• Jotform LA Registration_Packet_Electronic 2025-2026

  • Student Information

  • Date of Birth
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  • Sex
  • Date of Enrollment
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  • Child's Full Name                       

  • Primary Hours Of Care:

  • Family Information
  • Days of the Week in Care

  • Allergies:

  • Child Lives With:

  • Mother's Name

  • Format: (000) 000-0000.

  • Employer:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Employer:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Contacts

    Child will be released to custodial parent or legal guardian & persons listed below. The following people will also be contacted & are authorized to remove the child from the faculty in case of illness, accident, or emergency if for some reason the custodial parent or guardian cannot be reached

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  • Custody

  • State of Florida Department of Children and Families CHILD CARE APPLICATION FOR ENROLLMENT

  • Student Information

  • Date of Birth
     - -
  • Sex:
  • Date of Enrollment
     - -

  • Primary hours of Care

  • Days of the Week in Care

  • Family Information

  • Format: (000) 000-0000.

  • Employer:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Employer

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Type a question

  • 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.

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  • Dentist                             

  • Contacts

    Child will be released to only 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 faculty in case of illness, accident, or emergency if for some reason the custodial parent or guardian cannot be reached

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  • • Sections 7.1 and 7.2, of the Child Care Facility Handbook, require a current physical examination (Form3040) 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, "Know Your Child Care Facility” (CF/PI 175-24), 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, “Selecting A Family Day Care Home Provider” (CF/PI 175-28).• • 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
  • Today's Date
     - -

  • LIFTED CHURCH AND ACADEMY AGREEMENT FORM

    I have obtained, read, and understand the parent/student handbook especially regarding: • Discipline Policy and Procedures This childcare facility adopts a discipline policy consistent with the Department of Children &Families (DCF) Section 402.305(12), F.S., including standards that prohibit children from being subjected to discipline which is severe, humiliating, frightening, or associated with food, rest, or toileting. Spanking or any physical punishment is prohibited. o Discipline is teaching. Just as children learn colors, shapes, and to read and write, they must learn social skills such as how to be a part of a group, how to share, make friends, speak their feelings, and resolve conflict. • School’s Financial Policy • Curriculum • Statement of Faith • Spiritual Development • Influenza Virus Guide • Distracted Act • Attendance/Illness Policies I agree to encourage my child to support and cooperate with the policies and procedures of Lifted Academy and DCF stated therein
  • Today Date
     - -

  • Lifted Church and Academy Financial Agreement Form

    2025-2026
  • I'm registering my child for the following days (CHOOSE ALL THAT APPLY)
  • Days a week

  • I agree to pay the monthly sum of: Tuition/ Aftercare

  • + Lunch

  • Date
     - -

  • Pledge Of Acceptance

  • Date
     - -
  • Date
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  • Billing Name (Please Print)

  • Demographic Information Sheet

  • Todays Date
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  • Child's date of Birth Date
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  • If Child was Premature, # of Weeks Premature

  • question

  • Child's Race/Ethnicity

  • Child's Birth Weight(Pound/Ounces)*.

  • Parent/Primary Caregiver's Name:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Child's Primary Language

  • Child's Primary care Physician

  • Clinc/Practice mailing:                  

  • Format: (000) 000-0000.


  • Type a question

  • Lifted Church And Academy

  • Child Care Facility Authorization For Prescription and Non-Prescription Medication

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  • Record of Medication Given:

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  • Date
     - -

  • Alternate Nutrition Plan

  • understand and approve the use of the Alternate Nutrition Plan. I agree to provide the following meals and/or snacks to meet my child’s nutritional and dietary need
  • Date
     - -

  • Photography Permission

  • I grant Lifted Church and Academy, its representatives, and employees the right to take photographs of me and/or my child. Pictures and Videos can/will be used for promotional purposes, newsletter publications, advertising, Church events, and/or social media.
  • Date
     - -

  • Parent Teacher Fellowship

  • The Parent Teacher Fellowship or PTF is a school-based organization with a mission to make the school a better place for children to learn. It allows Parents and Faculty to work together to organize and facilitate events both during and after school hours that serve to enrich our children’s educational experiences and build a stronger community.
  • Date
     - -

  • School Improvement Fee

  • The School Improvement Fee is PER FAMILY. If siblings are attending, please mark one form for payment and “Sibling” for the other form

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  • Date
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  • Date
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  • Date Received
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  • Should be Empty: