Registration Form

Office Use
Start Date:_______ Term Date:________
Full Time
Part Time
Tuition Amount:$___________________
Comments:__________________________
___________________________________
_________
Registration Form
Child Information
Name: ______________________________________
Date of Birth: ____________________________
Address: ________________________________________________________________________________
Family Information
Mother’s Name: ______________________________
Father’s Name: __________________________
Home Phone: _________________________________ Home Phone: ____________________________
Work Phone: _________________________________
Work Phone: _____________________________
Cell Phone: __________________________________
Cell Phone: ______________________________
Driver’s License: _____________________________
Driver’s License: _________________________
Social Security Number: ______________________ Social Security Number:__________________
Email: _______________________________________
Email: ___________________________________
Emergency Contacts
Child may be released only to the custodial parent, legal guardian or persons listed below with
picture identification. If the custodial parent or legal guardian can not be reached the following
persons will be contacted and are authorized to remove the child from the facility in case of
illness, accident or emergency.
Name: _______________________ Relationship: __________________ Phone #:___________________
Name: _______________________ Relationship: __________________ Phone #:___________________
Name: _______________________ Relationship: __________________ Phone #:___________________
Special Needs or Allergies
____________________________________________________________________________________________
________________________________________________________________________________________
Florida Statues: I have read and understand the “Know Your Childcare Facility” brochure and the disciplinary
policies for this center. I also grant the center permission to transport my child for reasons of field trips, after
school programs or emergencies.
Collection Disclaimer: As parent or legal guardian you are responsible for all charges made and/or pending during
enrollment period and at the time of dismissal.
With my signature I assure that the information provided is true, correct and complete.
Parent Signature: _________________________________________ Date: ________________________
Authorization for Medical Treatment
The Employees of Kid City USA are committed to the provision of a safe environment for your
child. However, accidents may occur and children may become ill. Therefore, it may become
necessary to have your child medically treated.
In case of emergency, I _________________________________, parent or legal guardian of
____________________________________, do hold Kid City USA harmless of any injury/illness. I
understand that I am responsible for such treatment.
Insurance Company: __________________________________________________
Policy or Group Number: ______________________________________________
Parent/ Guardian Signature: ____________________________________
_____________________
Date:
State of Florida, County of __________________________________. The foregoing instrument was
acknowledge before me this _______________ day of ________________________, 20_____,
by ________________________________________, who is personally known to me or who has
produced ______________________________________________________ as identification.
_________________________________, Notary Public.
________________________________________________
Name of Notary Typed, Printed or Stamped
What Makes My Child Special
General Information
Name: _________________________________
DOB: _________________ Age: __________________
Previously my child was cared for:
_____ In a home daycare setting
_____ At another center
_____ Home with me
_____ By a relative, friend or neighbor
My child lives with: _____ Mom & Dad _____Mom
Any siblings? _____ Yes _____ No
_____ Dad _____ Other: _________________
Name and ages: _____________________________________
I would say that her/his day was relatively structured / unstructured. (Circle one)
In new situations, my child tends to: ______________________________________________________
What is the primary language at home? ______________________ Is she/he potty trained? Y / N
Special Needs / Allergies
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sleeping
Special sleep items (doll, blanket, etc) ____________________________________________________
Special hints to help at nap time: _________________________________________________________
Learning and Fun
Likes to do the following activities: _______________________________________________________
My child can’t part with (i.e. toy, stuffed animal) ___________________________________________
Others
Does your child has any other friends/acquaintances at this Center (Circle one) Yes / No
If yes, who are they? ____________________________________________________________________
I would describe my child as (shy, outgoing, a leader, strong willed, etc)___________________
Any other information that would help us best meet you and your child’s needs?
__________________________________________________________________________________________
Emergency Data
Child’s Name: ______________________________ Age: __________ Date of Birth: ________________
Address: _______________________________________________________________________________
Mother’s/Guardian’s Name: ______________________________________________________________
Cell #: _______________________ Work #: ______________________ Home # ______________________
Father’s/Guardian’s Name: _______________________________________________________________
Cell #: _______________________ Work #: ______________________ Home # ______________________
Emergency Contacts (When attempts to reach parents are unsuccessful and who may pick up child)
Other: _______________________________________ Relationship______________________________
Cell #: _______________________ Work #: ______________________ Home # ______________________
Other: _______________________________________ Relationship_______________________________
Cell #: _______________________ Work #: ______________________ Home # ______________________
Other: _______________________________________ Relationship______________________________
Cell #: _______________________ Work #: ______________________ Home # ______________________
Other: _______________________________________ Relationship_______________________________
Cell #: _______________________ Work #: ______________________ Home # ______________________
Special Needs / Allergies
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Insert Childs Picture
As parent/legal guardian, I give consent to have my child
receive first aid by Kid City USA’s staff, and, if
necessary, be transported to receive emergency care. I
understand that I will be responsible for all charges not
covered by insurance. I agree to review and update this
information whenever a change occurs and at least ones
a year.
___________________________________
____________
Parent’s signature
Date
___________________________________
____________
Director’s signature
Date
Child Care Nutrition and Physical Activity Policies
In an effort to provide the best possible nutrition and physical activity
environment for the children in our facility, we have adopted the following
policies. The administration and staff appreciate support from parents in
promoting the health of our children.
Nutrition
Fruits and Vegetables
 We offer fruit to children at least 2 times a day.
