Aftercare Registration Form

Parent/Guardian Information
Custody (Primary Caregiver)*
Does the child live with a legal guardian other than the mother or father?*
Caregiver preferred language for contact:*
Mother/Legal Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*
E-mail*
Father/Legal Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number
Number of Children living in the household (including child participant):*
Is the participant a child of a Military family?*

YesNo
Migrant Farm Work:*

YesNo
Dependency System:*

YesNo
Delinquency System:*

YesNo

Emergency Information

Note: In case of an emergency, at least one parent, guardian or designated emergency contact person needs to be available to respond to the site within 15 minutes. Responding party should be authorized to make an emergency medical decision on behalf of the child.
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Person(s) Authorized to pick-up child from program (Other than Parent/Guardian)

Your child will not be released to any person not listed herein.
Name*

First NameLast Name
Phone Number
Name

First NameLast Name
Phone Number
Name

First NameLast Name
Phone Number

Do you authorize the City of Hialeah to transport the participant to and from program/events/field trips sponsored and/or approved by the After-school Program.*

YesNo
DCF License Numbers
- Babcock # C11MD2033
- Bright # C11MD2755
- Goodlet # C11MD2737
- O’Quinn # C11MD2828
- Slade # C11MD2032
- Walker # C11MD2739
DCF Requirments
- Section 65C-22.006(2), F.A.C., requires a current immunization record (Form 680 or 681) within 30 days of enrollment
- Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure
- Section 65C-20.010(6)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility
REQUEST FOR A MINOR TO PARTICIPATE IN PROGRAMS/EVENTS SPONSORED/APPROVED
BY THE CITY OF HIALEAH AND HOLD HARMLESS AGREEMENT

PARTICIPATION: I hereby give permission for the participant named on this form to participate in the After-school Program, “Creative Learning & Play”
provided by the City of Hialeah, from when registered from timeframe 08/14/25 - 06/04/26. The After-School Program includes, but not limited to,
literacy programs, fitness, cultural arts, social development, indoor/outdoor games, crafts, fieldtrips and special events. My permission shall be effective upon signing this Request/Hold Harmless Agreement. I have instructed the participant to obey, at all times, all instructions, orders and commands given by the authorized representatives of the City of Hialeah or its designees. I further give permission for the participant to be filmed and/or photographed in such program/event for use in publicizing the program/event.

RELEASE OF ALL CLAIMS: The undersigned, individually and on behalf of the participant, releases, covenants not to sue and forever discharges the City
of Hialeah, its Officers, Agents, Employees, Counselors, Volunteers and their successors and assigns (all of whom constitute the released parties) of all
liabilities, claims, actions, damages, costs or expenses, that the participant may have against the released parties arising out of, or in any way connected with participation in the program/event sponsored/approved by the City of Hialeah, including travel to and from such program/event, and including injury or damage to person or property, or resulting in death of the participant, whether caused by the NEGLIGENCE of the released parties or otherwise.

CONSENT TO TREATMENT: I authorize such physician or medical staff as the City of Hialeah may designate, to carry out any minor medical
treatment deemed necessary, or to take my child to the emergency room of the nearest hospital for treatment, if necessary. I understand that, in
order to provide necessary medical treatment to my child, there may be an exchange or disclosure of confidential/protected health information
between the City of Hialeah and medical providers. I authorize the City of Hialeah to exchange or disclose my child's confidential/protected health
information with such medical providers, as well as with The Children's Trust. I further understand that the City of Hialeah shall protect my child's
confidential/protected health information and comply with all applicable federal and state laws by not disclosing such information to any third party
who does not have a need to know such information.

I, the undersigned, am the parent/guardian of the above-specified minor child. I have read and fully understand the provisions of the above Request/Hold
Harmless Agreement and have explained them to said minor. I hereby agree that the said minor and I will be bound thereby.
Under penalties of perjury, I declare that I have read the foregoing Request/Hold Harmless Agreement and that the facts stated in it are true.
I have fully completed the registration form and I have been provided the Program Handbook and a written program disciplinary policy by the ECS Division. I also give my permission for this information to be submitted to The Children’s Trust for program monitoring and evaluation purposes. The Children’s Trust provides funding for the program.*
Date

MonthDayYear
Date

Please upload your documents below:
Please upload the following documents: Copy of Birth Certificate or Passport*

Cancelof
Please upload the following documents: Proof of Residency-Utility Bill (Under Parents/Guardian Name)*

If you are rented, please submit a notarized letter from your landlord or Lease Agreement
Cancelof
Please upload the following documents: Most recent Report Card*

Cancelof
Please upload the following documents: License*

Cancelof
Please note that submitting a registration form does not confirm your enrollment in the program. To complete your registration, payment must be made at our main office. Additionally, if any required documents are missing, your registration will be returned for completion.
Signature*
Date

MonthDayYear
Date
We're sorry, our program is only available to Miami-Dade County residents.
Should be Empty:

CLAP Aftercare Registration

Child's Information

Your child will not be released to any person not listed herein.