Artz 4 Life Summer Camp 2026 - FULL FORM

CHILD'S ENROLLMENT RECORD
123

CHILD 1
Child 1 First Name*
Middle Name*
Last Name*
Nickname
Date of Birth*

MonthDayYear
Date
Sex*
MaleFemale
Primary Hours of Care
From*
To*
Days of Week in Care*
Child's 1 Physical Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Family Information:
Parent Email*
example@example.com
Child Lives With*
Parent 1's Full Name*
Yes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Format: (000) 000-0000.
Parent 1 Employer*
Parent 1 Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone*
Format: (000) 000-0000.
Cell*
Parent 2's Full Name
Yes
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Parent 2 Employer
Parent 2 Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Format: (000) 000-0000.
Cell
MotherFatherBothOther
If Other, Full Name
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 children's center in case of illness, accident or emergency, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached:
Full Name*
Home Phone*
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Full Name*
Home Phone*
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Please use additional sheet of paper to list name, address and phone number of any other people authorized to pick the child up.

CONTINUED ON BACK

CHILD'S ENROLLMENT RECORD CHILD 1

(Back Page)
Medical Information (Name of Child)*
Childs Physician/Health Resource*
Telephone Number*
Format: (000) 000-0000.
Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Preference*
Name of Dentist*
Telephone*
Format: (000) 000-0000.
Dentist's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BreakfastAM SnackLunchPM SnackSupper
Emergency Care Plan instructions (if applicable)*
MISCELLANEOUS INFORMATION
List all known allergies*
List all identifying scars birthmarks skin discolorations*
Special medical or dietary needs of child*
List any areas of concern*
My signature below verifies that: I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached.

I have received a copy of the "Know Your Child's Children's Center" brochure. I was notified in writing of the disciplinary and expulsion policies used by the children's center. I was provided the food and nutrition policies used by the children's center.

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 Custodial Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

CONTINUED ON BACK

CHILD'S ENROLLMENT RECORD CHILD 2

(Back Page)
Medical Information:
Childs Physician/Health Resource*
Telephone Number*
Format: (000) 000-0000.
Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Hospital Preference*
Name of Dentist*
Telephone*
Format: (000) 000-0000.
Yes
Dentist's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
BreakfastAM SnackLunchPM SnackSupper
Emergency Care Plan instructions (if applicable)*
MISCELLANEOUS INFORMATION
List all known allergies*
List all identifying scars birthmarks skin discolorations*
Special medical or dietary needs of child*
List any area of concern*
My signature below verifies that: I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached.

I have received a copy of the "Know Your Child's Children's Center" brochure. I was notified in writing of the disciplinary and expulsion policies used by the children's center. I was provided the food and nutrition policies used by the children's center.

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 Custodial Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

CONTINUED ON BACK

CHILD'S ENROLLMENT RECORD CHILD 3

(Back Page)
Medical Information:
Childs Physician/Health Resource*
Telephone Number*
Format: (000) 000-0000.
Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Hospital Preference*
Name of Dentist*
Telephone*
Format: (000) 000-0000.
Yes
Dentist's Address*

Street Address number apartment street

Street Address Line 2

CityState / Province

Postal / Zip Code
BreakfastAM SnackLunchPM SnackSupper
Emergency Care Plan instructions (if applicable)*
List all known allergies*
List all identifying scars birthmarks skin discolorations*
Special medical or dietary needs of child*
List any areas of concern*
Special medical or dietary needs of child

My signature below verifies that: I give permission to consult the child's physician/health resource listed above in case of emergency if parent/legal guardian cannot be reached.

I have received a copy of the "Know Your Child's Children's Center" brochure. I was notified in writing of the disciplinary and expulsion policies used by the children's center. I was provided the food and nutrition policies used by the children's center.

