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STATE OF FLORIDA - DEPARMENT OF CHILDREN AND FAMILIES
CHILD CARE APPLICATION FOR ENROLLMENT
Student Information :
Student Name
*
First
Last
Date of Birth
*
Gender
*
Male
Female
Student's Physical Address
*
Student Current School Grade ( Pre-K through 12)
*
Name of School Attending :
*
Preferred Class Timing :
From
*
7.30 am
8 am
9 am
10 am
11 am
12 noon
1 pm
2pm
3 pm
4 pm
5 pm
6 pm
To
*
8 am
9 am
10 am
11 am
noon
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
Days of the Week in Robotics Class
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Meals you would typically purchase while in class
*
Breakfast
AM Snack
Lunch
PM Snack
Eve Snack
Family Information
Child lives with :
*
Parent's Email :
*
Mother's Name
*
Address (Please fill in, if different from above)
*
Home Phone
*
Employer
*
Address
*
Work Phone
*
Cell Phone
*
Father's Name
*
Address (Please fill in, if different from above)
*
Home Phone
*
Employer
*
Address
*
Work Phone
*
Cell Phone
*
Custody
*
Mother
Father
Both
Other
Medical Information
I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.
Doctor
*
Address
*
Phone
*
Dentist
*
Address
*
Phone
*
Hospital Preference
*
Please list allergies, special medical or dietary needs, or other areas of concern :
*
Contacts :
Child will be released only to the custodial parent or legal guardian and the person 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 or legal guardian cannot be reached :
Name
*
Address
*
Phone
*
Helpful information about child
*
Upload a picture of Child
*
Max file size: 20MB
Please upload a clear picture of your child.
Section 65 C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. ( For Kids less than age 5, submitting physical examination and immunization record is mandatory. Not required for school age kids. ) Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "KNOW YOUR CHILD CARE FACILITY"(www.shivarobotics.com/brochure.html) Section 65C-22.006(4) (c)., requires that parents are notified in writing of the disciplinary practices(http://www.shivarobotics.com/discipline-policy.html) used by the child care facility. Your signature below indicates that you have received the above items and that all information on this enrollment form is complete and accurate. Please type your name to sign
*
Section 65 C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. ( For Kids less than age 5, submitting physical examination and immunization record is mandatory. Not required for school age kids. ) Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "KNOW YOUR CHILD CARE FACILITY" Section 65C-22.006(4) (c)., requires that parents are notified in writing of the disciplinary practices used by the child care facility. Your signature below indicates that you have received the above items and that all information on this enrollment form is complete and accurate.
Date
*
Submit
Home
About us
Our Story
Awards
Media Room
>
Media Kit
Press
Gallery
Programs
Robotics Class - After-School/Weekend
>
Robotics Class Information
Recreational Robotics Class Rates
Competitive Teams
>
Junior Team
Senior Team
SPRING CAMP
SUMMER CAMP
Robotics Workshop
Birthday Parties
School Field Trips
Application for Enrollment
Blog
Online Store
We are Hiring
Franchising
FLL Jr Expo Registration
Network
Testimonials
Contact Us
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