Artz 4 Life Afterschool Program Application 2024-2025

CHILD'S ENROLLMENT RECORD
How many children are you applying for:*

123

CHILD 1
Child 1 First Name*
Middle Name*
Last Name*
Nickname
Date of Birth*

MonthDayYear
Date
Sex*
If you chose non-binary please specify gender at birth.*

MaleFemale
Primary Hours of Care
From*
To*
Days of Week in Care*
Child's 1 Physical Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Family Information:
Parent Email*
example@example.com
Child Lives With*
Parent 1's Full Name*
Is this address the same as the child 1's address?*

Yes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Parent 1 Employer*
Parent 1 Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone*
Cell Phone Number*
Please enter a valid phone number.
Parent 2's Full Name
Is this address the same as the child 1's address?

Yes
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Parent 2 Employer
Parent 2 Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Cell
Custody:*

MotherFatherBothOther
If Other, Full Name
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 children's center in case of illness, accident or emergency, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached:
Full Name*
Home Phone*
Cell Phone*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Full Name*
Home Phone*
Cell Phone*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Please use additional sheet of paper to list name, address and phone number of any other people authorized to pick the child up.

CONTINUED ON BACK

CHILD'S ENROLLMENT RECORD CHILD 1

(Back Page)
Medical Information (Name of Child)*
Childs Physician/Health Resource*
Telephone Number*
Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Preference*
Name of Dentist*
Telephone*
Dentist's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Meals typically served while in care:*

BreakfastAM SnackLunchPM SnackSupper
Emergency Care Plan instructions (if applicable)*
MISCELLANEOUS INFORMATION
List all known allergies*
List all identifying scars birthmarks skin discolorations*
Special medical or dietary needs of child*
List any areas of concern*
My signature below verifies that: I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached.

I have received a copy of the "Know Your Child's Children's Center" brochure. I was notified in writing of the disciplinary and expulsion policies used by the children's center. I was provided the food and nutrition policies used by the children's center.

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 Custodial Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

CONTINUED ON BACK

CHILD'S ENROLLMENT RECORD CHILD 2

(Back Page)
Medical Information:
Childs Physician/Health Resource*
Telephone Number*
Is this address the same as the child 1's Physician's address?*

Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Hospital Preference*
Name of Dentist*
Telephone*
Is this address the same as the child 1's Dentist's address?*

Yes
Dentist's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Meals typically served while in care:*

BreakfastAM SnackLunchPM SnackSupper
Emergency Care Plan instructions (if applicable)*
MISCELLANEOUS INFORMATION
List all known allergies*
List all identifying scars birthmarks skin discolorations*
Special medical or dietary needs of child*
List any area of concern*
My signature below verifies that: I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached.

I have received a copy of the "Know Your Child's Children's Center" brochure. I was notified in writing of the disciplinary and expulsion policies used by the children's center. I was provided the food and nutrition policies used by the children's center.

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 Custodial Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

CONTINUED ON BACK

CHILD'S ENROLLMENT RECORD CHILD 3

(Back Page)
Medical Information:
Childs Physician/Health Resource*
Telephone Number*
Is this address the same as the child 1's Physician's address?*

Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Hospital Preference*
Name of Dentist*
Telephone*
Is this address the same as the child 1's Dentist's address?*

Yes
Dentist's Address*

Street Address number apartment street

Street Address Line 2

CityState / Province

Postal / Zip Code
Meals typically served while in care:*

BreakfastAM SnackLunchPM SnackSupper
Emergency Care Plan instructions (if applicable)*
List all known allergies*
List all identifying scars birthmarks skin discolorations*
Special medical or dietary needs of child*
List any areas of concern*
Special medical or dietary needs of child

My signature below verifies that: I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached.

I have received a copy of the "Know Your Child's Children's Center" brochure. I was notified in writing of the disciplinary and expulsion policies used by the children's center. I was provided the food and nutrition policies used by the children's center.

