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Student Informatoin Page
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Parent/Guardian Information page
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Emergency Contact Page
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Healthcare Page
Kate's Korner Child Care
Registration Form
Multiple choiceKate's Korner offers FREE Distance Learning to those families who qualify, please click each that your student qualifies:
*DHA: Durham Housing Authority
Free or Reduced Lunch
Houseless
Referral from CPS Agency
Referral from school social worker
Essential Worker
Lost Employment due to COVID
Living in a DHA Community
Which DHA community does your student live?
Please select
My student doesn't live in a DHA community
McDougald Terrace Community
Cornwallis Road Community
Hoover Road Community
Oxford Manor Community
Another DHA Community
Please select
Date Application Complete
04
/
01
/
2025
Date of Enrollment
MM
/
DD
/
YYYY
Child's name
Birthdate
MM
/
DD
/
YYYY
Address
Name of Elementary School
Please Indicate Grade Level
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
In an effort to serve all of your child(ren)s academic needs, please share any accommodations needed to ensure success for your student.
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Student Informatoin Page
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Parent/Guardian Information page
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Emergency Contact Page
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Healthcare Page
Kate's Korner Child Care
Registration Form
Mother/Guardian name
Address
Home Phone
Email
Cell Phone
Father/Guardian name
Address
Email
Copy of Email
Home Phone
Cell Phone
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Student Informatoin Page
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Parent/Guardian Information page
03
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Emergency Contact Page
04
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Healthcare Page
Kate's Korner Child Care
Registration Form
Contacts:
Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the Kate's Korner has permission to contact the following individuals.
Emergency Contact
Address
Home Phone
Cell Phone
Copy of Relationship
Emergency Contact
Copy of Address
Home Phone
Cell Phone
Relationship
Who does not have permission to pick up your child? If applicable
Name
Reason
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Student Informatoin Page
02
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Parent/Guardian Information page
03
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Emergency Contact Page
04
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Healthcare Page
Kate's Korner Child Care
Registration Form
Health Care Needs:
For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be filled out on site at Kate's Korner.
Date of child’s last physical exam
MM
/
DD
/
YYYY
Child’s health care provider
Phone
Address
Special health concerns
Yes
No
List any health care needs or concerns, symptoms of and type of responses for these health care needs or concerns
Allergies, including drug reactions
Yes
No
List any allergies and the symptoms and type of response required for allergic reactions
Regular medications
Yes
No
List any and all types of medication taken for health care needs
Please share any other information hat has a direct bearing on assuring safe medical treatment for your child
I as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.
Parent/guardian signature
Clear
Date
MM
/
DD
/
YYYY
I, as the operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medicaion without specific instructions from the physician or the child's parent, guardian, or full-time custodian.
Signature of Administrator
Clear
Date
MM
/
DD
/
YYYY
SEND REGISTRATION
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