FORZA Gulf Coast Child Development Center 215 Airport-Pulling Road N. Naples, FL 34104 Three and...

FORZA Child Development Center Three and Four Year Old ProgramsVPK ProgramHours of Operation 7:00 AM – 6:00 PM Child Application Form

CHILD INFORMATION:

Desired Pre-School Start Date for you child:*

Date

Child's Name:

Last:*

First:*

Middle:

Nick Name (if any):

Sex:*

MaleFemale

Date of Birth:*

Date

Address:*

City:*

State:*

Zip:*

Does your child have allergies or other medical conditions?*

YesNo

If Yes, please list allergies/condition and provide 3 step medical plan details. (ex. 1. epi pen 2. call parent 3. call 911)

Director's Signature to acknowledge medical plan

May your child participate in food related activities in the classroom?*

YesNo

Primary Hours of Care:

From:*

To:*

Days of the week in care:*

FAMILY INFORMATION:

Child lives with:*

Please discuss any custody-visiting arrangements:

MOTHER'S INFORMATION:

First Name:*

Last Name:*

Marital Status:*

MarriedSingle

Address:*

City:*

State:*

Zip:*

Email:*

Home Phone:*

Cell Phone:*

Work Phone:

Date of Birth:*

Date

Last four digits of Social Security Number (SSN):*

Employer:*

FATHER'S INFORMATION:

First Name:*

Last Name:*

Marital Status:*

MarriedSingle

Address:*

City:*

State:*

Zip:*

Email:*

Home Phone:*

Cell Phone:*

Work Phone:

Date of Birth:*

Date

Employer:*

Additional comments or information that will assist us in providing an optimum educational experience for your child:

Your child will only be released to the custodial parent(s) or legal guardians listed below:

Mother:*

YesNo

Father:*

YesNo

Others that are authorized to pick up your child: #1

Last Name:

First Name:

Home Phone:

Cell Phone:

Relationship:

#2

Last Name:

First Name:

Home Phone:

Cell Phone:

Relationship:

#3

Last Name:

First Name:

Home Phone:

Cell Phone:

Relationship:

EMERGENCY/MEDICAL INFORMATION & CONTACTS:

The following family and/or friends may be contacted in the event of an emergency. Said individuals are permitted 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.

#1

Last Name:*

First Name:*

Home Phone:*

Cell Phone:*

Relationship:*

#2

Last Name:

First Name:

Home Phone:

Cell Phone:

Relationship:

#3

Last Name:

First Name:

Home Phone:

Cell Phone:

Relationship:

OTHER AGREEMENTS AND RELEASES:

Agreement Upon Termination:

I hereby understand that I am required to give written notice of termination. Said notification must be dated and signed the day it is submitted. Without said notification, I realize that I will be responsible for two weeks of payment. An individual notification is required for each sibling that attends the FORZA Child Development Center (CDC).

Parent's Electronic Signature:*

Date Signed:*

Date

Media Release:

Taking photographs and videos is a part of our daily routine at FORZA Child Development Center (CDC). Said media promotes a better understanding of you child's activities and elevates the esprit de corps of all stakeholders. By signing below, you are giving permission to CDC to photograph and video your child. Pictures or recordings may be used CDC, on the web site, and for the purpose of advertising. Please advise us if you are not in agreement with this media release. There is no fee paid to any parent(s) for the use of said photos or recordings.

Comments:

Parent's Electronic Signature:*

Date Signed:*

Date

Medical Care and Access:

I authorize FORZA Child Development Center (FCDC) to give consent for any and all of my child's emergency medical care, including CPR and abdominal thrust maneuver while under the supervision of FCDC. I authorize any emergency transportation to transport my child from the center to to nearby hospitals if such a situation would occur.

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted:

Doctor*

Phone Number*

Dentist*

Phone Number*

Emergency care plan instructions if applicable:

I hereby grant permission for the staff of this facility to have access to my child's records.

Parent's Electronic Signature:*

Date Signed:*

Date

Curriculum & Screening Your Child:

FORZA CDC has adopted the ELLM/Plus curriculum that is recommended by the State of Florida. FORZA CDC also utilizes supplemental curriculum such as: Beyond Centers & Circle Time Curriculum Series, Creative Curriculum, and the Creative Curriculum.Our VPK curriculum is developmentally appropriate, designed to prepare your child for early literacy, enhance the age-appropriate progress of your child in attaining the state-adopted performance standards, and prepare them for kindergarten based on the statewide kindergarten screening. (Section 1002.67(2)(b), Florida Statutes) Moreover, we will be screening your child via the Teaching Strategies Gold and/or Ages and Stages Program, which was recommended by Dr. Reynolds, who is one of the top Early Childhood Professors in the State. Subsequent to the screening, you will receive the results of said instrument. By signing below you are giving both the CDC staff and director permission to screen your child using the Teaching Strategies Gold and/or Ages & Stages Program.

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.

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.

Parent's Electronic Signature:*

Date Signed:*

Date

Thank your for completing our form to enroll your child at FORZA Child Development Center! Please click the submit button only once. You will receive an email confirmation that your form was submitted successfully.