1. Student Information

Full Name

Nickname

Date of Birth

Sex

Start Date

Child’s Physical Address

Primary Hours of Care - Days

Times

2. Family Information

Child Lives With

Mother / Guardian

Full Name Address Home Phone Cell Phone Cell Carrier Employer Work Phone Email Address

Father / Guardian

Full Name Address Home Phone Cell Phone Cell Carrier Employer Work Phone Email Address

Custody

Mother Father Both Other

3. 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 Name Doctor Address Doctor Phone Dentist Name Dentist Address Dentist Phone Hospital Preference Food Allergies, Medical or Dietary Needs, or Other Concerns

4. Emergency Contacts

Child will be released only to the custodial parent or legal guardian and the persons listed below.

Name / Relationship Address Work # Home #

5. Helpful Information About Child

6. Additional Services & Fees

Please select any additional services or fees that apply:

Hollar Pizza Monday ($2 per pizza) School Activity Fee Technology Fee Field Trip Fee Aftercare Services Other

Additional Notes

7. Acknowledgment & Signature

Suncoast Community School admits students of any race, color, nationality, or ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students of the organization. It does not discriminate on the basis of color, nationality, or ethnic origin in administration of its admission policies, scholarships and loan programs, and other organizational administered programs.

Section 65C-22.006(2), F.A.C. requires a current physical examination and immunization record.
Section 402.3125(5), F.S. requires that parents receive a copy of the Child Care Facility Brochure.
Section 65C-22.006(3)(c)2., F.A.C. requires that parents are notified in writing of disciplinary practices used by the childcare facility.

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

Parent / Guardian Signature

Date

Parent / Guardian Signature

Date

Application for Enrollment