Child'S Enrollment/information Form printable pdf download

Child’s Enrollment/Information Form

CHILD’S NAME: __________________________________________ PREFERRED NAME: ______________________________

DOB: _________________

DATE ENROLLED: _____________________

ADDRESS: ________________________________________________________________ ZIP CODE: ______________________

MOTHER’S NAME: ________________________________________ FATHER’S NAME: ________________________________

CUSTODIAL PARENT (CIRCLE ONE):

MOTHER

FATHER

JOINT

HOME/CELL PHONE: _____________________________________ HOME/CELL PHONE:_____________________________

EMPLOYER: _____________________________________________

EMPLOYER: ___________________________________

WORK PHONE: __________________________________________

WORK PHONE: _________________________________

LEGAL GUARDIAN NAME (if different than above):______________________________________________________________

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PERSONS AUTHORIZED TO REMOVE CHILD (LEGAL IDENTIFICATION REQUIRED)

1. ________________________________________________________________________________________________________

NAME

RELATIONSHIP

PHONE

2. _______________________________________________________________________________________________________

NAME

RELATIONSHIP

PHONE

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ALTERNATE NUTRITION PLAN AGREEMENT

I understand and approve the use of the Alternate Nutrition Plan. I agree to provide the following meals and/or snacks to meet my

child’s nutritional and dietary needs.

Indicate any Special Dietary Requirements:

___________________________________________________________________________________________________________

(Mark “P” for Parent Provides, or “C” for Center Provides)

________

______

_____

______

_______

Breakfast

A.M.

Noon

P.M.

Dinner

Evening

Formula

Snack

Meal

Snack

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HILLSBOROUGH COUNTY ORDINANCE requires that parents must receive a copy of the “KNOW YOUR CHILD CARE

FACILITY/FCCH BROCHURE”, information on the INFLUENZA (FLU) VIRUS, and the parents are notified in writing of the

“DISCIPLINARY PRACTICES” used by the Child Care Facility/FCCH. The parent’s/ legal guardian’s signature certifies receipt of

the Child Care Facility/FCCH brochure, influenza information, discipline policies, alternate nutrition plan agreement and that all the

information on this form is complete and accurate.

______________________________________________________

__________________________

Signature of Parent or Legal Guardian

Date

Distributed by the Hillsborough County Childcare Licensing Program