State of Florida Department of Children and Families Child Care Application for Enrollment Student Information: Date of Birth: __________Sex:______ Date of Enrollment: _______________ Full Name: ______________________________________________________ Last First Middle Nickname Typical Hours of Care: From ______________ To ________________ Family Information : Child Lives With: ____________________________________ Phone # that I prefer to be called on during the day : _____________________________ Mother’s Name: ___________________ Father’s Name:_____________________ Address: ________________________ Address: __________________________ City/State/Zip: ____________________ City/State/zip: ______________________ Home Phone: ____________________ Home Phone: ______________________ Employer: _______________________ Employer: _________________________ Work Phone: _____________________ Work Phone: _______________________ Cell Phone: ______________________ Cell Phone: ________________________ 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: _____________ Dentist: ______________________ Address: ________________ Phone: ____________ Hospital Preference: _______________________________________________________ Allergies: _______________________________________________________________ Please list any special medical or dietary needs, or other areas of concern: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Other Helpful Information: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Primary Language Spoken at Home: __________________________________________ Contacts: My 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 Phone #1 Phone #2 ________________________________________________________________________ Name Address Phone #1 Phone #2 ________________________________________________________________________ Name Address Phone #1 Phone #2 _______________________________________________________________________ Name Address Phone #1 Phone #2 Rule 65C-22.006(2), F.S.C., and Section 65C-20. .011(1), F.A.C. require a current physical examination (DH 3040) and immunization record (DH680 or DH681) 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” Section 65C-22.006(4)2 , F.A.C. , requires that parents are notified in writing of the disciplinary practices used by the child care facility. By signing below, you verify that you have received the above items and that all information on this enrollment form is complete and accurate. __________________________________________ ____________________________ Signature of Parent/Guardian Date To Whom it May Concern: I hereby give my consent to any emergency facility and physician to administer necessary treatment to my child_____________________________________. In the event of an emergency and/or which time I cannot be reached, I give consent to transport by ambulance if the situation warrants it. _____________________________________ Physician’s Name ____________________ Phone Number ________________________________________________________________ Allergies ________________________________________________________________ Insurance Company covering child ___________________________________ Policy Number __________________________ Expiration Date __________________________ Signature of parent/guardian __________________________ Date State of Florida County of Polk On the__________ Day of_______________________, in the year___________ Before me came___________________________________________________ To be known to me personally or who has produced Florida’s Driver’s license #___________________________________________ As identification and who did not take an oath. ___________________________________ Notary Public ___________________________________ Print Name Parent Release Form for Media Recording I, the undersigned, do hereby grant or deny permission to Precious Children in the Highlands to use the image of my child, ________________________ as marked by my selections(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 the Precious Children in the Highlands web site. □ 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): o Limited usage: I want my child’s image used within the Precious Children in the Highlands setting only (not in the larger community o Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within Precious Children in the Highlands or in the larger community. One example of this could be videos in parent education classes. o Limited Usage: I want my child’s image used on printed materials only (no digital or video use). o 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 Precious Children in the Highlands 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. ____________________________________________ Parent/guardian signature ________________ Date Dear Parent, We want to work hand in hand with you to provide the best possible care for your child. Please feel free to answer any or all of the following questions in order for us to better understand and meet the needs of your child. Thank you very much for your time. 1. What are your child’s favorite foods? 2. What calms your child down when he or she gets upset? 3. Is your child attached to a special toy, blanket, or stuffed animal? 4. Who are the special people in your child’s life? 5. What frightens your child? 6. Does your child have a special pet in the home? 7. Does your child have regular chores? 8. Do you have something special about your culture that you would like to share with your child’s class? 9. What special holidays does your family celebrate? 10. Are there any holidays that your family chooses not to celebrate? 11. How does your family celebrate individual birthdays? 12. Are there any skills or talents someone in your family has that you would like to share with the class? Thank you so much for taking time to answer these questions.