Parrish Charter Academy Preschool - Enrollment Application

Enrollment Application

Parrish Charter Academy Preschool
Four-Year-Old and VPK Programs

Hours of Operation: 7:00 AM - 6:00 PM

Student Information
Date of Application*

MonthDayYear
Date
Preferred Start Date*

MonthDayYear
Date
Child's Name*

First NameMiddle NameLast Name
Nickname (If Applicable)
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Social Security Number
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the child's sibling(s) attend Parrish Charter Academy OR North River Charter Academy?*

Yes - Parrish Charter AcademyYes - North River Charter AcademyNo
If "YES," please list all sibling names and grades.

Medical Conditions
Does your child have any allergies or other medical conditions?*

YesNo
If "Yes," please list allergies/conditions and provide 3-step medical plan details (ex. 1. administer epi-pen, 2. call parent, 3. call 911)
May your child participate in food-related activities in the classroom?*

YesNo

Primary Hours of Care
From:*
To:*
Days of the Week*

MondayTuesdayWednesdayThursdayFriday

Authorized Pick-Ups
Please list all non-custodial people who are authorized to pick up your child.
Authorized Pick-Up #1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Student
Authorized Pick-Up #2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Student
Authorized Pick-Up #3

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Student

Emergency/Medical Information & Contacts
By signing this portion, you agree that your child's "Authorized Pick-ups" may be contacted in the event of an emergency if the custodial parent(s) or legal guardian(s) cannot be reached. Said individuals are permitted to remove the child from the facility in case of illness, accident, if for some reason the custodial parent(s) or legal guardian(s) cannot be reached.*

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Date Signed*

MonthDayYear
Date
Pediatrician's Name:*
Pediatrician's Address:*
Pediatrician's Phone Number*
Please enter a valid phone number.
Dentist's Name:*
Dentist's Address:*
Dentist's Phone Number*
Please enter a valid phone number.
Hospital Preference*
Please list any allergies, special medication, dietary needs, or other areas of concern. If none, please write "None."*
By signing this portion, you hereby grant permission for the staff of the Parrish Charter Academy Preschool to contact your child's medical personnel or obtain emergency medical care if warranted:*

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Date Signed*

MonthDayYear
Date

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 Parrish Charter Academy Preschool (PCAP).
Child's Name

First NameLast Name
Parent Signature*

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Date Signed*

MonthDayYear
Date
Media Release:

Taking photographs and videos is a part of our daily routine at the Parrish Charter Academy Preschool (PCAP). 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 PCAP to photograph and video your child. Pictures or recordings may be used PCAP, on the website, 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.
Please select one:*

I DO give the Parrish Charter Academy Preschool permission to photograph my child.I DO NOT give the Parrish Charter Academy Preschool permission to photograph my child.
Child's Name*

First NameLast Name
Parent Signature*

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Date Signed*

MonthDayYear
Date
Medical Care:

I authorize Parrish Charter Academy Preschool (PCAP) to give consent for any and all of my child's emergency medical care, including CPR and abdominal thrusts maneuver while under the supervision of PCAP.

I authorize any emergency transportation to transport my child from the center to to nearby hospitals if such a situation would occur.
Child's Name*

First NameLast Name
Parent Signature*

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Date Signed*

MonthDayYear
Date
Curriculum & Screening Your Child:

PCAP has adopted the ELLM/Plus curriculum that is recommended by the State of Florida. PCAP 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 PCAP staff and director permission to screen your child using the Teaching Strategies Gold and/or Ages & Stages Program.
Child's Name*

First NameLast Name
Parent Signature*

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Date Signed*

MonthDayYear
Date
Thank your for completing our form to enroll your child at Parrish Charter Academy Preschool!

Please click the submit button only once.

You will receive an email confirmation that your form was submitted successfully.

Please find additional information online at www.PCAedu.org/PCAP
Should be Empty:

Enrollment Application

Mother's Information

Father's Information

Thank your for completing our form to enroll your child at Parrish Charter Academy Preschool!

Please click the submit button only once.

You will receive an email confirmation that your form was submitted successfully.

Please find additional information online at www.PCAedu.org/PCAP