Signature of Parent/Guardian to be used in this application
(please sign electronically below)
Today's Date :
Student Information
Child's Date of Birth :
Child's Sex:
Child's First Name:
Child's Middle Name:
Child's Last Name:
Child's Nickname:
Child's Physical Address:
Primary Hours of Care:
From: (Please enter the time and AM or PM)
To: (Please enter the time and AM or PM)
Days of the Week in Care:
Monday
Tuesday
Wednesday
Thursday
Friday
Family Information
Child lives with:
Parent/Guardian #1
Parent/Guardian Name:
Address:
Home Phone:
Employer:
Work Address:
Work Phone:
Cell Phone:
Relationship to the child:
Parent/Guardian #2
Parent/Guardian Name:
Address:
Home Phone:
Employer:
Work Address:
Work Phone:
Cell Phone:
Relationship to the child:
Custody:
Medical Information
I hereby grant permission to the staff of this facility to contact the following medical personnel to obtain medical care if warranted.
Doctor #1
Doctor Name:
Address:
Phone:
Doctor #2
Doctor Name:
Address:
Phone:
Dentist
Dentist Name:
Address:
Phone:
Hospital Preference:
Please list allergies, special medical or dietary needs, or other areas of concern:
Emergency Care Plan instructions including symptoms, medication, and notification in the event of an actual emergency (if applicable):
Emergency Contacts
Child will be released only to the custodial parent(s)or legal guardian(s)and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason,the custodial parent(s)or legal guardian(s)cannot be reached:
Emergency Contact #1
Name:
Address:
Work #
Cell/Home #
Emergency Contact #2
Name:
Address:
Work #
Cell/Home #
Emergency Contact #3
Name:
Address:
Work #
Cell/Home #
Emergency Contact #4
Name:
Address:
Work #
Cell/Home #
Helpful Information about the Child:
•Section 7.3, of the Child Care Facility Handbook, requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility” (CF/PI 175-24), or
•Section 8.3, of the Family Day Care Home/ Large Family Child Care Home Handbook,requires that parent(s) receive a copy of the family day care home brochure,“Selecting A Family Day Care Home Provider” (CF/PI 175-28).
•Section 7.3, C.3 of the Child Care Facility Handbook, requires that parents are provided food and nutrition policies used by the child care facility.
•Section 2.8, of the Child Care Facility Handbook,requires that parents are notified in writing of the discipli5ary and expulsion policies used by the child care facility,or •Section 2.3,of the Family DayCare Home/ Large Family Child Care Home Handbook,requires that parents are notified in writing of the disciplinary and expulsion policies used by the family day care provider.
I 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.
Please click here to read the Release and Waiver of Liability and Indemnity Agreement.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME, AND INTEND MY ELECTRONIC SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
Permission for Food-Related Activities and Special Occasion Food Consumption
Pursuant to 65C-22.005(1)(c)2., F.A.C.. licensed child care facilities must obtain written permission from parents/guardians regarding a child’s participation in food related activities. These activities include such things as: classroom cooking projects, gardening, school wide celebrations, and birthdays.
I (please check one)
GIVE DECLINE
permission for my child to participate in food related activities and special occasions wherein food is consumed.
Please check one of the following:
My child DOES NOT have a food allergy or dietary restriction. He or she MAY participate in food related activities and special occasions wherein food is consumed.
My child DOES NOT have a food allergy or dietary restriction. He or she MAY NOT participate in food related activities and special occasions wherein food is consumed.
My child DOES have a food allergy or dietary restriction. He or she MAY NOT participate in food related activities and special occasions wherein food is consumed.
My child DOES have a food allergy or dietary restriction. He or she may participate in food related activities and special occasions wherein food is consumed, but may not eat or handle the following items (please list below):
I understand that it is my responsibility to update this form in the event that my child's food permissions change. I agree that this form will remain in effect during the term of my child's enrollment or until changes are made in writing my completing an updated form.
Required Forms
Please read the Influenza Virus : The Flu, A Guide to Parents brochure ( English | Spanish)
I verify that I have received the Influenza Virus : The Flu, A Guide to Parents brochure.
Please read the Distracted Adult brochure ( English | Spanish)
I verify that I have received the Distracted Adult brochure.
School Pickup Permission
I give Kids Kicking High permission to drop off and pick up my child from his/her school, so they may attend the Kids Kicking High before and after school program.
School Name :
School Year :
Emergency Pickup Information
I, in case of an emergency where it is necessary to evacuate, give Kids Kicking High permission to transport my child/children to a safe shelter where they will remain until they are safely picked up by the parents and/or the emergency contact person.
The location will be 9852 Little Road (empty store front)
The following people can pick up my child/children in an emergency:
Emergency Pickup Contact #1
Name :
Phone number :
Emergency Pickup Contact #2
Name :
Phone number :
Emergency Pickup Contact #3
Name :
Phone number :
Emergency Pickup Contact #4
Name :
Phone number :
I verify that this will stay in effect while my child remains enrolled in Kids Kicking High.
Authorization for Publication Release
I give Kids Kicking High, Inc my permission to take photographs of my child at special events, holiday activities, tournaments, and during class. I understand that the photographs may be posted on the website, or used in forms of publications such as handbooks, flyers, advertisements, and social media.
I acknowledge that I have read and understand the publication policy.
Parent Handbook
Please read the Parent Handbook
I acknowledge that I have received and read the Parent Handbook including the discipline, suspension, and expulsion policy of Kids Kids Kicking Inc. If at any time I have any questions or concerns I will address them with the Director or Owners.
Does your child have an IEP?
If 'Yes', please bring the IEP in with you on your first day and we will make a copy of it.
