Michelle International Application

Michelle's International Learning House Enrollment Application

Student Information
Participant’s Name:*

First NameLast Name
Emergency Code:*
Gender:*
Date of Birth:*

MonthDayYear
Date
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company:*
Policy#:*
Allergies:*

Parent Information

Parent#1
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Employer:*
Work#:*
Please enter a valid phone number.

Parent 2
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Email
example@example.com
Employer:
Work Phone Number
Please enter a valid phone number.
Does your child have an IEP?*

YesNo
If yes, would you be willing to share the IEP with us?*
Email
example@example.com
Other than parent(s) listed above, who may pick-up or be notified in case of illness, accident, or emergency?
Parent #1 permitted?*

YesNo
Parent #2 permitted?*

YesNo

Additional Emergency Pick-Up/Notification:
Name:*
Phone Number*
Please enter a valid phone number.
Relationship:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to add additional contact information?*

YesNo
Name:
Phone Number:
Please enter a valid phone number.
Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name:
Phone Number
Please enter a valid phone number.
Relationship:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician’s Name:
Physician’s #:
Please enter a valid phone number.
In the event I cannot be reached in an emergency, I give consent to Michelle’s International Learning House to select a physician, and for said physician to hospitalize, secure proper treatment for, and to order, inject and/or anesthesia and/or surgery for my child, as named above. I understand that Michelle’s International Learning House has secondary insurance coverage and that the personal insurance bears primary responsibility in case of accident. The undersigned expressly recognizes that there are risks in children’s play and I hereby grant permission for my child to use all of the playground equipment and to participate in all activities of the school.
Parent/GuardianSignature:*

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Today's Date*

MonthDayYear
Date

Photography Consent Form
Dear Parent/Guardian,

As the parent of a child(ren) at Michelle’s International Learning House, I agree to the following:

I understand that my child(ren) whose name(s) are listed below may be photographed at Michelle’s International Learning House during normal childcare hours, field trips, or activities. I understand that these photographs may be used in promoting child care services, either in print or on the internet.
Parent/Guardian Name:

First NameLast Name
Relationship to child:
Child 1 Name:
Child 2 Name:
Child 3 Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I give permission for my child(ren) to be photographed, or their images recorded for print or electronic use in promoting our child care services. I understand that it is my responsibility to update this form in the event that I

no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child’s enrollment. I understand that there will be no payment for me for my child’s participation.
Parent/Guardian Signature:

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Name:
Date:

MonthDayYear
Date

Food Participation Policy
Dear MILH Parents,

For our school to be in compliance with the Childcare Standards of the Florida AdministrativeCode, we must keep your written permission on file for your child to participate in any food-relatedactivities that occur at our school. To meet this requirement, we have complied a list of our food-related activities items are brought into the classroom as part of an instructional activity, dailyclassroom reward (candy or pretzels), or birthday/holiday (cupcakes, cookies, potato chips)celebration. Please read the list carefully and note the statements at the bottom of this permissionslip.
YES, my child, has permission to participate in food activities under the direction of the classroom teacher.NO, my child, may not participate in food activities under the direction of the classroom teacher.My child, may participate in food activities under the direction of the classroom teacher with the exception of the following foods (due to allergies or religious restrictions).
Child's name:
child name:
child's name . Please List restrictions here
Parent/Guardian signature:*

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Today's Date*

MonthDayYear
Date

Hours of Operation Acknowledgement

Michelle’s International Learning House hours of operation are from 7:30am to
5:30pm, Monday through Friday. We look forward to serving you during these
times. Thank you for choosing our preschool for your child’s early education
journey. We appreciate the trust you have placed in us.

I Parent's name acknowledge that I am aware of MILH hours.
Date: today's date.

Nutrition Form
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, amd sign.
The parent agrees to provide a nutritious:

Mid-morning snackLunchMid-afternoon snack
I have read the preceding and agree to meet the child’s nutritional needs as defined above.
Parent’s Signature*

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Today's date:*

MonthDayYear
Date

I parent/guardian name, parent/guardian ofchild's name, enrolled at Michelle International Learning House, Hereby grant permission for the preschool staff to access and review my child's educational; and personal records maintained by the preschool.
I understand these records may include, but are not limited to, academic assessments, progress reports, health records, and any other relevant information pertaining to my child's development at MILH.
This authorization is granted to felicitate effective communication and collaboration between parents/guardians and preschool staff, ensuring the best possible care and educational experience for my child. I trust that access to these records will be handled with confidentiality and used for solely for educational and administrative purposes.
I also understand this permission does not authorize release my child's information to any third parties without explicit consent, except, as required by law necessary for the operation by the preschool.
Parent/guardian name:
Signature

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Parent/Guardian Release of Information
Michelle’s International Learning House is held accountable by county, state and our accreditation agency. These entities do periodic inspections and may randomly choose children’s files for compliance checks. In addition, in the case of an emergency, Michelle’s House staff may need to access your child’s file in order to reach you. Please sign below granting permission to share your child’s information with these parties under these, or other necessary circumstances.
Child’s Name:*
Parent/Guardian's Name:*
Parent/GuardianSignature:*

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Date*

MonthDayYear
Date

Authorization For Emergency Treatment
Today’s Date*

MonthDayYear
Date
To Whom it may concern:
I hereby give consent to Hospital name* to administer necessary treatment of my child,name of child* in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
Name of Physician*
Phone*
Allergies of Child:*
Date of Last DPT or Tetanus*

MonthDayYear
Date
Insurance Company Covering Child*
Policy Number*
Signature of parent or legal guardian:*

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Expiration Date*

MonthDayYear
Date
Today's Date:*

MonthDayYear
Date

Discipline Policy
Parent/Guardian Signature:*

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Today's Date:*

MonthDayYear
Date

Parent/Guardian signature:*

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Today's date:*

MonthDayYear
Date

PHYSICAL ACTIVITY
I grant permission for my child to participate in physical activity at Michelle’s International Learning House. I am aware that my child will participate in at least forty (40) minutes of physical activity for every three hours in child care. I confirm that my child has no limitations that would prevent him/her from participating. In the event that weather does not allow for outdoor play my child’s teacher will utilize the inclement weather activities to ensure that the children participate in physical activity indoors.

Proper attire must be worn by children at all times. Rubber -soled, closed shoes must be worn. Clothing should not have long drawstrings or other tripping hazards, including overly long pants or skirts. Clothing should be comfortable and weather appropriate.

Children are scheduled for playground time both in the morning and the afternoon.
Child’s Name:*
Parent's Name:*
Signature*

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Today's Date:*

MonthDayYear
Date

Child's Name:*
Parent Name:*
Signature:*

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Date:*

MonthDayYear
Date
Parent Initial:*
Child's Name:*
Parent signature:*

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Today's Date:*

MonthDayYear
Date

Influenza
Durind the 2009 legislative session a new law was passed the requires child care facilities, family day care homesand large family homes provide parents with infromation detailing the cause, symptons, and transmission of the infuenza virus (the flu) every year during August and september.
Parent/ guardian name:
Child's name:*
Today's Date:*

MonthDayYear
Date
Signature:*

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Safe Sleep for your baby
Parent Initial:*
Should be Empty:

Michelle's International Learning House Enrollment Application

Parent Information

Parent 2

Additional Emergency Pick-Up/Notification:

Photography Consent Form

Food Participation Policy

Nutrition Form

Parent/Guardian Release of Information

Authorization For Emergency Treatment

Discipline Policy

PHYSICAL ACTIVITY

Influenza

Safe Sleep for your baby