Child's Full Name:


    Full Name of Parent/Guardian submitting this application:


    Signature of Parent/Guardian to be used in this application
    (please electronically sign below)



    Today's Date :

    Student Information

    Date of Birth :

    Sex:

    First Name:

    Middle Name:

    Last Name:

    Nickname:

    Child's Physical Address:

    Primary Hours of Care:

    From:

    To:

    Days of the Week in Care:

    Monday
    Tuesday
    Wednesday
    Thursday
    Friday



    Family Information



    Child lives with:

    Parent/Guardian Name:

    Address:

    Home Phone:

    Employer:

    Work Address:

    Work Phone:

    Cell Phone:

    Relationship to the child:




    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:

    Address:

    Phone:


    Doctor:

    Address:

    Phone:


    Dentist:

    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:



    Name:

    Address:

    Work #

    Cell/Home #


    Name:

    Address:

    Work #

    Cell/Home #


    Name:

    Address:

    Work #

    Cell/Home #


    Name:

    Address:

    Work #

    Cell/Home #

    Helpful Information about the Child:



    •Sections 7.1 and 7.2, of the Child Care Facility Handbook, require a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.
    •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.

    Please click here to read the Release and Waiver of Liability and Indemnity Agreement.

    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):


    Required Forms

    Please read the Influenza Virus : The Flu, A Guide to Parents brochure ( English | Spanish)

    Please read the Distracted Adult brochure ( English | Spanish)

    School Pickup Permission

    School Name :

    School Year :

    Emergency Pickup Information

    The location will be 9852 Little Road (empty store front)

    The following people can pick up my child/children in an emergency:

    Name :

    Phone number :


    Name :

    Phone number :


    Name :

    Phone number :


    Name :

    Phone number :

    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, , DO give permission for photographs of my child.

    I, , DO NOT give permission for photographs of my child.

    Parent Handbook

    Please read the Parent Handbook

    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.