NOVA CHILD LEARNING ACADEMY

Who has Legal Custody

Other

Date of Birth

Date

Date of Application

Date

Date of Enrollment

Date

Full Name

Nickname

1st

2nd

Childs Physical Address

Childs Secondary Address

Primary Hours of Care: From

To

Days of the Week in Care

Child lives with

Name

Relation to child

Parent 1/ Legal Guardian

Name

Parent 1/ Legal Guardian

Name

Home Phone

Format: (000) 000-0000.

Home Phone

Format: (000) 000-0000.

Parent 1 Email

Parent 2 Email

Address

Employer

Work Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Cell

Relationship to the child

Meals Served While in Care:

Special Diet: ________ _______ _____ ______Other

Other

Please provide details also include nutritional doctor guidelines meal plan

Note: NOVA WILL NOT BE RESPONSIBLE FOR CHILD'S SPECIAL DIET WITHOUT DOCTOR'S -

NUTRICIONIST SPECIFICATIONS. PARENT IS RESPONSIBLE TO BRING CHILD'S SPECIAL DIET.

I hereby grant permission for the staff of NOVA to contact the following medical personnel to obtain emergency

Doctor

Phone

Format: (000) 000-0000.

Phone

Format: (000) 000-0000.

Hospital Option 1

Name

Dentist

Name

Hospital Option 2

Name

Phone

Format: (000) 000-0000.

Hospital Option 3

Address

Please any Specialist involved with Child wellbeing: (Nutritionist, Allergist, Therapist, etc

Doctor

Phone

Format: (000) 000-0000.

Phone

Format: (000) 000-0000.

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

Emergency Care Plan instructions including symptoms medication and notification in the event of an actual emergency if applicable.

childs name

(child's name) will be released only to the custodial parent(s) or legal guardian(s) 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(s) or legal guardian(s) cannot be reached:

Name

Address

Work

CellHome

Name

Address

Work

CellHome

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, "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 7.3, C.3 of the Child Care Facility Handbook, requires that parents are provided food and nutrition policies used by the child care facility. 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

Date

Parent/Legal Guardian Name

Relationship with Child

_{CF-FSP 5219, Child Care Application for Enrollment, May 2019, 65C-22.001(7f F.A.C. NOVA Child Learning Academy I 9951 Atlantic Blvd Suite 310 Jacksonville, FL 32225 I 904-684-8454}

APPLICATION FOR ENROLLMENT