Online Application Packet

Kidz College

Child Care Application for Enrollment

Date of Enrollment*

1st Child's Name*

First Middle Last

Nickname

Date of Birth*

Sex*

Boy

Girl

2nd Child's Name

First Middle Last

Date of Birth

Sex

Boy

Girl

Address*

Street Address City ZIP / Postal Code

Primary Hours of Care From:*

:

What is the primary start and end time needed for your child'd care?

Primary Hours of Care To:*

:

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*

Employer*

Employer Address*

Street Address City ZIP Code

Employer Address*

Street Address City ZIP Code

Work Phone*

Cell Phone*

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

Phone

Hospital 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*

Signature of Parent/Guardian

Date

Signature of Parent/Guardian*

Date*

Kidz College

Parent Release Form for Media Recording

Child'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*

Kidz College

Emergency Contact and Medical Information for a Child

Child's Name*

First Last

Date of Birth*

Sex*

Male

Female

Parent’s/Guardian’s Name*

First Last

Parent’s/Guardian’s Name

First Last

Home Phone*

Work Phone

Home Phone

Work Phone

Address*

Street Address City ZIP Code

Address

Street Address City ZIP Code

Alternative Emergency Contacts

Primary Emergency Contact*

First Last

Secondary Emergency Contact

First Last

Home Phone*

Work Phone*

Home Phone

Work Phone

Primary Contact Address*

Street Address City ZIP Code

Secondary Contact Address

Street Address City ZIP Code

Medical Information

Hospital/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*

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*

Witness Signature*

Date*

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*

Phone

This field is for validation purposes and should be left unchanged.

Customer Login

Customer Register

Online Application Packet

Kidz College

Child Care Application for Enrollment

Family Information:

Medical Information:

Contacts:

Kidz College

Parent Release Form for Media Recording

Kidz College

Emergency Contact and Medical Information for a Child

Alternative Emergency Contacts

Medical Information