After School Enrollment Application

After School Application

(Please complete one per child)
ABOUT MY CHILD:
Name*

First NameLast Name
Elementary School Name*
Transportation only available from Glen Springs, Talbot, Norton and Meadowbrook
if other, please fill in name of school
Grade*
Child Gender*

FemaleMale
Child DOB*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
PRIMARY CONTACTS (Parent/Guardian):
Parent 1 Name*

First NameLast Name
Parent 1 Relationship to Child*
Parent 1 Has Same Address as Child? (Will auto fill address from Above)

Type option 1
Parent 1 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent 1 Cell Phone*
Please enter a valid phone number.
Parent 1 Email*
example@example.com
Check here if one parent is NOT authorized to pick up the child. Parent's name: A copy of the Court Order is required to be effective. Required by Florida Department of Children and Families (DCF): at least one emergency contact who is authorized to pick up your child in the event that neither parent/guardian can be reached. Your child will not be released to anyone who is not listed on this page without YOUR written permission. "I hereby authorize A Child's Academy/Bouncers to allow my child to leave with the following people:" Cell Phone
AUTHORIZED PICKUP PERSONS:
Auth Pickup 1 Name
Auth Pickup 1 Cell Phone
Auth Pickup 2 Name
Auth Pickup 2 Cell Phone
Auth Pickup 3 Name
Auth Pickup 3 Cell Phone
In accordance with the Min. Standards and Guidelines from DCF. please list problems or needs, including known allergies, existing illnesses, previous illnesses and injuries, any disabilities or behavior issues, any hospitalizations during the past twelve months, and any medication prescribed for long-term. continuous use. and any other information the staff should be aware. If none, please write "None" *
To better accommodate any special needs of your child, we will require a written authorization for need and care from the parent or guardian and/or the child's physician. The parent/guardian is responsible for providing any equipment and/or training that staff personnel may requirein relation to special needs and care of the child. In some instances, determined on a case-by-case basis, a personal meeting with the child's physician and parent/guardian may be required.

Upload the written authorization below:
File Upload

Cancelof
Name of Physician
Physician Address
Physician Phone
Hospital of Clinic (if you have a preferred care facility)
Hospital Address
Hospital Phone

After School Application

ABOUT MY CHILD:

PRIMARY CONTACTS (Parent/Guardian):

AUTHORIZED PICKUP PERSONS: