FOR OFFICE USE: FT – MWF – T/TH

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)

Child's Address:

__________________________________________________________________________

Days of the Week in Care: M T W Th F

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Family Information:

Child Lives With: ___________________________________________________________

Mother's Name: ______________________
Address: ____________________________
Home Phone: ________________________
Cell Phone: __________________________

E-mail: _____________________________

Employer: ___________________________
Employer's Address:___________________
___________________
___________________
Work Phone: _________________________

Father's name: ______________________
Address: ____________________________
Home Phone: ________________________
Cell Phone: __________________________

E-mail: _____________________________

Employer: ___________________________
Employer's Address:___________________
___________________
___________________
Work Phone: _________________________

Custody: Mother ________Father ________ Both ________ Other ___________________

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REGISTRATION FORM

Registration opens March 1^st and is based on first come bases with completed application form, registration forms and $150 fee (non-refundable).

Child's Name: __________________________________________________________

Date of Birth: ___________________________________________________________

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:

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

__________________________________________________________________________

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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:

List Name/Address/Work#/Home# for each:

__________________________________________________________________________

Helpful Information About Child:

__________________________________________________________________________

Rule 65C-22.006(2), F.A.C., and Section 65C-20.011(1), F.A.C., require a current physical examination (DH3040) 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)(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

Information and Resources

1. Please list child's siblings (names and ages).

2. What is the Primary language spoken at home?

3. Do you have any skills or interests you would be willing to share with the children?

4. List any unique abilities/ways you might be able to contribute to the co-op. (e.g., gardening, accounting, maintenance, photography, computer skills etc.).

5. Please list possible ideas and/or contacts for potential field trips.

6. Do you have tools or equipment that you would be willing to share with the co-op (e.g., musical, indoor or outdoor tools, etc.)?

7. Do you have any resources for wholesale supplies or play equipment for indoor or outside use?

Florida Department of Children & Families Charlie Christ

District 11 Governor

Dade and Monroe Counties

http://www.state.fl.us Bob Butterworth

Secretary

"COMMITTED TO EXCELLENCE"

On_______________________________I,_____________________________________

Reviewed the pamphlet "CHILD ABUSE AND NEGLECT IN FLORIDA", I understand the legal responsibility to report such incidents to the Abuse Registry Toll Free Line 1-800-962-2873, which is in operation 24 hours per day.

Signature

_________________________________________

Child Care Licensing

401 N.W. 2^nd Avenue, Suite N-221, Miami Florida 33128

The Department of Children and Families is committed to working in partnership with local communities to ensure safety, well-being and self-sufficiency for the people we serve.

FIELD TRIP PERMISSION

I hereby give my child permission to go on field trips with the Bilingual Cooperative Preschool. I understand that my consent hereby authorizes my child to participate in field trips throughout the year, and that I will be notified of the day and destination of field trips in advance. I am aware that it is a parent's responsibility to attend the field trip with his/her child or make arrangements with another parent. A separate permission form needs to be completed if another parent will be responsible for my child.

If I do not wish my child to go on a field trip I will keep my child home that day and see that his teacher is notified. If the field trip is scheduled on a regular school day, I understand that the school will be closed.

Child's Name____________________________________________________________

Signature__________________________________________Date__________________