Preschool Enrollment Application (Online)

Date of Birth*

Date

Sex*

Date of Enrollment*

Date

First Name*

Middle Name

Last Name*

Email*

example@example.com

Child's Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

From*

To*

Days of the Week in Care*

Child’s Lives With*

Mother’s Name*

Address*

Home Phone

Employer*

Address*

Work Phone*

Cell*

Father’s Name

Address

Home Phone

Employer

Address

Work Phone

Cell

Custody*

MotherFatherBothOther (specify)

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 Number*

Doctor

Address

Phone Number

Dentist

Address

Phone Number

Hospital Preference

Please list allergies, special medical or dietary needs, or other areas of concern*

Emergency Care Plan Instructions (if applicable)

Name*

Address*

Work Phone*

Home Phone*

Name*

Address*

Work Phone*

Home Phone*

Name

Address

Work Phone

Home Phone

Name

Address

Work Phone

Home Phone

Helpful Information About 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 of Parent/Guardian*

Date*

Date

State of Florida

CHILD CARE APPLICATION FOR ENROLLMENT

Student Information:

Primary Hours of Care

Family Information: