State of Florida - Learning Ladders Preschool



State of Florida Department of Children and Families

LEARNING LADDERS PRESCHOOL APPLICATION FOR ENROLLMENT

Student Information: Child’s Date of Birth: ____________Gender: _______

Date of Enrollment _________________________

Child’s Full (first day of class) Name:___________________________________________________________________________

Last First Middle Nickname

Child’s Address: ____________________________________ City _______________ Zip________

Primary Hours of Care: From: _______To: _______ Days of the Week Care: M T W TH F

Family Information:

Mother’s Name: ______________________ Father’s Name:____________________________

Address:____________________________ Address:_________________________________

Home Phone: ________________________ Home Phone: _____________________________

Cell Phone: __________________________ Cell Phone: ______________________________

Employer: ___________________________ Employer: ________________________________

Phone: ____________________________ Phone:________________________________

Address:___________________________ Address: _______________________________

Email address so you can receive school updates and information:

Mother _______________________________ Father___________________________________

Updates and information will also be on Facebook and twitter under Learning Ladders Preschool or website:

Custody: Mother ______ Father _______ Both _______ Other ______

Child lives with: _____________________________

Medical Information

I hereby grant permission for the staff of this facility to contact the following personnel to obtain emergency medical care if warranted.

Doctor:_______________________ Phone: _______________ Address: ____________________

Doctor:_______________________ Phone: _______________ Address: ____________________

Dentist:_______________________ Phone: _______________ Address: ____________________

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 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:

Name Address Work # Home #

Name Address Work # Home #

Name Address Work # Home #

Name Address Work # Home #

Helpful Information About Child:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

My child has permission to attend all field trips with Learning Ladders Preschool. I do understand I will be notified of events in advance.

I do understand that my child will on occasion be using the playground, basketball court, and field area directly behind and beside the back parking lot of the church as well as other rooms and areas on the church property.

I understand that some classrooms and outdoor areas of the school have fish, crabs, hamsters, bugs, lizards, and other crawling creatures. I also understand that pets are brought to the school on special occasions and with consent of the Director.

I give Learning Ladders permission to have my child photographed by the press of the facility to use for Public Relations at any time.

By signing below, you verify that you have received the above items, you have agreed to the above statements, and that all information on this enrollment form is complete and accurate.

By signing below, I also understand I am accountable for payment due of services rendered for my child.

_________________________________________ __________________

Signature of Parent / Guardian Date

January 2017

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Parent Handbook under section “General Information” Admission requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) before your child can attend school.

Section 402.3125(5), F.S., requires that parents

receive a copy of the Child Care Facility Brochure, “KNOW YOUR CHILD CARE CENTER”.

Section 10M-12.025(4)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility.

I have been provided information detailing the causes, symptoms, and transmission of the influenza virus (the flu) every year during August and September.

My signature below verifies receipt of the brochure on “Influenza Virus, the Flu, A Guide to Parents”.

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