REGISTRATION PROGRAM 2017-2018

                    KID’S VILLAGE ARTS PRE-SCHOOL PROGRAM

 

Registration form Program Year 2017-2018

 

STUDENT

Name:____________________________________________________________

 

Age: ___________Birthday: _________________Sex: ________________

 

Child lives With:____________________

 

Mother’s first name: __________________ Father’s first name: ___________________

Mother’s last name:  __________________ Father’s last name: ___________________

Home phone________________________   Home Phone: ________________________

Address: __________________________              Address: ____________________________

Employer: _________________________           Employer:___________________________

Mother’s work: _____________________    Father’s work: _______________________

Mother’s Cel.: ______________________    Father’s Cel. : ________________________

E-mail Address:__________________________________________________________

Custody:   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.

Doctor: ____________________________ Address: ___________________________

Phone: _______________

Doctor: ____________________________ Address: ___________________________

Phone: _______________

Dentist: ____________________________ Address: ___________________________  Phone:________________

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:

 

 

 

 

 

 

 

 

Section   65C –22.006 (2), F.A.C., requires a current physical examination (form DH 3040) and immunization record (Form DH 680 or DH 681) within 30 days of enrollment.

 

Section 402.3125(5), FS., requires that parents are notified in writing  of the disciplinary practices used by the child care facility.

 

Section 65C-20.11(2)(c)(1), F.A.C., requires that parent(s) receive a copy of the family day care home brochure, “Selecting A Family Day Care Home Provider” (CF/PI 175-28)

 

Section 65C-22.006(3)(c)2., F.A.C. requires that parents are notified in writing of disciplinary practices used by the child care facility, or

 

Section 65C-20.010(6)(c), F.A.C., requires that a written a copy of the family day care provider’s discipline policy be available for review by the parent(s).

 

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

 

Please complete registration, to ensure space you must make payment with the registration form to Doral Conservatory and School of the Arts.

 

 

_____________________________________________________________________

Signature of parent\ guardian                                            Date

 

 

Name: ____________________________ Driver’s license:______________________

 

 

 

 

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