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 Custodial Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

EMERGENCY MEDICAL RELEASE

CHILD 1

This form must contain only one child's name, and be the original notarized form. A new notarized form is required when there is a change in legal guardianship.
Childs Full Name*
Birthdate*

MonthDayYear
Date
Allergies*
Medicines Routinely Taken*
Name of Custodial Parents/Legal Guardians*
Is this address the same as the child 1's address?*

Yes
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Cell Telephone*
Work Telephone*
Family Physicians Name/Health Care Resource*
Is this address the same as the Physician's address?*

Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Hospital Preference:*
City*
Medical Insurance Company*
Policy#*
Expiration Date*

MonthDayYear
Date
Emergency Contact (if custodial parent/guardian cannot be reached)*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Cell Telephone*
Work Telephone*
Sign in the presence of the Notary.
I hereby give consent to any emergency facility and physician to administer necessary treatment to my child (child's full name)*, in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
STATE OF FLORIDA COUNTY OF*
The foregoing instrument was acknowledged before me this (Month) (Day) 20 (Year) by means of physical presence or online notarization by (First Name of Parent)* Parent Last Name* who is personally known to me or has produced (Type of Identification))* as identification.
Signed: FC-0003 Sample (2/19/20)

EMERGENCY MEDICAL RELEASE

CHILD 2

This form must contain only one child's name, and be the original notarized form. A new notarized form is required when there is a change in legal guardianship.
Childs Full Name*
Birthdate*

MonthDayYear
Date
Allergies*
Medicines Routinely Taken*
Name of Custodial Parents/Legal Guardians*
Is this address the same as the child 1's address?*

Yes
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Cell Telephone*
Work Telephone*
Family Physicians Name/Health Care Resource*
Is this address the same as the Physician's address?*

Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Telephone*
Hospital Preference*
City*
Medical Insurance Company*
Policy#*
Expiration Date*

MonthDayYear
Date
Emergency Contact (if custodial parent/guardian cannot be reached)*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Cell Telephone*
Work Telephone*
Sign in the presence of the Notary.
I hereby give consent to any emergency facility and physician to administer necessary treatment to my child (child's full name)*, in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
STATE OF FLORIDA COUNTY OF*
The foregoing instrument was acknowledged before me this (Month)* (Day)* (Year)* by means of physical presence or online notarization by (First Name of Parent)* (Last Name of Parent)* who is personally known to me or has produced (Type of Identification))* as identification.
Signed: FC-0003 Sample (2/19/20)

EMERGENCY MEDICAL RELEASE

CHILD 3

This form must contain only one child's name, and be the original notarized form. A new notarized form is required when there is a change in legal guardianship.
Childs Full Name*
Birthdate*

MonthDayYear
Date
Allergies*
Medicines Routinely Taken*
Name of Custodial Parents/Legal Guardians*
Is this address the same as the child 1's address?*

Yes
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Cell Telephone*
Work Telephone*
Family Physicians Name/Health Care Resource*
Is this address the same as the Physician's address?*

Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Telephone*
Hospital Preference*
City*
Medical Insurance Company*
Policy*
Expiration Date*

MonthDayYear
Date
Emergency Contact (if custodial parent/guardian cannot be reached)*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Cell Telephone*
Work Telephone*
Sign in the presence of the Notary.
I hereby give consent to any emergency facility and physician to administer necessary treatment to my child (child's full name)*, in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
STATE OF FLORIDA COUNTY OF*
The foregoing instrument was acknowledged before me this (Month)* (Day)* (Year)* by means of physical presence or online notarization by (First Name of Parent)* (Last Name of Parent)* who is personally known to me or has produced (Type of Identification))* as identification.
Signed: FC-0003 Sample (2/19/20)

Food Experience Permission Form
CHILD 1
I give permission for my child (full name)*to participate in food related activities.
Please check one of the following:*

My child DOES NOT have a food allergy or dietary restrictionMy child DOES have a food allergy or dietary restriction He or she may participate but may not eat or handle the following items (please list below)My child DOES have a food allergy or dietary restriction He or she may not participate in activities
List food allergies here:*
Parent Signature*

Clear
Date*

MonthDayYear
Date
C- 1050 Sample Form PCLB 12/13

Food Experience Permission Form
CHILD 2
I give permission for my child (full name)*to participate in food related activities.
Please check one of the following:*

