Enrollment Application Form

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.

In order to assist us in providing the best possible service, please answer the following questions.

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.)

Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate.