Early Learning Centers of Plantation

CHILD ENROLLMENT INFORMATION
Child's Name*

First NameLast Name
Date of Enrollment*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
Sex*

MaleFemale
Preferred Name
Email*
example@example.com
Program*
Starting Classroom*
Elementary School
Referred By
Mother's Name*
Place of Employment*
Phone Number*

Area CodePhone Number
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Work Phone Number*

Area CodePhone Number
Father's Name*

First NameLast Name
Place of Employment*
Business Phone Number*

Area CodePhone Number
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address (if not same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Guardian Name*
Place of Employment*
Phone Number*

Area CodePhone Number
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address (if not same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Child's Physician*
May the center call another physician if unable to contact the above? *
Other persons to be notified in case of an illness or an accident?*
Name of 1st person to be notified in case of illness or accident*
Address of 1st person to be notified in case of illness or accident*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of 1st person to be notified in case of illness or accident*

Area CodePhone Number
Name of 2nd person to be notified in case of illness or accident
Address of 2nd person to be notified in case of illness or accident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number of 2nd person to be notified in case of illness or accident

Area CodePhone Number
Persons Permitted to Remove Child*
Name of 1st person permitted to remove child*
Address of 1st person permitted to remove child*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship with 1st person permitted to remove child*
Name of 2nd person permitted to remove child
Address of 2nd person permitted to remove child

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship with 2nd person permitted to remove child
Allergies*
If none, write NA
Diet Restrictions*
If none, write NA
Name of Person Enrolling Child*

First NameLast Name
Signature of Person Enrolling Child*

Clear
Date*

MonthDayYear
Date

CHILD RELEASE FORM
Child's Name*
Persons permitted to pick up child: Mother*

YesNo
Persons permitted to pick up child: Father*

YesNo
Persons permitted to pick up child:

Is there any court order restricting visitation of your child? If so, please list person or persons restricted from picking your child up:
Restricted Name 1*
If none, write NA
Restricted Relationship 1*
If none, write NA
Restricted Name 2
Restricted Relationship 2
Think of a code word of 4 to 6 letters and list below to be kept on file at Early Learning Centers of Broward. When you are unable to get your child, call the center to notify the director.

The director of the school will ask for this code word to verify your identity. Please keep this code word confidential. The authorized pick-up person will be asked to show a photo ID upon arrival at the center. The code word is utilized when you are calling Early Learning Centers of Broward to verify yourself with our office staff.

If necessary, you can change the code word and we will update our files to reflect your decision.
The Code Word to be used is:*
List persons permitted to pick up your child. Please keep their phone numbers current. For any spaces you do not want to fill, please write NA
Permitted Pickup Name 1*

First NameLast Name
Permitted Pickup Phone Number 1*

Area CodePhone Number
Permitted Pickup Name 2*

First NameLast Name
Permitted Pickup Phone Number 2*

Area CodePhone Number
Permitted Pickup Name 3*

First NameLast Name
Permitted Pickup Phone Number 3*

Area CodePhone Number
Parent Signature 1*

Clear
Parent Signature 2

Clear
Date (Parent)*

MonthDayYear
Date
Director's Signature

Clear
Date (Director)

MonthDayYear
Date

FINANCIAL AGREEMENT
We, the parents of (Child’s Name) understand and agree to abide by the following financial terms and procedures:

a) Tuition payment is due in advance on the Monday (and no later than Tuesday) for that week (after Friday the child will be disenrolled

b) Any checks returned by the bank will have a $50.00 (Fifty dollars) charge assessed and check writing privileges will be revoked.

c) Tuition payments made after Tuesday are considered late and a late fee of $30.00 (thirty dollars) will be assessed.

d) Tuition may be paid in advance for more than one week.

e) No tuition reimbursement or credit will be given for a child’s absence, except for pre-approved vacations.

f) Infants and toddlers are permitted to take one week vacation during the year. Each preschool child is permitted to take two weeks’ vacation during the year, (two weeks together or one week separate from the other The year runs from your start date of registration, not the calendar year. Vacations or sick time runs Monday – Friday in the same week. Vacation time can also be used if your child is sick. Any additional time required for a vacation or sickness will require a RESERVATION FEE, (1/2 the weekly tuition), in order to maintain your child’s enrollment.