My child DOES NOT have a food allergy or dietary restrictionMy child DOES have a food allergy or dietary restriction He or she may participate but may not eat or handle the following items (please list below)My child DOES have a food allergy or dietary restriction He or she may not participate in activities
List food allergies here:*
Parent Signature*

Clear
Date*

MonthDayYear
Date
C- 1050 Sample Form PCLB 12/13

Food Experience Permission Form
CHILD 3
I give permission for my child (full name)*to participate in food related activities.
Please check one of the following:*

My child DOES NOT have a food allergy or dietary restrictionMy child DOES have a food allergy or dietary restriction He or she may participate but may not eat or handle the following items (please list below)My child DOES have a food allergy or dietary restriction He or she may not participate in activities
List food allergies here:*
Parent Signature*

Clear
Date*

MonthDayYear
Date
C- 1050 Sample Form PCLB 12/13

What is the influenza (flu) virus?

Influenza ("the flu") is caused by a virus which infects the nose, throat, and lungs. According to US Center for Disease Control and Prevention (CDC), the flu is more dangerous than the common cold for children. Unlike the common cold, the flu an cause severe illness and life threatening complications in many people. Children under 5 who have the flu commonly need medical care. Severe flu complications are most common in children younger than 2 years old. Flu season can begin as early as October and last as late as May.

Florida Department Children & Families

How can I tell if my child has a cold, or the flu?

Most people with the flu feel tired and have fever, dache, dry cough, sore throat, runny or stuffy , and sore muscles. Some people, especially children, may also have stomach problems and diarrhea. Because the flu and colds have similar symptoms, it can be difficult to tell the difference between them based on symptoms alone. In general, the flu is worse than the common cold, symptoms such as fever, body aches, extreme tiredness, and dry cough are more common and intense. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations.

For additional information, please visit www.myflorida.com/childcare or contact your local licensing office below:

This brochure was created by the Department of Children and Families in consultation with the Department of Health.
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:
Name*
Child(rens) Name*
Date Received*

MonthDayYear
Date
Signature*

Clear
What should I do if my child gets sick?

Consult your doctor and make sure your child gets plenty of rest and drinks a lot of fluids. Never give aspirin or medicine that has aspirin in it to children or teenagers who may have the flu.

Call or take you child to a doctor right away if your child:
- Has a high fever or fever that lasts a long time
- Has trouble breathing or breathes fast
- Has skin that looks blue
- Is not drinking enough
- Seems confused, will not wake up, does not want to be held, or has seizures (uncontrolled shaking)
- Gets better but then worse againHas other conditions (like heart or lung disease, diabetes) that get worse
How can I protect my child from the flu?

A flu vaccine is the best way to protect against the flu. Because the flu virus changes year to year, annual vaccination against the flu is recommended. The CDC recommends that all children from the ages of 6 months up to their 19th birthday receive a flu vaccine every fall or winter (children receiving a vaccine for the first time require two doses You also can protect your child by receiving a flu vaccine yourself.
What can I do to prevent the spread of germs?

The main way that the flu spreads is in respiratory droplets from coughing and sneezing. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and infect someone nearby. Though much less frequent, the flu may also spread through indirect contact with contaminated hands and articles soiled with nose and throat secretions. To prevent the spread of germs:
- Wash hands often with soap and water.
- Cover mouth/nose during coughs and sneezes. If you don't have a tissue, cough or sneeze into your upper sleeve, not your hands
- Limit contact with people who show signs of illness.
- Keep hands away from the face. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
When should my child stay home from child care?

A person may be contagious and able to spread the virus from 1 day before showing symptoms to up to 5 days after getting sick. The time frame could be longer in children and in people who don't fight disease well (people with weakened immune systems When sick, your child should stay at home to rest and to avoid giving the flu to other children and should not return to child care or other group setting until his or her temperature has been normal and has been sign and symptom free for a period of 24 hours.

