Update Information

Update Information
CHILD NAME

First NameLast Name
What would you like to update ?
1- Update Your Contact information
Parents Name

First NameLast Name
Who is filling the form ?
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2- Update Your Email and Phone Numbers
Name

First NameLast Name
Update Email
example@example.com
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Home Number
Work Numbers
3- Update Your Credit cards
Name

First NameLast Name
Please upload a picture of the both side of the credit card.

Cancelof
Expiration Date of Credit Card
Security Code of Credit Card
Billing Address for Credit Card

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Credit Card (Optional)
Please upload a picture of the both side of the Secondary Credit Card.

Cancelof
Billing Address for Secondary Credit Card

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4-Update Your Child's Shot Records
Childs Name
Upload the Child's immunization and physical records here

Cancelof
Childs Name
Upload the Child's immunization and physical records here

Cancelof
Childs Name
Upload the Child's immunization and physical records here

Cancelof
Childs Name
Upload the Child's immunization and physical records here

Cancelof
Childs Name
Upload the Child's immunization and physical records here

Cancelof
Do you need Religious Exemption from Immunization.
7. RELIGIOUS EXEMPTION FORM IMMUNIZATION
Parents may also choose to opt out of immunizations by submitting a completed Religious Exemption Form DH681 CR-DH 681 09-0514.eps

https://fl.childrenshealthdefense.org/wp-content/uploads/Religious-exemption-form-Florida.pdf
If you have filled form please upload

Cancelof
5. Step Up for Students
Reward Id #
Reward Amount $
Child Name

First NameLast Name
Parent Name

First NameLast Name
School Year
Date Last School Enrolled

If Other type School Name
Number Days Attended
Days Absent
Date withdrawn

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Course and Record of Achievement
Program Achievement
Date of Graduation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School Address:

Street Address

Apartment/Unit #

CityState / Province

Postal / Zip Code
6. VPK Certificate Upload
if dont have VPK here where you apply

How do I qualify?
• Parents/guardians must be Florida residents.

• Children must turn 4 years old on or before September 1st of the current school year.

https://familyservices.floridaearlylearning.com/
Parent signature is required
The uploaded certificate must include your parent signature

Cancelof
I confirm that I have signed the VPK certificate in the ‘Parent Signature’ section
“Please sign and upload a signed certificate.”

Parent Signature is required.
Should be Empty:

Update Information

1- Update Your Contact information

2- Update Your Email and Phone Numbers

3- Update Your Credit cards

Secondary Credit Card (Optional)

4-Update Your Child's Shot Records

7. RELIGIOUS EXEMPTION FORM IMMUNIZATION

5. Step Up for Students

6. VPK Certificate Upload