g) Two week written notice must be given to the office, or tuition will be charged until the child is properly withdrawn. Children that have been withdrawn from the program will be required to pay the Registration Fee at the point of reenrollment.

h) Registration fees are non-refundable.

i) All delinquent accounts or returned checks will be submitted to the credit bureau and collection agency.
Child's Name*

First NameLast Name
Parent Signature 1*

Clear
Parent 1 (Mother)'s Social Security Number*
Parent 2 (Father)'s Social Security Number*
Parent Signature 2

Clear
Director's Signature:

Clear

ADMISSIONS AGREEMENT
I have read, understand, and agree to comply with all procedures, policies, and conditions set forth in the handbook presented by Early Learning Centers of Broward. The handbook is available here for your reading and records.
Parent Signature 1*

Clear
Date (Parent 1)*

MonthDayYear
Date
Parent Signature 2

Clear
Date (Parent 2)

MonthDayYear
Date
Director's Signature

Clear

ALTERNATE LUNCH SCHEDULE
Dear Parent:
In accordance with Broward County Child Care Ordinance, parents and the child care facility are urged to work cooperatively to assure that children are provided with nutritious snacks and meals where lunches are not provided by the facility.

Please read the following carefully, sign, and return as soon as possible.

The facility agrees to provide a nutritious:

Breakfast

Mid-afternoon snack

Lunh
I have read the preceding and agree to meet the child's nutritional needs as defined above.
Parent's Signature*

Clear
Date (Parent)*

MonthDayYear
Date
Director's Signature

Clear
Date (Director)

MonthDayYear
Date

DISCIPLINARY POLICY
We, the parents of (Child’s Name) have read, understand and approve of the disciplinary procedures implemented at Early Learning Centers of Broward, as stated in the handbook.
Child's Name*

First NameLast Name
Parent's Signature*

Clear
Date*

MonthDayYear
Date

PHOTO RELEASE
The Staff at Early Learning Centers of Broward take many pictures of the children throughout the year to illustrate, for you and them, the many activities in which the children are engaged. The children’s names are not used when the pictures are displayed outside of Early Learning Centers of Broward. I hereby grant Early Learning Centers of Broward the right to take photographs of my child. I authorize Early Learning Centers of Broward, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I have read and understand the above:
Parent's Signature*

Clear
Date*

MonthDayYear
Date

MEDICATION
To insure medication prescribed by your child’s doctor is administered properly, Early Learning Centers of Broward asks that you follow these guidelines: Medication cannot be dispensed without a note from the child’s physician. Verify the amount, any reaction & other information/instructions pertaining to the medication and tell your child’s teacher. A medication must be kept out for us to administer, MUST have your child’s name clearly written on it. ALL medication must be kept out of the reach of children. Never mix medications with food or drinks in your child’s lunch.
Parent's Signature*

Clear
Date*

MonthDayYear
Date

MEDICAL RELEASE FORM
I hereby grant permission for my child, to use all the play equipment and participate in all activities of the center.
Child's Name*

First NameLast Name
Parent's Signature*

Clear
In the event of an extreme medical emergency situation, as deemed by the Director or Acting Director, paramedics or medical personnel will be notified IMMEDIATELY to escalate medical attention for my child. All efforts will be made to notify me (or the guardian), immediately as well.

Due to insurance regulations, injured or ill children must be transported to a hospital, when necessary, by paramedics or ambulance. They cannot be transported by school bus or school personnel.

Any expense for medical care or transportation involved with a medical emergency, which is an inherent risk,

“WILL BE BORNE BY THE PARENT”.

The school will not be responsible for anything that may happen as a result of false information given at the time of enrollment.
Child's Name*

First NameLast Name
Allergy 1*
If none, write NA
Allergy 2
Allergy 3
Medical Condition 1*
If none, write NA
Medical Condition 2
Medical Condition 3
Hospitalization Insurance*
Name of Insurance Company*
Policy Number*
Group Number*
Hospital Preference*
Upon immediate need for medical attention for your child, the undersigned hereby gives consent to any X-ray examinations, anesthetics, medical or surgical diagnosis or treatment, and hospital care to be rendered to said minor upon the advice of a physician and/or surgeon licensed under the provisions of the Medical Practice Act.

The undersigned further authorizes the above named school to have the above named minor released into the custody of its representative, should hospital care no longer be required.