For additional helpful information about the dangers of the flu and how to protect your child, visit: http://www.cdc.gov/flu/

DISTRACTED ADULT
The Office of Child Care Regulation

www.myflfamilies.com/childcare CF/PI 175-12, May 2018
A change in daily routine, lack of sleep, stress, fatigue, cell phone use, and simple distractions are some things parents experience and can be contributing factors as to why children have been left unknowingly in vehicles...
During the 2018 legislative session,

a new law was passed that requires child care facilities, family day care homes and large family chi care homes to provide parents, during the months of April and September each year, with information regarding the potential for distracted adults to fail to drop off a child at the facility/home and instead leave them in the adult's vehicle upon arrival at the adult's destination.

My signature below verifies receipt of the Distracted Adult brochure
Signature*

Clear
Childs Name*
FACTS ABOUT HEATSTROKE:

It only takes a car 10 minutes to heat up 20 degrees and become deadly.

Even with a window cracked, the temperature inside a vehicle can cause heatstroke.

The body temperature of a child increases 3 to 5 times faster than an adult's body.

PREVENTION TIPS:
- Never leave your child alone in a car and call 911 if you see any child locked in a car!
- Make a habit of checking the front and back seat of the car before you walk away.
- Be especially mindful during hectic or busy times, schedule or route changes, and periods of emotional stress and chaos.
- Create reminders by putting something in the back seat that you will need at work, school or home such as a briefcase, purse, cell phone or your left shoe.
- Keep a stuffed animal in the baby's car seat and place it on the front seat as a reminder when the baby is in the back seat.
- Set a calendar reminder on your electronic device to make sure you dropped your child off at child care.
- Make it a routine to always notify your child's child care provider in advance if your child is going to be late or absent; ask them to contact you if your child

Authorization and Consent for Disclosure,

Receipt, and Use of Confidential Information

by the Juvenile Welfare Board of Pinellas County

I, print participant name(s)*) acknowledge that I am a participant of (name of program or service)* . I acknowledge that the Juvenile Welfare Board of Pinellas County ("JWB") provides funds to make the program or service in which I am participating available. I also acknowledge that in order to make sure that all services delivered to participants are of the highest possible quality, JWB may need to review information about me and these services.

By signing this Authorization, I am indicating that I understand and agree that my confidential information may be contained in a JWB data collection system, and that this data collection system is exempt from disclosure under the Florida Public Records Act. This means that by law, JWB cannot release individually identifiable information about me or the services I receive (Fla. Stat. $119.071). I acknowledge that as necessary to carry out the purposes listed herein, JWB may review all information about me, including my participant file and all other information pertaining to me held by the agency providing the program or service, regardless of whether that information is entered into a JWB data collection system. I further acknowledge that JWB is simply storing and reviewing records and information as the payor for these services, and that JWB generally provides no direct services to me, except in certain circumstances may facilitate service delivery I further acknowledge that JWB does not provide medical diagnoses to me and JWB is not a covered entity as that term is defined under HIPAA (the Health Insurance Portability and Accountability Act)

I authorize JWB to utilize my confidential information to verify eligibility for funded services or programs, to facilitate service delivery, make payment for services rendered to me by funded programs or services, quality control of funded services or programs, evidence-based research of JWB funded services or programs, including, but not limited to, tracking outcomes of funded programs and services, and determination of future services/programs funded by JWB. I understand that the confidential information disclosed, received or used by JWB related to my Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law unless it is presented in a report that presents information on a group of individuals in de-identified format, which means that no information that identifies me as an individual is revealed.

I acknowledge that this Authorization covers all information about me including, but not limited to, personally identifiable information, Protected Health Information, general medical, general counseling, as well as psychiatric/psychological/substance abuse information from my medical health record, any information concerning the performance of any tests, results of those tests, and counseling and treatment records, as allowed by all state, federal and local laws, including, but not limited to the following: Florida Statutes 394.459, 381.004, and 395.3025; Florida Evidence Code 90.503, 90.5035, and 90.5036; HIPAA, and the Code of Federal Regulations (CFR) Title 42. I consent to my minor participating in online or paper surveys that will be used for program improvements and enhancements. I understand that my records have a privileged and confidential status. I am waiving that status for the purposes contained by this Authorization.

I understand that the confidential information disclosed, received or used by JWB based on this Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law. However, the individually identifiable confidential information received by JWB based on this Authorization may be used by JWB and its agents for research purposes, so long as the research results are reported as a whole in de-identified format, which means that no information that identifies me as an individual is revealed. Except, JWB will not provide any records covered by CFR Title 42 to any JWB agents.

