Child:
Birth Parent
Legal Guardian
Grandparent
Aunt/Uncle
Babysitter
Other
Is this child currently attending a childcare or preschool program?
Yes
No
Child #2
Child's First Name
Child's Last Name
Are you the primary caregiver for this child?
Yes
No
Child's Gender
Male
Female
Prefer to not answer
Child's Date of Birth
Child's Age
Relationship to Child:
Birth Parent
Legal Guardian
Grandparent
Aunt/Uncle
Babysitter
Other
Is this child currently attending a childcare or preschool program?
Yes
No
Child #3
Child's First Name
Child's Last Name
Are you the primary caregiver for this child?
Yes
No
Child's Gender
Male
Female
Prefer to not answer
Child's Date of Birth
Child's Age
Relationship to Child:
Birth Parent
Legal Guardian
Grandparent
Aunt/Uncle
Babysitter
Other
Is this child currently attending a childcare or preschool program?
Yes
No
Household Information
Are there any additional children in the home 6-12 years of age?
Yes
No
Is a primary caregiver or household member of the child active duty military?
Yes
No
Contact Information