Application for Enrollment

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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 *

Student's Physical Address *

Student Current School Grade ( Pre-K through 12) *

Name of School Attending : *

Preferred Class Timing :

From *

To *

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

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STATE OF FLORIDA - DEPARMENT OF CHILDREN AND FAMILIESCHILD CARE APPLICATION FOR ENROLLMENT

Student Information :

Preferred Class Timing :

Family Information:

Medical Information:

Contacts:

Stay connected & receive our special Promo Codes!

TESTIMONIALS

Need help? Contact us!

Telephone

Email

Contact Us

About Us

Programs

Online Store

STATE OF FLORIDA - DEPARMENT OF CHILDREN AND FAMILIES
CHILD CARE APPLICATION FOR ENROLLMENT