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Welcome to the 2024 - 2025 KITCA: Enrollment Form

Kids in the City Academy

KITCA Form

Child's First Name:

Child's Last Name:

Primary Parent/Guardian Name:

Address:

Parent/Guardian Cell with area code:

Parent/Guardian Work Phone and Ext. #

Parent/Guardian Email:

Child's DOB (MM/DD/YYY):

Age:

Gender:

Ethnicity:

School:

School Lunch Program:

School release information: I understand that Kids in the City Academy will work with the St. Lucie County Schools to obtain academic information, attendance and behavioral information to better serve my child’s academic needs. I give permission to access my child’s academic school records.

Yes

No

School Skyward ID #

Teacher's Name:

Current Grade:

List any allergies (if none, type NA):

List of daily medications (if none, type NA):

Does your child use/have any of the following:

Does your child receive any special accommodations at school? If so, please explain:

Field label

Mother/Guardian Name:

Place of Employment/Occupation

Cell Phone:

Father/Guardian Name:

Place of Employment/Occupation:

Cell Phone:

New Field:

Name:

Relationship:

Cell Phone (with area code):

Name:

Relationship:

Cell Phone (with area code):

Name:

Relationship:

Cell Phone (with area code):

List anyone who is NOT authorized to pick up your child:

How did you hear about us:

Household information

Primary language in household:

Is this a foster child?

Does this child receive funding from ELC (Early Learning Coalition)?

Check all those living in current household:

Total number of people under the age of 18?

Household income:

Single parent/guardian

Is the parent/guardian a member of the military:

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Contributions benefit Youth Empowered to Prosper, a not-for-profit, tax-exemption organization. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES AT www.FloridaConsumerHelp.com OR BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. Registration #CH58265.

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