Child Care Aplication For Enrollment
Child Care Aplication For Enrollment
Sex:
Student Information:
Date of Birth:
Full Name:
Nickname:
Child's Physical Address:
Primary Hours of Care:       From:
To:
Sunday  Monday  Tuesday  Wednesday  Thursday  Friday  Saturday
Days of the Week in Care:
Meals Typically Served While in Care:

Breakfast: A.M. Snack   Lunch: P.M. Snack   Sup: Eve Snack
Family Information:
Child Lives With:
Mother's Name:
Father's Name:
Address:
Address:
Home Phone:

Employer:

Address:

Work Phone:

Cell:
Home Phone:

Employer:

Address:

Work Phone:

Cell:
Medical Information:
I Hereby grant permission for the staff of this facility to contact the following medical personnel to
obtain emergency medical care if warranted.
Doctor:

Doctor:

Dentist:
Address:

Address:

Address:
Phone:

Phone:

Phone:
Hospital Preference:
Please list allergies, special medical or dietary needs, or other areas of concern:
Contact Information:
Child will be released only to the custodial parent or legal guardian and the persons listed below.
The following people will also be contacted and are authorized to remove the child from the facility
in case of illness, accident or emergency, if for some reason the custodial parent or legal guardian
cannot be reached:
Name:

Name:

Name:

Name:
Address:

Address:

Address:

Address:
Work/Home Ph:

Work/Home Ph:

Work/Home Ph:

Work/Home Ph:
Helpful information About the Child:
Section 65C-22.006(2), F.A.C., requires a current physicalexamination (Form3040)and immunization
record (Form 680 or 681) within 30 days of enrollment.

Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure,
"Know Your Child Care Facility" (CF/PI 175-24) or Section 65C-20.11 (2)(c)(1), F.A.C., requires that
parents receive a copy of the Family Day Care Home Brochure, "Selecting a Family Day Care Home
Provider" (CF/PI175-28).

Section 65C-22.006(3)(c)2, F.A.C.,requires that parents are notified in writing of the disciplinary
practices used by the Child Care facility, or Section 65C-20.010(6)(c), F.A.C., requires that a written
copy of the Family Day Care provider's discipline policy be available for review by the parent(s).
Your Signature below indicates that you have received the above itemsand that all information on
this enrollment form is complete and accurate.
(Will be Sign at the Day Care)
_______________________________________________
Signature of Parent/Guardian


_______________________________________________
Signature of Parent/Guardian


_______________________________________________
Signature of Parent/Guardian


_______________________________________________
Signature of Parent/Guardian


_______________________________________________
Signature of Parent/Guardian
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Date


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Date


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Date


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Date


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Date