I understand that I have the right to withdraw my approval in writing at any time. However, it is possible that JWB may have already relied on this Authorization before it receives notice of my withdrawal and that JWB may have already taken action based on the Authorization. If I do not withdraw my approval, it will automatically end one (1) year from the last day I received services from this program, or with respect to information used in research, or for compliance and quality review activities performed by JWB or its agents, upon completion of the last research project or compliance/ quality review, whatever occurs latest. By my signature below, I acknowledge that I have given my consent as indicated above freely, voluntarily, and without coercion, and that I have been given a copy of this authorization, signed by me on the date shown below.
Witness Signature

Clear
Date*

MonthDayYear
Date
print participant name*
Signature of Participant or Participants Authorized Representative check one*

Clear
Upon signing please check one:*

ParticipantParentGuardianPersonal Representative (Legal Documents Required)
Effective Date*

MonthDayYear
Date

LATE PICK-UP POLICY FORM
Dear Artz 4 Life Parents and Guardians,

We appreciated your child's participation in our various programs. As an organization that provides after school enrichment and creative outlets for youth, Artz 4 Life believes exposure to cultural and creative outlets enhances and supports the emotional, spiritual, psychological, and physical wellbeing throughout our children's development/lifespan.

As of the 2022/2023 school year, Artz 4 Life implemented new guidelines for dismissal and aftercare. To stay in g, the guidelines with our summer camp program hours of 7:00 am-5:00 PM, we have implemented a new lateness policy.

Children should be picked up by 5:00 PM. For any child picked up after the 15-minute grace period, there will be a $10 late fee. After 15 minutes, the charge will be $1 for every minute.

We appreciate your commitment to your child's success and we look forward to a wonderful 2024 summer camp experience. Thank you for your cooperation, and if you have questions or concerns, please contact Artz 4 Life at (727) 216-3519.

Please fill out the information below for participant(s) and acknowledge the Late Pick-Up Policy.
Participant(s) Name*
Parent/Guardian Name (print)*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
This is a double-sided form, please turn over to fill out Pick-Up Authorization List.

Parent Pick-Up Authorization List
Parent Name*
Child(ren)'s Name*
Phone Number*
I, (name of parent)* give the following persons permission topick up my child from Artz 4 Life Academy. I understand that only I can add or remove namesfrom this list. I will make sure that the persons on this list present their I.D. at the time of pick up.
Parent Signature*

Clear
Date*

MonthDayYear
Date
Name*
Phone #*
Date added*

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address*
Name
Phone #
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Date added
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Date added
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Date added
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address

ARTZ 4 LIFE ACADEMY MEMBER EXPECTATIONS

Children are asked to adhere to the following agreement.

As a Artz 4 Life Academy Afterschool Participant, I promise to:

1. Always treat others with respect.

2. Use only polite, kind words.

3. Always listen to and respect the Afterschool staff.

4. Respect Recreation Center property.

5. Respect other people and their property.

6. Always keep my hands and feet to myself.

7. Always ask permission before leaving the Afterschool area.

8. Avoid fighting, bullying, and teasing others.

9. Follow the Afterschool schedule.

10. Always resist peer pressure.

11. Take responsibilities for my actions.

12. Always stand up for my beliefs.

13. Always resolve conflict nonviolently.

14. Respect other people's cultural/racial/ethnic background.

15. Always help others when they are in need of help.

16. Always tell the truth.

17. Always clean up after myself.

18. Be proud of who I am.

19. Always try my best.
Participant Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CHILD'S ENROLLMENT RECORD

CHILD 1

Primary Hours of Care

Family Information:

MISCELLANEOUS INFORMATION

CHILD'S ENROLLMENT RECORD (CHILD #2)

CHILD 2

Primary Hours of Care

Medical Information:

MISCELLANEOUS INFORMATION

CHILD'S ENROLLMENT RECORD

CHILD 3

Primary Hours of Care

Medical Information:

CHILD 1

CHILD 2

CHILD 3

DISTRACTED ADULT

jwb- Additional participants

LATE PICK-UP POLICY FORM