Registration

Kids Unlimited Registration Form

Thank you for your interest in Kids Unlimited Learning Center Inc!
Please fill out this registration form to be considered for enrollment. After this form is submitted, we will contact you to schedule an interview to meet your lovely family! We will discuss your childcare needs and our philosophy. Space is limited so don't delay!
Child's Name*

First NameMiddle NameLast Name
Child's Birth Date*

MonthDayYear
Child's Gender*
Which Center Are You Interested In?
Date Of Enrollment*

MonthDayYear
Date
Parent #1 Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent #2 Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary E-mail*
example@example.com
Parent #1 Primary Phone Number*
Parent #2 Primary Phone Number
Child Lives With:*
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*

First NameLast Name
Phone Number*
Doctor

First NameLast Name
Phone Number
Hospital Preference*
Please list allergies, special dietary needs or other areas of concern, *
Emergency Contacts

Emergency Contacts: 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:
Emergency Contact 1*

First NameLast Name
Phone Number*
Emergency Contact 2*

First NameLast Name
Phone Number*
HELPFUL INFORMATION ABOUT YOUR CHILD
• Sections 7.1 and 7.2 of the Child Care Facility Handbook require a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.

• Section 7.3 of the Child Care Facility Handbook requires that parents receive a copy of the Child Care Facility Brochure entitled “Know Your Child Care Facility” (CF/PI 175-24) [also available on-line at
https://eds.myflfamilies.com/DCFFormsInternet/Search/OpenDCFForm.aspx?FormId=860], or

• Section 8.3 of the Family Day Care Home/ Large Family Child Care Home Handbook requires that parent(s) receive a copy of the family day care home brochure entitled “Selecting A Family Day Care Home Provider” (CF/PI 175-28) [also available on-line at
https://eds.myflfamilies.com/DCFFormsInternet/Search/OpenDCFForm.aspx?FormId=841].

• Section 2.8 of the Child Care Facility Handbook requires that parents are notified in writing of the disciplinary and expulsion policies used by the child care facility, or

• Section 2.3 of the Family Day Care Home/ Large Family Child Care Home Handbook requires that parents are notified in writing of the disciplinary and expulsion policies used by the family day care provider.

Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate.

I hereby grant permission for the staff of this facility to have access to my child’s records.
__________________________________________ _____
Signature*

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Date*

MonthDayYear
Date
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Kids Unlimited Registration Form

Medical Information

Emergency Contacts