State Of Florida - Child Care Application For Enrollment Form
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2State of Florida
CHILD CARE APPLICATION FOR ENROLLMENT
Student Information:
Date of Birth: ______________ Sex: ____ Date of Enrollment ________________
Full Name: _____________________________________________________________________________________
Last
First
Middle
Nickname
Child's Physical 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:
Child Lives With: ______________________________
Mother's Name:
Father's Name:
Address:
Address:
Home Phone:
Home Phone:
Employer:
Employer:
Address:
Address:
Work Phone: _______________/Cell: _____________
Work Phone: _______________/Cell: ____________
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:
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#
Home#
Name
Address
Work#
Home#
Name
Address
Work#
Home#
Name
Address
Work#
Home#
June 2014
I-149-03
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