Excel Kids Academy 2024-2025 Afterschool Enrollment Application

Family Information
Parent/Guardian Name*

PrefixFirst NameLast NameSuffix
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer*
Work Number*

Area CodePhone Number
Cell Number *

Area CodePhone Number
Email*
example@example.com
Parent/Guardian Name

PrefixFirst NameLast NameSuffix
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Employer
Work Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Email
example@example.com
Student's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contacts

& Authorized Persons Allowed to Pick Up Your Child
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to Student*
Is this contact authorized to pick up your child?*

YesNo
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Student
Is this contact authorized to pick up your child?

YesNo
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Student
Is this contact authorized to pick up your child?

YesNo
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Student
Is this contact authorized to pick up your child?

YesNo
Is there any person NOT allowed to pick up your child?
Name

First NameLast Name
Relationship to Student
Race, Height, Weight, and any Comments
Photo of Person NOT allowed to pick up your child.

Browse Files
File must be smaller than 10 MB. Cancelof
Name

First NameLast Name
Relationship to Student
Race, Height, Weight, and any Comments
Photo of Person NOT allowed to pick up your child.

Browse Files
File must be smaller than 10 MB. Cancelof

Medical Information
In case of emergency, Excel Kids Academy staff in collaboration with 21st CCLC will call 911 and contact the parent/legal guardian and/or emergency contacts listed with Excel Kids Academy.

Please provide Excel Kids Academy in collaboration with 21st CCLC with medical personnel contact information to obtain emergency medical care if warranted.
Doctor's Name

First NameLast Name
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor's Phone Number

Area CodePhone Number
Insurance Company
Policy/Group Number
Name policy is under

First NameLast Name
Phone Number

Area CodePhone Number
Hospital Preference
List any Health Restrictions (Allergies, Vision, Hearing, Etc.) *
List any Diet Restrictions (Allergies-Gluten, Dairy, Nuts, Etc.)*
Does your child take any medication?*

YesNo
If yes, please list.
Actions to take if medical care is needed.*
Are there any unusual factors in the child's life which the teacher or staff should be aware of?*
I give consent to Excel Kids Academy in collaboration with 21st CCLC staff to apply provided sunscreen and/or bug spray for my child.*

Bugspray only; please initial below.Sunscreen only; please initial below.Both; please initial below.None
Initials

Privacy Rights & Authorizations
PRIVACY RIGHTS
I understand that pictures, and/or video will be taken during program activities/events. I give permission to Excel Kids Academy in collaboration with 21st CCLC and/or its Community Partners to use said photos/videos of my child, family and myself to be used in educational, promotional or informational materials or press media for positive public relations purposes.*

Yes; please initial below.No
Initials
I give consent to Excel Kids Academy in collaboration with 21st CCLC to contact me via my email provided within this application for updates pertaining to my child and program activities. (Excel Kids Academy in collaboration with 21st CCLC will not share your email address to third parties without your consent.)*

Yes; please initial below.No
Initials
PERMISSION TO EVALUATE PROGRAMS AND TRACK STUDENT PROGRESS
I give permission for Excel Kids Academy in collaboration with 21st CCLC staff to review my child's school data (test scores, report cards, attendance, and other performance indices), for the purpose of providing targeted support, academic instruction and assessing the effectiveness of Excel Kids Academy in collaboration with 21st CCLC. I also give permission for the Excel Kids Academy in collaboration with 21st CCLC staff to monitor my child's progress and to require my child to complete evaluation surveys for the purpose of determining program effectiveness.*

Yes; please initial below.No
Initials
FLORIDA CHILD CARE STANDARDS AND STATUTES
- Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility" (CF/PI 175-24).
- Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility.

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Excel Kids Academy

We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child.

Family Information

Emergency Contacts

Medical Information

Privacy Rights & Authorizations

Program Expectations