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 Custodial Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

EMERGENCY MEDICAL RELEASE

CHILD 1

This form must contain only one child's name, and be the original notarized form. A new notarized form is required when there is a change in legal guardianship.
Childs Full Name*
Birthdate*

MonthDayYear
Date
Allergies*
Medicines Routinely Taken*
Name of Custodial Parents/Legal Guardians*
Yes
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Format: (000) 000-0000.
Cell Telephone*
Format: (000) 000-0000.
Work Telephone*
Format: (000) 000-0000.
Family Physicians Name/Health Care Resource*
Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Preference:*
City*
Medical Insurance Company*
Policy#*
Expiration Date*

MonthDayYear
Date
Emergency Contact (if custodial parent/guardian cannot be reached)*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Format: (000) 000-0000.
Cell Telephone*
Format: (000) 000-0000.
Work Telephone*
Format: (000) 000-0000.
Sign in the presence of the Notary.
I hereby give consent to any emergency facility and physician to administer necessary treatment to my child (child's full name)*, in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
Signature of Custodial Parent/Legal Guardian (Affiant)*

Clear
STATE OF FLORIDA COUNTY OF*
The foregoing instrument was acknowledged before me this (Month)* (Day)* 20 (Year)* by means of physical presence or online notarization by (First Name of Parent)* Parent Last Name* who is personally known to me or has produced (Type of Identification))* as identification.
Signed: FC-0003 Sample (2/19/20)

EMERGENCY MEDICAL RELEASE

CHILD 2

This form must contain only one child's name, and be the original notarized form. A new notarized form is required when there is a change in legal guardianship.
Childs Full Name*
Birthdate*

MonthDayYear
Date
Allergies*
Medicines Routinely Taken*
Name of Custodial Parents/Legal Guardians*
Yes
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Format: (000) 000-0000.
Cell Telephone*
Format: (000) 000-0000.
Work Telephone*
Format: (000) 000-0000.
Family Physicians Name/Health Care Resource*
Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Telephone*
Format: (000) 000-0000.
Hospital Preference*
City*
Medical Insurance Company*
Policy#*
Expiration Date*

MonthDayYear
Date
Emergency Contact (if custodial parent/guardian cannot be reached)*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Format: (000) 000-0000.
Cell Telephone*
Format: (000) 000-0000.
Work Telephone*
Format: (000) 000-0000.
Sign in the presence of the Notary.
I hereby give consent to any emergency facility and physician to administer necessary treatment to my child (child's full name)*, in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
Signature of Custodial Parent/Legal Guardian (Affiant)*

Clear
STATE OF FLORIDA COUNTY OF*
The foregoing instrument was acknowledged before me this (Month)* (Day)* (Year)* by means of physical presence or online notarization by (First Name of Parent)* (Last Name of Parent)* who is personally known to me or has produced (Type of Identification))* as identification.
Signed: FC-0003 Sample (2/19/20)

EMERGENCY MEDICAL RELEASE

CHILD 3

This form must contain only one child's name, and be the original notarized form. A new notarized form is required when there is a change in legal guardianship.
Childs Full Name*
Birthdate*

MonthDayYear
Date
Allergies*
Medicines Routinely Taken*
Name of Custodial Parents/Legal Guardians*
Yes
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Format: (000) 000-0000.
Work Telephone*
Format: (000) 000-0000.
Work Telephone*
Format: (000) 000-0000.
Family Physicians Name/Health Care Resource*
Yes
Physician's Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Telephone*
Format: (000) 000-0000.
Hospital Preference*
City*
Medical Insurance Company*
Policy*
Expiration Date*

MonthDayYear
Date
Emergency Contact (if custodial parent/guardian cannot be reached)*
Address*

Street Address number apartment street

Street Address Line 2

CityState

Zip Code
Home Telephone*
Format: (000) 000-0000.
Cell Telephone*
Format: (000) 000-0000.
Work Telephone*
Format: (000) 000-0000.
Sign in the presence of the Notary.
I hereby give consent to any emergency facility and physician to administer necessary treatment to my child (child's full name)*, in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
Signature of Custodial Parent/Legal Guardian (Affiant)*

Clear
STATE OF FLORIDA COUNTY OF*
The foregoing instrument was acknowledged before me this (Month)* (Day)* (Year)* by means of physical presence or online notarization by (First Name of Parent)* (Last Name of Parent)* who is personally known to me or has produced (Type of Identification))* as identification.
Signed: FC-0003 Sample (2/19/20)

