Enrollment Form

Student Information

Date of Birth *

Sex

Male

Female

Date of Enrollment

Full Name (Last,First,Middle) *

Nickname

Child's Physical Address *

Primary Hours of Care:
From

To

Family Information

Child Lives With *

Mother's Name

Address

Home Phone

Employer

Work Phone

Address

Cell

Custody

Mother

Father

Both

Other

Father's Name

Address

Home Phone

Employer

Work Phone

Address

Cell

Medical Information

I hereby grant permission for the staff of this facility to contract the following medical personnel to obtain emergency medical care if warranted.

Doctor

Address

Phone

Dentist

Address

Phone

Hospital Preference

Please list allergies, special medical or dietary needs, or other areas of concern

Contacts:
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 *

Address *

Work Number

Home Number

Name

Address

Work Number

Home Number

Name

Address

Work Number

Home Number

Name

Address

Work Number

Home Number

Helpful information about child

Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) 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), R

Section 65C-20.11(2)(c)(1), F.A.C., requires that parent(s) receive a copy of the family day care home brochure, "Selecting A Family Day Care Home Provider" (CF/PI 175-28)
Sectioin 65c-22.006(3)(c)2., 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 a 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 items and that the information on this enrollment form is complete and accurate.

Name of Parent/Guardian *

Date

Br	AM Snack
Lunch	PM Snack
Sup	Eve Snack