This form is to be used ONLY in extreme EMERGENCY.
Signature of Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

MEDICAL EXPENSE AGREEMENT
Due to the nature of our business there is a degree of inherent risk of injury to the children. As in any other school environment or place of activity where children are involved these injuries do take place.

Due to Insurance Regulations and a lawyer driven litigious society this Release is an Agreement that ALL EXPENSES as the result of injuries, medical care, transportation, or legal fee involved with medical care or a medical emergency “WILL BE THE RESPONSIBILITY AND BORNE BY THE PARENTS”.
Child's Name*

First NameLast Name
DATE*

MonthDayYear
Date
Signature of Parent or Legal Guardian*

Clear

PERMISSION FOR FOOD-RELATED ACTIVITIES & SPECIAL OCCASION FOOD CONSUMPTION FORM

Pursuant to 65C-22.005(1)(c)2., F.A.C., licensed child care facilities must obtain written permission from parents/guardians regarding a child's participation in food related activities. These activities include such things as: group cooking projects, gardening, program wide celebrations, birthdays and can include food items prepared in persons homes.
Please choose one of the following options for your child's permission to participate in food related activities.*

My child DOES NOT have a food allergy or dietary restriction. He or she MAY participate in activities.My child DOES NOT have a food allergy or dietary restriction. He or she MAY NOT participate in activities.My child DOES have a food allergy or dietary restriction. He or she MAY NOT participate in activities.My child DOES have a food allergy and/or dietary restriction. He or she may participate in activities, but not eat or handle the following items (Please list below)
Food allergy or dietary restriction (for those who selected 4th option)
I understand that is my responsibility to update this form in the event that my decision for permission changes. I agree that this form will remain in effect during the term of my child's enrollment.
Child's Name*

First NameLast Name
Guardian Name*

First NameLast Name
Guardian Signature*

Clear
Date*

MonthDayYear
Date

Outdoor Play/ Closed Shoes
Welcome to the Early Learning Center. We believe that outdoor time is just as important as indoor time for young children. At the Early Learning Center, the children spend a minimum of 45 minutes in the afternoon doing large muscle activitiy, running, climbing, stretching, and exercising. These are just a few of the many activities we have planned for your child.

Please make sure your child is wearing closed toed shoes everyday so they may safely participate in these fun activities that also promote socialization, teamwork, and physical fitness. The children also use the playground equipment, which is safer when children are wearing proper shoes.

Thank you.
Child's Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Immunization/Vaccination Policy
The Early Learning Centers of Broward will accept children who have not been vaccinated only if parents submit the exemption form from the local Health Department prior to the start of care at our facility
Child's Name*

First NameLast Name
Guardian Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Arrival Time
Parents/Guardians,

Please be advised all children must be in the building no later than 8:45am. If you have an appointment and cannot be here by 8:45 am, please call the school and let us know.

Breakfast is from 7:00am until 8:30am. If your child needs breakfast after that time, you must provide it and stay with your child until they finish.

All children must be in their classrooms by 9:00am, the start of their day.

Just a reminder we close at 6:00pm - pick-up after this time will be charged $1.00 per minute per child, no exceptions

Thank you for your cooperation.
Child's Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Child Emergency Contact Form
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Parent's Name*

First NameLast Name
Personal Contact Info
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Emergency Contact Info:
Contact 1 Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Employer*
Name of 2nd Emergency Contact*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Employer*
Preferred Hospital*
Insurance*
Doctor Name*
Doctor's Phone Number*

Area CodePhone Number
Dentist Name*
Dentist's Phone Number*

Area CodePhone Number
Parent Signature*

Clear
Date*

MonthDayYear
Date

Safe Sleep Policy

Sudden Infant Death Syndrome is the unexpected death of a seemingly healthy baby for whom no cause of death can be determined. In the belief that proactive steps can be taken to lower the risk of SIDS in our setting and so that childcare professionals can keep babies safer while they sleep, we practice the following safe sleep policies:
1. Infants less than one year will be placed on their backs
2. Infants that roll over will be repositioned on their backs
3. Sleeping infants are supervised
4. Steps will be taken to keep the room cool
5. Lighting will remain on
6. One infant to a crib
7. No blankets will be placed in the cribs
8. Tight fitting sheets will be used
9. No toys or mobiles will be allowed in our around the cribs
10. To promote health development, infants who are awake will be given supervised "tummy time" for exercise and for play
11. A written copy of this infant/toddler safe sleep policy will be provided to infant room parents/guardians prior to enrollment.
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date

