Liberty Academy Preschool Student Application
Childcare Application for enrollment adapted by The Department of Children and Families
Student Information
Please Fill out one application per child
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Gender
*
Male
Female
Date of Enrollment
-
Month
-
Day
Year
Date
Student Full Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Student's SSN
*
Required for enrollment for the National School Lunch Program
Student Academic Info
*
Rows
Which Preschool Class Are you applying for?
Do You have School Readiness ELC?
Is your Child VPK Eligible?
Do You have Step up Scholarship FES-UA?
StepUp Award ID
Previous School
Reason for Withdrawal
Select from Dropdown
Infants
1 year old
2 year olds
3 year olds
4 year old
VPK
Yes
No
Yes
No
Yes
No
Family Information
Please fill out all required information
Students Lives with
*
One Parent
Both Parents
Legal Guardian
Other
Custody
*
Mother
Father
Both
Other
Mothers Information
*
Rows
Infromation
Parent Full Name
Birth Date
Primary Phone Number
Secondary Phone Number
Email
Home Address
Father Infromation
Rows
Information
Parent Full Name
Date of Birth
Primary Phone Number
Secondary Phone Number
Email
Home Address
Medical Information
I hereby grant permission for the staff of this facility to contact the following medicalpersonnel to obtain emergency medical care if warranted
Doctor
*
First Name
Last Name
Doctor Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Student Medical Info
*
Rows
Student Allergies,Medical or Dietary Needs.
Does Student Wear Glasses?
Does Student use hearing Aid(s)?
Other Info Possibly needed?
Please Answer All Questions
Yes
No
Needs Glasses
Yes
No
Needs Hearing Aide
Emergency Contacts:
Child will be released only to the custodial parent or legal guardian and the personslisted 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 or legal guardian cannot be reached:
Required Authorized Contacts for Pickup (Please don't not add the parent or guardians)
*
Rows
Name
Relationship to child
Phone Number
Address
Contact #1
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #2
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Additional Authorized Contacts for Pickup
Rows
Name
Relationship to child
Phone Number
Address
Contact #3
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #4
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #5
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #6
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
I consent to receiving text messages and E-mail from Liberty Academy for application and enrollment purposes.
*
Yes
By checking this box, I give Liberty Academy permission to submit an application for my child for the school year chosen above, using the information I have provided.
*
Yes
Agreement
Submitting this application does not mean or guarantee that the student will be accepted. By completing this application correctly and notifying us of changes, we guarantee that you will be contacted. If the student is accepted because you submitted false, incorrect or misleading information, we may refuse to enroll the student. By signing your name below and submitting this application you are agreeing that the information you provided is true and correct.
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 athttps://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 athttps://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
*
Date
*
-
Month
-
Day
Year
Date
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Media Release
Please fill out all information
Media Release Form for all Liberty Academy Students (All Grades)
*
I WILL permit my child to be photographed, videotaped, and/ or interviewed by the media when the news media has secured proper authorization from Liberty Academy and Miami-Dade COunty Schools
I WILL NOT permit my student to be photographed, videotaped, and/or interviewed by the media.
Signature for Media Release
*
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Getting to Know Me
We want to get to know your child better so that we can provide the best possible educational experience. No one knows your child better than you. Tell us more about your child?
1. What are your child's favorite and least favorite toy or activity?
*
2. What calms your child? What upsets your child?
*
3. How would you describe your child’s personality? (e.g., outgoing, quiet, energetic, cautious)?
*
4. How does your child communicate?
*
Verbally
With Vocalizations
Through Gestures (i.e. pointing, pulling, blinking)
American Sign Language (ASL)
With Communication devices (i.e. pictures)
Other
5. What services does your child receive?
*
Speech/ Language Therapy
Behavioral
Physical Therapy
Mental Health Counseling
Occupational Therapy
None
Other
6. Does your child require assistive devices or equipment? (i.e., braces, walker, wheelchair, communication device, insulin, nebulizer)
*
Yes
No
If Yes to question 6 please describe.
7. Do you suspect your child has a hearing problem or vision problem?
*
Yes
No
If Yes to question 7, please describe
8. Which statement best describes your child's ability to move from one activity to another
*
Easily moves from one activity to another
Needs assistance to move from one activity to another
9. How does your child play/ interact best? (please check all that apply)
*
Independently
With another child
Small group
Large Group
Outdoors
Indoors
With Adults
Other
10. Do any of the following bother your child?
*
Noise
Texture (i.e. sand, water)
Lights
Touch (i.e. Hugs)
Smells
Other
11. Does your child wander, run away or bolt?
*
Yes
No
If yes to question 11, what situations precede this behavior?
12. Is your child able to do the following activities by him/herself?
*
Rows
Yes
No
If no please describe
Use the toilet
Eat or Drink
Walk/ move about
Wash hands
13. Does your child take medication?
*
Yes
No
If yes to question 13. what medications and are there any side effects
Is there anything else you would like to share about your child (i.e., allergies, diet, seizures, nosebleeds)?
*
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