Enrollment Application Form

Application Date
Date Format: MM slash DD slash YYYY
Date of Enrollment
Date Format: MM slash DD slash YYYY
Student Information
Social Security#
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Full Name
Full Name
First Middle Last
Child's Home Address
Address, Apt#, City State / Province / Region ZIP / Postal Code
Home Phone

Family Information
Mother's Name
Mother’s Social Security#
Nationality
Country
Email Address
Home Phone (If different from child’s)
Address (If different from child’s)
City State / Province / Region ZIP / Postal Code
Employer
Occupation
Address
City State / Province / Region ZIP / Postal Code
Work Phone
Cell
Father's Name
Father’s Social Security#
Nationality
Country
Email Address
Home Phone (If different from child’s)
Address (If different from child’s)
City State / Province / Region ZIP / Postal Code
Employer
Occupation
Address
City State / Province / Region ZIP / Postal Code
Work Phone
Cell
Who has custody?
- Mother
- Father
- Both
Other
Child lives with
- 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. I hereby give permission to provide first aid care for my child. In the event I cannot be reached, I hereby authorize North Miami Beach Learning Center, Inc. or their designated representative to transport my child to the nearest emergency room or any other that I designate, and I hereby grant my consent for the hospital and its medical staff to provide my child with emergency medical treatment which a physician deems necessary. If I have not specified any hospital below, my child will be taken to and cared for at the nearest hospital.
Child’s Physician or Clinic Name (Child’s Primary Health Source):
Address
Phone
Hospital Preference
I accept responsibility for any necessary medical expenses incurred in the medical treatment of my child, which is not covered by the following
Health Insurance Company
ID #
Group#
Name of Policy Holder
Relationship to Child
Please list allergies, special medical or dietary needs, or other areas of concern:
My child is currently on medication(s) prescribed for long-term continuous use:
Describe past serious illnesses or hospitalization, with dates:

Additional Information
Was your child premature?
- Yes
- No
Born at ______weeks
What language(s) does your child speak?
If your child doesn’t speak yet, what language(s) does your child understand?
In order to assist us in providing the best possible service, please answer the following questions.
How did you hear about us?
If a friend or relative recommended us, may we have their name? We provide an incentive.
What convinced you to enroll your child at our preschool?
What school did your child last attend and why did you withdraw your child?

Contacts
Child will be released only to the custodial parent or legal guardian 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 or legal guardian cannot be reached: (A picture ID must be submitted at the time of registration or prior to picking up the child.)
Contact List
Name Address Work/Home# Cell# Relationship to Child

Please list anyone NOT allowed to have any contact with your child? It is legal for either parent to pick up their child unless we have a copy of the court order restricting violation or unless it is noted on this form.
• Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) in each child’s file. • Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility” (CF/PI 175-24). • Section 39.604 requires that parents receive a copy of the Rilya Wilson Act Flyer and Distracted Adults Flyer. • Section 65C-22.006(3)(c)2., F.A.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 the information on this enrollment form is complete and accurate.
Signature of Parent/Guardian
Date
Date Format: MM slash DD slash YYYY
Signature of Parent/Guardian
Date
Date Format: MM slash DD slash YYYY

Student Information

Name	Address	Work/Home#	Cell#	Relationship to Child