Children’sEnrollment ApplicationDate of Registration:______________Date of Termination of Services:___________Child’s Name:______________________Child’s Primary language:__________________ Sex:___________Date of Birth:___________________ Nickname:______________Home Email Address:____________________________________Child’s Home Address:___________________________________Circle Days to Attend:AM MON TUES WED THU FRIArrival Time:_______________Departure Time:____________PM MON TUES WED THU FRIArrival Time:_______________Departure Time:____________
Meals: Breakfast______ AM Snack_____ PM Snack_____Lunch_____SCHOOL INFORMATIONDoes your child attend school? Yes______ No______Elementary School Name:________________________________School Start Time:________________ School EndTime:_____________EMERGENCY CONTACT AND RELEASE PERSONSChild’s Name: Age: Date:Date of Enrollment: Address:Mother’s Name: Home Phone:Home Address:Mother’s Employer: Address:Mother’s Work #: Mother’s Cell #:Father’s Name: Home Phone:Home Address:Father’s Employer: Address:Father’s Work #: Father’s Cell #:Custody: Mother: Father: Both OtherPersons authorized to assume responsibility for your child if parents arenot available.Guardian’s Name: Guardian’s Name:Relationship: Relationship:
Address: Address:Phone: Phone:If you want a person who is not identified above to pick up your child,you must notify in advance.CUSTODIAL INFORMATION: If a non-custodial parent is not includedamong those people authorized by a custodial parent to pick up thechild, please explain below and attach a copy of appropriate documents(court order or other).PARENTAL AUTHORIZATION FOR EMERGENCY TREATMENTCHILD’SNAME_________________________________________________PARENT/GUARDIANNAME:______________________________________CHILD’S MEDICAL INFORMATIONMedicalProblems:_______________________________________________Allergies to drugs, foods orother:___________________________________Medicine(s) Child istaking_________________________________________If an event of an emergency requiring a physician’s care, do youconsent to call your family physician?
Yes _________ No___________Physician’s Name: PhoneNumber:_____________CHILD’S INSURANCE:Company/Policy Number: ________________________Secondary Health Insurance Provider/PolicyNumber:___________________Please list any specialmedications:_________________________________________________________________________________________________I (we) state that we are the parent(s) guardian(s) having legal custodyof the child above and attest that the information above is correct. I(we) authorize L.O.A. director or director’s designee to transport byambulance and obtain emergency treatment for my child. I consent toan x-ray examination, anesthetic, medical or surgical diagnosis ortreatment, and hospital care to be rendered to the minor under thegeneral supervision of any physician or surgeon.THE FOLLOWING STEPS WILL BE FOLLOWED IN AN EMERGENCY:1. The parent/Guardian will be contacted immediately.2. We will attempt to contact you through all of the emergency personslisted on the child’s application form.3. If we cannot contact you or your physician, we will do any or all ofthe following.
(a)Call for emergency first aid assistance/transportation.(b) Call another physician.(c)Have the child transported to an emergency hospital in thecompany of a staff member.Parent/Guardian Signature:________________Date:________________MEDICAL HISTORYHeight:__________________ Weight:______________________Allergies and another medical conditions:Allergies: Yes No My child is allergic to Peanut ButterYes No My child is allergic to StrawberriesYes No My child is allergic to Milk or DiaryProductsYes No Explain:Yes No My child is on a specialExplain:_____________________________Asthma Yes ________ No________Diabetes Yes________ No________Other:_______________________________________________________-Medication that will be administered regularly at the academy:-Is your child toilet trained?-Medications will be administered in accordance with Florida StateCare licensing.-Prescription medication must include a prescriptionlabel with specific dispensing instructions and a current date.PERMISSION TO CHANGE CHILD’S CLOTHING
We at The Little Orange Academy would like your permission tochange your child’s clothes. During the day children do manyactivities and sometimes they get wet or soiled and need to bechanged.I____________________________________ give my permission forthe staff of The Little Orange Academy to change my child’s clothingas needed.Please be sure shoes are rubber-soled and closed-toe. Flip-flops,sandals, are not appropriate in our environment. Shoes or securesneakers that slip on or fasten Velcro are required for all walkingchildren.PERMISSION FOR YOUR CHILD TO BE PHOTOGRAPHEDAt The little Orange Academy we photograph children during specialactivities, daily routines and families as they arrive at our center. Thesepictures will only be used to display in our center and in your child’sclassroom.I ______________________________ give my permission for my child_______________ to be photographed for The Little Orange Academy,and picture should only be displayed in the Academy.