State of Florida Department of Children and Families Student Information:

State of Florida Department of Children and Families
Child Care Application for Enrollment
Student Information:
Date of Birth: __________Sex:______
Date of Enrollment: _______________
Full Name: ______________________________________________________
Last
First
Middle
Nickname
Typical Hours of Care: From ______________ To ________________
Family Information :
Child Lives With: ____________________________________
Phone # that I prefer to be called on during the day : _____________________________
Mother’s Name: ___________________
Father’s Name:_____________________
Address: ________________________
Address: __________________________
City/State/Zip: ____________________
City/State/zip: ______________________
Home Phone: ____________________
Home Phone: ______________________
Employer: _______________________
Employer: _________________________
Work Phone: _____________________
Work Phone: _______________________
Cell Phone: ______________________
Cell 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.
Doctor: ______________________ Address: ________________ Phone: _____________
Dentist: ______________________ Address: ________________ Phone: ____________
Hospital Preference: _______________________________________________________
Allergies: _______________________________________________________________
Please list any special medical or dietary needs, or other areas of concern:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other Helpful Information:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Primary Language Spoken at Home: __________________________________________
Contacts:
My 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
Phone #1
Phone #2
________________________________________________________________________
Name
Address
Phone #1
Phone #2
________________________________________________________________________
Name
Address
Phone #1
Phone #2
_______________________________________________________________________
Name
Address
Phone #1
Phone #2
Rule 65C-22.006(2), F.S.C., and Section 65C-20. .011(1), F.A.C. require a current physical examination (DH
3040) and immunization record (DH680 or DH681) 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)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
To Whom it May Concern:
I hereby give my consent to any emergency facility and physician to administer necessary
treatment to my child_____________________________________.
In the event of an emergency and/or which time I cannot be reached, I give consent to
transport by ambulance if the situation warrants it.
_____________________________________
Physician’s Name
____________________
Phone Number
________________________________________________________________
Allergies
________________________________________________________________
Insurance Company covering child
___________________________________
Policy Number
__________________________
Expiration Date
__________________________
Signature of parent/guardian
__________________________
Date
State of Florida
County of Polk
On the__________ Day of_______________________, in the year___________
Before me came___________________________________________________
To be known to me personally or who has produced
Florida’s Driver’s license #___________________________________________
As identification and who did not take an oath.
___________________________________
Notary Public
___________________________________
Print Name
Parent Release Form for Media Recording
I, the undersigned, do hereby grant or deny permission to Precious Children in the
Highlands to use the image of my child, ________________________ as marked by my
selections(s) below. Such use includes the display, distribution, publication, transmission,
or otherwise use of photographs, images, and/or video taken of my child for use in
materials that include, but may not be limited to, printed materials such as brochures and
newsletters, videos, and digital images such as those on the Precious Children in the
Highlands web site.
□ Deny permission to use my child’s image at all.
□ Grant permission to use my child’s image in the following ways (mark all that apply):
o Limited usage: I want my child’s image used within the Precious Children
in the Highlands setting only (not in the larger community
o Limited usage: I want my child’s image used for educational materials only
(not marketing). This could be either within Precious Children in the
Highlands or in the larger community. One example of this could be videos
in parent education classes.
o Limited Usage: I want my child’s image used on printed materials only (no
digital or video use).
o Unrestricted usage: I give unrestricted permission for my child’s image to
be used in print, video and digital media. I agree that these images may be
used by Precious Children in the Highlands for a variety of purposes and
that these images may be used without further notifying me. I do understand
that the child’s last name will not be used in conjunction with any video or
digital images.
____________________________________________
Parent/guardian signature
________________
Date
Dear Parent,
We want to work hand in hand with you to provide the best possible care for your
child. Please feel free to answer any or all of the following questions in order for us to
better understand and meet the needs of your child. Thank you very much for your time.
1. What are your child’s favorite foods?
2. What calms your child down when he or she gets upset?
3. Is your child attached to a special toy, blanket, or stuffed animal?
4. Who are the special people in your child’s life?
5. What frightens your child?
6. Does your child have a special pet in the home?
7. Does your child have regular chores?
8. Do you have something special about your culture that you would like to share
with your child’s class?
9. What special holidays does your family celebrate?
10. Are there any holidays that your family chooses not to celebrate?
11. How does your family celebrate individual birthdays?
12. Are there any skills or talents someone in your family has that you would like to
share with the class?
Thank you so much for taking time to answer these questions.