"*" indicates required fields Step 1 of 10 10% Kidz CollegeChild Care Application for EnrollmentDate of Enrollment* MM slash DD slash YYYY 1st Child's Name* First Middle Last Nickname Date of Birth* MM slash DD slash YYYY Sex* Boy Girl 2nd Child's Name First Middle Last Date of Birth MM slash DD slash YYYY Sex Boy Girl Address* Street Address City ZIP / Postal Code Primary Hours of Care From:* Hours : Minutes AM PM AM/PM What is the primary start and end time needed for your child'd care?Primary Hours of Care To:* Hours : Minutes AM PM AM/PM Family Information:Mother's Name* First Last Father's Name* First Last Address* Street Address City ZIP Code Address* Street Address City ZIP Code Home Phone*Home Phone*Employer* Employer* Employer Address* Street Address City ZIP Code Employer Address* Street Address City ZIP Code Work Phone*Work Phone*Cell Phone*Cell Phone*Email Address* Email Address* 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 PhoneHospital Preference* Please list all allergies, special medical, dietary needs or other areas of concerns:*Contacts:Child will be released only to the custodial parents, legal guardian and the person listed below. The following people will 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 or legal guardian cannot be reached:Name* First Last Relation* Home #*Work #*Cell #*Name First Last Relation Home #Work #Cell # Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate.Custody:* Mother Father Both Other Helpful Information About Child:* 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. 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). Section 65C-22.006(3)(c), F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility. 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* MM slash DD slash YYYY Signature of Parent/GuardianDate MM slash DD slash YYYY Consent* I have read and understand page 1 of 2 of the Discipline Policy. Consent* I have read and understand page 2 of 2 of the Discipline Policy.Signature of Parent/Guardian*Date* MM slash DD slash YYYY Kidz CollegeParent Release Form for Media RecordingChild's Name* I, the undersigned, do hereby grant or deny permission to Kidz College to use the image of my child as marked by my selection(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 Kidz College web site.Permissions* 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): Limited usage: I want my child’s image used within the Kidz College setting only (not in the larger community). Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within Kidz College’s or in the larger community. One example of this could be videos in parent education classes. Limited Usage: I want my child’s image used on printed materials only (no digital or video use). 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 Kidz College 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. Signature of Parent/Guardian*Date* MM slash DD slash YYYY Kidz CollegeEmergency Contact and Medical Information for a ChildChild's Name* First Last Date of Birth* MM slash DD slash YYYY Sex* Male Female Parent’s/Guardian’s Name* First Last Parent’s/Guardian’s Name First Last Home Phone*Work PhoneHome PhoneWork PhoneAddress* Street Address City ZIP Code Address Street Address City ZIP Code Alternative Emergency ContactsPrimary Emergency Contact* First Last Secondary Emergency Contact First Last Home Phone*Work Phone*Home PhoneWork PhonePrimary Contact Address* Street Address City ZIP Code Secondary Contact Address Street Address City ZIP Code Medical InformationHospital/Clinic Preference* Physician’s Name* First Last Physician's Phone Number*Insurance Company* Policy Number* Allergies/Special Health Considerations*I authorize all medical and surgical treatment, X ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.Parent’s/Guardian’s Signature*Date* MM slash DD slash YYYY I give permission for my child to go on field trips. I release Kidz College and individuals from liability in case of accident during activities related to Kidz College, as long as normal safety procedures have been taken.Parent’s/Guardian’s Signature*Date* MM slash DD slash YYYY Witness Signature*Date* MM slash DD slash YYYY 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 Name* First Last Child's Name* First Last Signature*Date Received* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.