Sports Club Child Care Enrollment Application Form Page 2
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2• Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form
680 or 681) within 30 days of enrollment. (PRE K/ VPK ONLY)
• Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility
Brochure, "Know Your Child Care Facility” (CF/PI 175-24), or Section 65C-20.11(2)(c)(1), F.A.C., requires that
parent(s) receive a copy of the family day care home brochure, “Selecting A Family Day Care Home Provider” (CF/PI
175-28).
• Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by
the child care facility, or Section 65C-20.010(6)(c), F.A.C., requires that a written a copy of the family day care
provider’s discipline policy be available for review by the parent(s).
* During the 2009 legislative session, a new law was passed that requires child care facilities, family day care homes
and large family child care homes provide parents with information detailing the causes, symptoms, and transmission of
the influenza virus (the flu) every year during August and September. My signature below verifies receipt of the
brochure on Influenza Virus, The Flu, A Guide to Parents:
Your signature below indicates that you have received the above items and that the information on this
enrollment form is complete and accurate.
_________________________________________________
_____________________
Signature of Parent/Guardian
Date
I give permission to Sports Camp Inc. DBA Sports CLUB (SC) to record the appearance, physical likeness and/or voice
on videotape, on film, or digital video disk, and/or take photographs of the appearance of my child, and to release these
images to the news media, use for posting on the SC Internet Website, use in internal or external publications, or use in
any other manner deemed appropriate by SC to publicize SC, its programs and activities, or to otherwise fulfill the
mission of SC.
I acknowledge that SC is the sole owner of all rights in, and to, this visual and/or sound production and/or photograph(s)
and the recordings, thereof, and that it has the right to use or reproduce the resulting images and/or sound as often as it
finds necessary. The video and/or photographs may be used indefinitely by television, radio, newspapers, magazines,
newsletters, brochures, Internet, or in other media once released. SC has the right, among other things, to edit and/or
otherwise alter the visual or sound recording, or photographs, as needed. I understand I will receive no compensation for
the appearance of the above-named person or for participation in said productions. I agree to hold SC, its employees, its
board members, and other parties harmless against claim, liability, loss, or damage caused by, or arising from, my
child’s participation in this production.
By signing below I acknowledge and agree with the statement above:
_________________________________________________
_____________________
Signature of Parent/Guardian
Date
I do not want my child photographed or videotaped.
I hereby acknowledge that participation in Sports Camp / Sports CLUB and related activities is at the sole discretion and
judgment of the parent or guardian and involves the possible risk of personal injury. I, on behalf of my child, hereby
assume all such risk. I hereby release and agree to hold harmless Sports Camp / Sports C.L.U.B., owners, directors,
students and employees from all claims, actions, damages and liabilities for personal injury or damage relating to, or
arising out of any Sports Camp activity except where the injury or damage is caused by the gross negligence of Sports
Camp / Sports C.L.U.B. employees.
Signature (Parent or Guardian): ____________________________________________________________
Child’s Name: _________________________________________________________ Date: _____________
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