2020-2021 Growing Learners After School Application

Family Information
Parent/Guardian Name *

Prefix First Name Last Name Suffix
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Cell Number *

Area Code Phone Number
Email *
example@example.com
Employer *
Work Number *

Area Code Phone Number
Parent/Guardian Name

Prefix First Name Last Name Suffix
Home Address

Street Address

Street Address Line 2

City State

Zip Code
Cell Number

Area Code Phone Number
Email
example@example.com
Employer
Work Number

Area Code Phone Number

Emergency Contacts

& Authorized Persons Allowed to Pick Up Your Child
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to Student *
Is this contact authorized to pick up your child? *

Yes No
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Student
Is this contact authorized to pick up your child?

Yes No
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Student
Is this contact authorized to pick up your child?

Yes No
Is there any person NOT allowed to pick up your child?
Name

First Name Last Name
Relationship to Student
Race, Height, Weight, and any Comments
Photo of Person NOT allowed to pick up your child.

Browse Files
File must be smaller than 10 MB. Cancel of
Name

First Name Last Name
Relationship to Student
Race, Height, Weight, and any Comments
Photo of Person NOT allowed to pick up your child.

Browse Files
File must be smaller than 10 MB. Cancel of

Medical Information
In case of emergency, Growing Learners staff will call 911 and contact the parent/legal guardian and/or emergency contacts listed within this application.

Please provide Growing Learners with medical personnel contact information to obtain emergency medical care if warranted.
Insurance Company
Policy/Group Number
Name policy is under

First Name Last Name
Phone Number

Area Code Phone Number
Hospital Preference
List any Health Restrictions (Allergies, Vision, Hearing, Etc.) *
List any Diet Restrictions (Allergies-Gluten, Dairy, Nuts, Etc.) *
Does your child take any medication? *

Yes No
If yes, please list.
Actions to take if medical care is needed. *
Are there any unusual factors in the child's life which the teacher or staff should be aware of? *
I give consent to Growing Learners staff to apply provided sunscreen and/or bug spray for my child. *

Sunscreen only; please initial below. Bug Spray only; please initial below. Both; please initial below. None
Initials

Privacy Rights & Authorizations
PRIVACY RIGHTS
I understand that pictures, and/or video will be taken during program activities/events. I give permission to Growing Learners Summer Program and/or its Community Partners to use said photos/videos of my student, family and myself to be used in educational, promotional or informational materials or press media for positive public relations purposes. *

Yes; please initial below. No
Initials
I give consent to Growing Learners Summer Program to contact me via my email provided within this application for updates pertaining to my child and program activities. (Growing Learners Summer Program will not share your email address to third parties without your consent.) *

Yes; please initial below. No
Initials
PERMISSION TO EVALUATE PROGRAMS AND TRACK STUDENT PROGRESS
I give permission for the Growing Learners staff to review my child's school data (test scores, attendance, and other performance indices), for the purpose of providing targeted support, academic instruction and assessing the effectiveness of the Growing Learners Summer Program. I also give permission for the Growing Learners staff to monitor my child's progress and to require my child to complete evaluation surveys for the purpose of determining program effectiveness. *

Yes; please initial below. No
Initials
FLORIDA CHILD CARE STANDARDS AND STATUTES
- 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)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility.

Growing Learners

Family Information

Emergency Contacts

Medical Information

Privacy Rights & Authorizations

Program Expecations