CHILD CARE APPLICATION FOR ENROLLMENT

CHILD CARE APPLICATION FOR ENROLLMENT

Let's Get To Know You!

Parental (Guardian) Authorization Form

Liberty Academy Preschool

CHILD CARE FOOD PROGRAM FREE AND REDUCED-PRICE MEAL APPLICATION - COMBO

DCF Required Forms

Student Information:

Family Information:

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.

Helpful Information About Child:

All About Your Child

Favorite Things

Daily Routines & Comfort

Your Hopes for your child

Anything Else you'd like us to know?

Eating, sleeping & Self help

Media Release Parental Consent Form

STEP 2: Do any household members (children or adults) receive Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) benefits?

STEP 4: Household income and adult household member information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)

STEP 5: Contact information and adult signature

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 facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:
Name
Address
Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
Name
Address
Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
Name
Address
Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
Name
Address
Primary Phone
Format: (000) 000-0000.
Secondary Phone
Format: (000) 000-0000.
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 entitled "Know Your Child Care Facility" (CF/PI 175-24) [also available on-line at https://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 at https://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 of Parent/Guardian
Date

MonthDayYear
Date

Parental (Guardian) Authorization Form
Parent's Name:
Child's Name:
Child's S.S. #

Authorization is given to release the child(ren) listed on this page to the following named individuals:

Rows	Name	Home Phone	Work Phone	Relationship
1
2
3
4
5
6
7
8
9
10

I am aware that all individuals granted permission to drop off or pick up my child (ren) must be at least 18 years of age.
(Signature of Parent/Guardian)
Date:

MonthDayYear
Date
(Telephone # of Parent/Guardian)
Format: (000) 000-0000.
Date:

MonthDayYear
Date

Liberty Academy Preschool
Media Release Parental Consent Form
Dear Parent or Guardian,
Please be advised that during the year your child may be photographed, videotaped or interviewed at various school events. With your consent, photograph, video or interview may be reproduced and released for use in the media, i.e., newspaper brochures, video, television, and intent, and Liberty Academy's website and social media platforms such as Facebook, Twitter, Instagram, etc.
Student Name:
Media Release Consent
(Signature)
(Date)

MonthDayYear
Date

CHILD CARE FOOD PROGRAM FREE AND REDUCED-PRICE MEAL APPLICATION - COMBO
Child's Name:
Please read the instructions and accompanying Parent Letter before completing this form. If you need assistance completing this form, call: ()

YesSTEP 1: Complete the following table for all INFANTS and CHILDREN through age 18 that reside in the household, even if not related. (include child listed at top of form)

STEP 2: Do any household members (children or adults) receive Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) benefits?
If NO, go to STEP 3. If YES, enter one of the following case numbers, then go to STEP 5.
FAP/SNAP Case Number:
or TANF Case Number:
STEP 4: Household income and adult household member information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)
Adult Household Members and Income - list all adult household members (age 19 and up) even if they do not receive income. For each adult, list the total gross income (before taxes & deductions) from each source in whole dollars only (no cents) and how often it is received (i.e., weekly, bi-weekly, twice a month, monthly, or annually). For an adult that does not receive income from any source, write "none" or "0." If you enter "none" or "0" or leave any income fields blank, you are certifying that there is no income to report.

Rows	Adult Household Member's Name (Last Name, First Name)	Earnings from Work ($ Amount / How often?)	Public Assistance/Child Support/Alimony ($ Amount / How often?)	Pensions/Retirement/All Other Income ($ Amount / How often?)
1
2

Total Household Members (Add STEP 1 & 4):
STEP 5: Contact information and adult signature
Last four digits of Social Security Number (SSN) of adult household member:
If no SSN, write "none."
By signing below, I am certifying (promising) that all information on this application is true and that all income is reported. I understand that this information is being given in connection with the receipt of federal funds and that institution officials may verify (check) the information. I am aware that if I purposely give false information, I may be prosecuted under applicable state and federal laws.
Home address (if available):
Signature of adult household member:
Printed name:
Daytime phone #:
Format: (000) 000-0000.
Date signed:

MonthDayYear
Date

DCF Required Forms
My signature below verifies receipt of the Flyer on the
Rilya Wilson Act from the Department of Children and
Families.
Name:
Child's Name:
Date Received:

MonthDayYear
Date
Signature:
My signature below verifies receipt
of the Distracted Adult brochure
Parent/Guardian:
Child's Name:
Date:

MonthDayYear
Date
My signature below verifies receipt of the
brochure on Influenza Virus, The Flu, A
Guide to Parents:
Name:
Child's Name:
Date Received:

MonthDayYear
Date
Signature:
Should be Empty:

Child's Name (Last Name, First Name)

Date of Birth

Attends this center? (circle)

Foster Child? (circle)

Migrant? (circle)

Homeless/Runaway? (circle)