Permission to Access Child's File
I, the parent/guardian of my child, give the Early Learning Centers of Broward consent to access my child's personal file to obtain any and all information within the file.
Child's Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Agree to the School Handbook
I, the parent/guardian of my child, affirm that I have read and agree to adhere to the policies and requirements laid out in the child handbook, which will be provided to me by the Early Learning Centers of Broward. The handbook is available here for your reading and records.
Child's Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Discipline Policy
The Early Learning Centers of Broward are committed to providing a safe and nurturing environment conductive to learning and growth for all our children. We strive to ensure that each child is set up for success regardless of their developmental level. Children will never be embarrassed or humiliated during the discipline process, nor will they be compared to other children. The following procedures are implemented in our facility to correct and limit behavioral interruptions:

Children will be redirected to an alternative activity.

Explaining to the child that the behavior is unacceptable and model correct behavior. For example, rather than using physical means, we will train the child to express their emotions verbally and demonstrate proper play with classroom materials.

Short term restrictions of the use of specific play materials may be required if the child repeatedly utilizes said material to harm other children.

In the event that a child’s behavior becomes an extreme disruption to the classroom environment and none of the above procedures have corrected the behavior, the parent will be contacted to pick up the child for the reminder of the day; any additional days for suspension can be applied if deemed necessary.

Corporal punishment will not be used under any circumstances. Our discipline policy is intended to be constructive, non-humiliating and will never be physical in nature.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Expulsion Policy
Every effort will be made to keep your child in our care. However, the Early Learning Centers of Broward reserves the right to cancel enrollment for the following reasons:
- Nonpayment of tuition
- Failure to adhere to policies
- The child’s needs exceed the capabilities of our center
- Child’s behavior endangers the safety and wellbeing of other children and or staff
- Parent/Guardian’s behavior and or actions threatens other children, parents, or staff
Child's Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Influenza Information

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, which can be found at the following website here
Child's Name*

First NameLast Name
Guardian Name*

First NameLast Name
Signature*

Clear
Date Received*

MonthDayYear
Date

Know Your Child Care Facility
This child care facility is licensed according to the minimum licensure standards included in section 402.305, Florida Statutes (F.S.) and Chapter 65C-22, Florida Administrative Code (F.A.C.)

License Number: 46727

License Issued On: 03/31/2020

License Expires On:03/31/2021

For more information Regarding the compliance history of this child care provider, please visit: www.myflorida.com/childcare
I have read and understood the information about licensing standards and quality child care found in the online brochure HERE
Signature*

Clear
Date*

MonthDayYear
Date

Safe Sleep for your Baby
Please read the following state form on safe sleep habits here

Confirm your receipt of the form by signing and dating below:
Signature*

Clear
Date*

MonthDayYear
Date

Distracted Adult Brochure

This is a state mandated form that all parents/guardians must receive and acknowledge receipt (https://www.myflfamilies.com/service-programs/child-care/docs/20190130/CFPI%20175-12,%20Distracted%20Adult%20Brochure.pdf )
Child's Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

CHILD ENROLLMENT INFORMATION

CHILD RELEASE FORM

FINANCIAL AGREEMENT

ADMISSIONS AGREEMENT

ALTERNATE LUNCH SCHEDULE

DISCIPLINARY POLICY

PHOTO RELEASE

MEDICATION

MEDICAL RELEASE FORM

MEDICAL EXPENSE AGREEMENT

PERMISSION FOR FOOD-RELATED ACTIVITIES & SPECIAL OCCASION FOOD CONSUMPTION FORM

Outdoor Play/ Closed Shoes

Immunization/Vaccination Policy

Arrival Time

Child Emergency Contact Form

Personal Contact Info

Emergency Contact Info:

Safe Sleep Policy

Permission to Access Child's File

Agree to the School Handbook

Discipline Policy

Expulsion Policy

Influenza Information

Know Your Child Care Facility

Safe Sleep for your Baby

Distracted Adult Brochure

SWIM CENTRAL WATER SAFETY EDUCATION QUESTIONNAIRE