HTML Preview First For Kids Enrollment Application page number 1.
CF-FSP 5219, January 2008
State of Florida
Department of Children and Families
CHILD CARE APPLICATION FOR ENROLLMENT
Student Information
: Date of Birth: ___Sex:
Date of Enrollment:________
Full Name: _____________________________________________________________________________________
Last First Middle Nickname
Child's Physical Address:_________________________________________________________________________
Primary Hours of Care: From __________________ To _________________
Days of the Week in Care: M T W Th F Sa Su
Meals Typically Served While in Care: Br AM Snack Lunch PM Snack Sup Eve Snack
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Family Information
: Child Lives With: ______________________________
Mother's Name:
Father's Name:
Address:
Address:
Home Phone:
Home Phone:
Employer:
Employer:
Address:
Address:
Work Phone: ________________/
Cell:___________ Work Phone:______________/Cell______________
Custody: Mother ________ Father ________ Both ________ Other ________
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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:
Doctor:
Address: Phone:
Dentist:
Address: Phone:
Hospital Preference:
Please list allergies, special medical or dietary needs, or other areas of concern:
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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#