Food Experience Permission Form
CHILD 1
I give permission for my child (full name)*to participate in food related activities.
My child DOES NOT have a food allergy or dietary restrictionMy child DOES have a food allergy or dietary restriction He or she may participate but may not eat or handle the following items (please list below)My child DOES have a food allergy or dietary restriction He or she may not participate in activities
List food allergies here:*
Parent Signature*

Clear
Date*

MonthDayYear
Date
C- 1050 Sample Form PCLB 12/13

Food Experience Permission Form
CHILD 2
I give permission for my child (full name)*to participate in food related activities.
My child DOES NOT have a food allergy or dietary restrictionMy child DOES have a food allergy or dietary restriction He or she may participate but may not eat or handle the following items (please list below)My child DOES have a food allergy or dietary restriction He or she may not participate in activities
List food allergies here:*
Parent Signature*

Clear
Date*

MonthDayYear
Date
C- 1050 Sample Form PCLB 12/13

Food Experience Permission Form
CHILD 3
I give permission for my child (full name)*to participate in food related activities.
My child DOES NOT have a food allergy or dietary restrictionMy child DOES have a food allergy or dietary restriction He or she may participate but may not eat or handle the following items (please list below)My child DOES have a food allergy or dietary restriction He or she may not participate in activities
List food allergies here:*
Parent Signature*

Clear
Date*

MonthDayYear
Date
C- 1050 Sample Form PCLB 12/13

Authorization and Consent for Disclosure,

Receipt, and Use of Confidential Information

by the Juvenile Welfare Board of Pinellas County

I, print participant name(s)*) acknowledge that I am a participant of (name of program or service)* . I acknowledge that the Juvenile Welfare Board of Pinellas County ("JWB") provides funds to make the program or service in which I am participating available. I also acknowledge that in order to make sure that all services delivered to participants are of the highest possible quality, JWB may need to review information about me and these services.

By signing this Authorization, I am indicating that I understand and agree that my confidential information may be contained in a JWB data collection system, and that this data collection system is exempt from disclosure under the Florida Public Records Act. This means that by law, JWB cannot release individually identifiable information about me or the services I receive (Fla. Stat. $119.071). I acknowledge that as necessary to carry out the purposes listed herein, JWB may review all information about me, including my participant file and all other information pertaining to me held by the agency providing the program or service, regardless of whether that information is entered into a JWB data collection system. I further acknowledge that JWB is simply storing and reviewing records and information as the payor for these services, and that JWB generally provides no direct services to me, except in certain circumstances may facilitate service delivery I further acknowledge that JWB does not provide medical diagnoses to me and JWB is not a covered entity as that term is defined under HIPAA (the Health Insurance Portability and Accountability Act)

I authorize JWB to utilize my confidential information to verify eligibility for funded services or programs, to facilitate service delivery, make payment for services rendered to me by funded programs or services, quality control of funded services or programs, evidence-based research of JWB funded services or programs, including, but not limited to, tracking outcomes of funded programs and services, and determination of future services/programs funded by JWB. I understand that the confidential information disclosed, received or used by JWB related to my Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law unless it is presented in a report that presents information on a group of individuals in de-identified format, which means that no information that identifies me as an individual is revealed.

I acknowledge that this Authorization covers all information about me including, but not limited to, personally identifiable information, Protected Health Information, general medical, general counseling, as well as psychiatric/psychological/substance abuse information from my medical health record, any information concerning the performance of any tests, results of those tests, and counseling and treatment records, as allowed by all state, federal and local laws, including, but not limited to the following: Florida Statutes 394.459, 381.004, and 395.3025; Florida Evidence Code 90.503, 90.5035, and 90.5036; HIPAA, and the Code of Federal Regulations (CFR) Title 42. I consent to my minor participating in online or paper surveys that will be used for program improvements and enhancements. I understand that my records have a privileged and confidential status. I am waiving that status for the purposes contained by this Authorization.

I understand that the confidential information disclosed, received or used by JWB based on this Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law. However, the individually identifiable confidential information received by JWB based on this Authorization may be used by JWB and its agents for research purposes, so long as the research results are reported as a whole in de-identified format, which means that no information that identifies me as an individual is revealed. Except, JWB will not provide any records covered by CFR Title 42 to any JWB agents.

