State of Florida Department of Children and Families
CHILD CARE APPLICATION FOR ENROLLMENT
Student Information:
Date of Birth: _________________
Sex: ____________________
Date of Enrolment: ____________
Full Name: _________________________________________________
Last –
First –
Middle –
Nickname
Child’s Address:
____________________________________________________________
Primary Hours of Care: From __________________ To _________________
Days of the Week in Care: M – T – W – Th – F – Sa – Su
Meals Typically Served While in Care: Br AM Snack Lunch PM Snack Sup Eve Snack
Family Information: Mother’s Name: Address:
Home Phone: Employer:
Address:
Work Phone: _________________________________
Work Phone: _________________________________
Custody: Mother ________ Father ________ Both ________ Other ________
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.
Child Lives With: ______________________________
Father’s Name:
Address:
Home Phone:
Employer: Address:
Doctor: Address: Doctor: Address: Dentist: Address: Hospital Preference
Please list allergies, special medical or dietary needs, or other areas of concern:
Phone: Phone: Phone:
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#
Home#
Name
Address
Work#
Home#
Name
Address
Work#
Home#
Name
Address
Work#
Home#
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”
Section 65C-22.006(4)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility.
By signing below, you verify that you have received the above items and that all information on this enrollment form is complete and accurate.
______________________________ _____________ _____________________
Signature of Parent / Guardian & Date