 We only offer fruit canned in its own juice (no syrups), fresh, or frozen.
 We offer vegetables to children at least 2 times a day. We only offer
vegetables steamed, boiled, or roasted.
Meats, Fats, and Grains
 We offer fried or pre-fried (frozen and breaded) meats (chicken nuggets) or
fish (fish sticks) once a week or less.
 We offer fried or pre-fried potatoes (French fries, tater tots, hash browns)
once a week or less.
 We offer high fat meats like sausages, bacon, hot dogs, or bologna once a
week or less.
 We offer beans or lean meats at least once a day.
 We offer high fiber, whole grain foods at least 2X a day.
 We offer sweets or salty foods less than once a week or never.
Beverages
 We make drinking water freely available so children can serve themselves
both inside and outdoor.
 We rarely offer sweetened drinks other that 100% juice.
 We serve only 1% or skim milk to children age 2 or older.
 We do not have soda or other vending machines on site.
Menus and Variety
 We have 3 week (or greater) cycle menu that allows for seasonal changes.
 Our menus include healthy items from a variety of cultures.
 Our menus include a combination of new and familiar foods.
Feeding Practices
 Our staff help children determine if they are full before removing their plate.
Our staff help children determine if they are still hungry before serving
additional food.
 Our staff gently and positively encourages children to try new or less
favorite food.
 We do not use food to encourage positive behavior.
Foods Offered Outside of Regular Meals and Snacks
 We provide and enforce written guidelines for healthier food brought in and
serve for holidays and celebrations.
 We celebrate holidays with mostly healthy foods or non-food treats.
 Our fundraising efforts consist of selling non-food items only.
Supporting Healthy Eating
 Our staff joins children at the table for meal times.
 We always serve meals family style.
 Our staff always consumes the same food and drink as the children.
 Our staff rarely eats less healthy foods in front of the children.
 We provide visible support for good nutrition in 2-to 5-year old classrooms
and common areas through use of posters, pictures, and displayed books.
 Our staff often talks informally with the children about trying and enjoying
healthy foods.

Nutrition Education for Staff, Children, and Parents
 We provide training opportunities for staff on nutrition (other than food
safety and food programs guidelines) 2X per year or more.
 We provide teacher-directed nutrition education to the children, through a
standardized curriculum, 1X per week or more.
 We provide nutrition education to parents 2X per year or more.
Physical Activity
Active Play and Inactive Time
 We provide at least 120 minutes of active play to all children each day.
 We provide opportunities for outdoor play 2 or more times per day.
 We ensure that children are rarely seated for periods of more than 30
minutes. We do not withhold active play time for children who misbehave.
Instead, we provide additional active play time for good behavior.
 We rarely show television and videos.
___________________________________________
Parent Signature
_____________________
Date
Audio/Video/Photo Form
I ______________________________ the parent or legal guardian of ____________________________
give my permission to Kid City USA, to tape record, video record or photograph my child for
educational, security and/or publicity purposes while participating in the regular activities of
this program.
Yes _________
No _________
Signature: ________________________________________
Date: ______________________________
Uniform Order Form
Child’s Name: ________________________ Parents Name:________________________
Order Date:___________________________
Color
Black
Yellow
Amount
2T
2T
Please
3T
3T
Circle
4T
4T
Size
5
5
S
S
M
M
Cost: 5 for $65.00 or $15.00 each
Paid:___________ Date:_________ Circle: Check
Parent’s Signature: _____________________________
Cash
Credit Card
Date: ______________
Permission for Food -related Activities and Special Occasion
Pursuant to 65C-22.005(1)(c)2.,F.A.C., licensed child care must obtain written permission from
parents/ guardians regarding a child’s participation in food related activities. These activities
include such things as: classroom cooking projects, gardening, school wide celebrations, and
birthdays.
I ___________________________ give/decline permission for my child _________________________
(Parent or Guardian)
(Circle One)
(child’s name)
to participate in food related activities and special occasions wherein food is
consumed.
Please provide the following information:
____ My child DOES NOT have a food allergy or dietary restriction. He or she may
participate in activities.
____ My child DOES NOT have a food allergy or dietary restriction. He or she may
not participate in activities.
____ My child DOES have a food allergy or dietary restriction. He or she may
participate in activities, but may not eat or handle the following items (please list
below):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________
____ My child DOES have a food allergy or dietary restriction. He or she may not
participate in activities.
_____________________________________________________________________________
I understand that is my responsibility to update this form in the event that my
decision for permission changes. I agree that this form will remain in effect during
the term of my child’s enrollment.
______________________________________
(Parent or Guardian)
_______________________
(Date)
Student File Check List
Name: ________________________________________________________
Start Date: _____________________________
DOB: ________________
Class: ________________
______ Registration Form
______ Authorization for Medical Treatment (Notarized)
______ Audio/Video/Photo Release Form
______ Copy of Parents Identification
______ Influenza Information
______ Parent Handbook Receipt
______ Permission for Food-related Activities and Special Occasion
Food Consumption
______ Child Care Nutrition and Physical Activity Policies
______ What Makes My Child Special
______ Emergency Contact Form
______ Food Program Forms
______ Shot Record
______ Physical Form
______ 4C / ELC Voucher
Form
Immunization
Physical
4C
Exp. Date
Exp. Date
Exp. Date
Exp. Date
Exp. Date
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