I understand that I have the right to withdraw my approval in writing at any time. However, it is possible that JWB may have already relied on this Authorization before it receives notice of my withdrawal and that JWB may have already taken action based on the Authorization. If I do not withdraw my approval, it will automatically end one (1) year from the last day I received services from this program, or with respect to information used in research, or for compliance and quality review activities performed by JWB or its agents, upon completion of the last research project or compliance/ quality review, whatever occurs latest. By my signature below, I acknowledge that I have given my consent as indicated above freely, voluntarily, and without coercion, and that I have been given a copy of this authorization, signed by me on the date shown below.
Witness Signature

Clear
Date

MonthDayYear
Date
print participant name*
Signature of Participant or Participants Authorized Representative check one*

Clear
ParticipantParentGuardianPersonal Representative (Legal Documents Required)
Effective Date*

MonthDayYear
Date

LATE PICK-UP POLICY FORM
We appreciated your child's participation in our various programs. As an organization that provides after-school enrichment and creative outlets for youth, Artz 4 Life believes exposure to cultural and creative outlets enhances and supports the emotional, spiritual, psychological, and physical well-being throughout our children's development/lifespan.

In observation of Artz 4 Life Academy’s dismissal lateness policy for aftercare and summer programming:

The Summer Camp program’s hours of operation are 7:00 AM- 5:00 PM. Children must be picked up by 5:00 PM. For any child picked up after the 15-minute grace period, there will be a $10 late fee. After 15 minutes, the charge will be $1 for every minute.

We appreciate your commitment to your child's success, and we look forward to a wonderful summer camp experience. Thank you for your cooperation, and if you have questions or concerns, please contact Artz 4 Life at (727) 216-3519.

Please fill out the information below for participant(s) and acknowledge the Late Pick-Up Policy.
Participant(s) Name*
Parent/Guardian Name (print)*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
This is a double-sided form, please turn over to fill out Pick-Up Authorization List.

Parent Pick-Up Authorization List
Parent Name*
Child(ren)'s Name*
Phone Number*
Format: (000) 000-0000.
I, (name of parent)* give the following persons permission topick up my child from Artz 4 Life Academy. I understand that only I can add or remove namesfrom this list. I will make sure that the persons on this list present their I.D. at the time of pick up.
Parent Signature*

Clear
Date*

MonthDayYear
Date
Name*
Phone #*
Format: (000) 000-0000.
Date added*

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address*
Name
Phone #
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Date added
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone #
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone #
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address
Name
Phone
Format: (000) 000-0000.
Date added

MonthDayYear
Date
Date Removed

MonthDayYear
Date
Address

ARTZ 4 LIFE ACADEMY MEMBER EXPECTATIONS

Children are asked to adhere to the following agreement.

As a Artz 4 Life Academy Afterschool Participant, I promise to:

1. Always treat others with respect.

2. Use only polite, kind words.

3. Always listen to and respect the Afterschool staff.

4. Respect Recreation Center property.

5. Respect other people and their property.

6. Always keep my hands and feet to myself.

7. Always ask permission before leaving the Afterschool area.

8. Avoid fighting, bullying, and teasing others.

9. Follow the Afterschool schedule.

10. Always resist peer pressure.

11. Take responsibilities for my actions.

12. Always stand up for my beliefs.

13. Always resolve conflict nonviolently.

14. Respect other people's cultural/racial/ethnic background.

15. Always help others when they are in need of help.

16. Always tell the truth.

17. Always clean up after myself.

18. Be proud of who I am.

19. Always try my best.
Participant Signature*

Clear
Date*

MonthDayYear
Date

YesNo
Participant(s) Name*
Parent Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CHILD'S ENROLLMENT RECORD

CHILD 1

Primary Hours of Care

Family Information:

MISCELLANEOUS INFORMATION

CHILD'S ENROLLMENT RECORD (CHILD #2)

CHILD 2

Primary Hours of Care

Medical Information:

MISCELLANEOUS INFORMATION

CHILD'S ENROLLMENT RECORD

CHILD 3

Primary Hours of Care

Medical Information:

CHILD 1

CHILD 2

CHILD 3

jwb- Additional participants

LATE PICK-UP POLICY FORM