Application form child day care (0 till 4 years old)

APPLICATION FORM – CHILD DAY CARE (0 – 4)
Information about your child
First name: _________________________________
Last name: __________________________________ gender: O boy
O girl
(Expected) date of birth: ____________________
BSN (social security number)
Is a child in your family currently attending KOK kinderopvang?
Does your child need special care?
Would you like us to contact you to do a tour?
Preference
0 Full day care
(0 - 4 years)
0 Half day care
(0 - 4 years)
0 Flexible day care
(0 - 4 years)
0 Pre school
(2,5 - 4 years)
0 Day care for a child with special needs
(0 - 4 years)
Preferred day care centre
0 KC De Bomschuit, de Krom 101, Katwijk
0 KC Het Zandkasteel, Zeehosplein 17, Katwijk
0 KC Binnenste Buiten, P. Oosterleestraat 1,Valkenburg ZH
0 KC Spelevaren, Luit Katlaan 7, Valkenburg ZH
0 KC Kinderpaleis, Louise de Colignylaan 59, Katwijk
0 KC Belle Fleur, Burgemeester Koomansplein 1, Rijnsburg
Preferred day(s) / day part(s)
Monday
0 morning
Tuesday
0 morning
Wednesday
0 morning
Thursday
0 morning
Friday
0 morning
0
0
0
0
0
afternoon
afternoon
afternoon
afternoon
afternoon
Opening hours: 07:30 – 18:30
Starting date:
Day: ______ Month: ________________ Year: _______
BB/rev.1/ 14
O yes O no
O yes O no
O yes O no
Information about the parent(s)
Last name/Initials, mrs./mr.
Last name/Initials, mrs./mr.
Parent 1 _________________________________
Parent 2 _____________________________
Date of birth ____________________________ *
Date of birth _______________________*
BSN:*
BSN:*
Address _________________________________
Postal code ______________________________
City ____________________________
Home phone number _____________________
Mobile phone number _________________________ Mobile phone number ___________________
Work phone number __________________________
Work phone number ____________________
Emergency phone number ________________________
E-mail address ____________________________________________________________________
You will receive a monthly invoice at this e-mail address.
Doctor’s name _______________________________
To advertise effectively we would like to know how you found us:
_____________________________________________________________________
Comments ______________________________________________________________________
_________________________________________________________________________________
Date:
Signature:
BB/rev.1/ 14

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