Child’s Full Name:

(Last) (First) (Middle)

Child's Date of Birth

YYYY

Sex

Male

Female

Nickname

Child’s Full Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

First day of Attendance (when they will start)

(school begins Monday, 8/14/23)

YYYY

Date of Enrollment (Today's Date)

YYYY

Primary Hours of Care (Anticipated Drop-off & Pick-Up Time)

From ____ to ____

Did your child participate in a VPK4 program last year?

Grade to Enter for "2023-2024" School Year

Has he/she failed any grade?

If Yes, what grade?

Last school attended

Reason for selecting this school

School recommended by

Name of your church

Family Information:

Child lives with (Please Check One)

Mother

Father

Both

Other

If Other, Print Name & Number

If Other, Custody?

Mother’s Name

First Name

Last Name

Mother’s Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother’s Cell

(###)

###

####

Mother’s Work

(###)

###

####

Mother - Legal custody?

Mother - Permitted to remove child?

Father’s Name

First Name

Last Name

Father’s Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Cell

(###)

###

####

Father’s Work

(###)

###

####

Father - Legal custody?

Father - Permitted to remove child?

Medical Information:

Child’s Physician

Physician's Address

Physician's Phone

(###)

###

####

Please list All known allergies, special medical needs & other areas of concern/helpful info:

Please list any hobbies, extracurricular activities, interests, etc.

Emergency Contacts:

Child will be released to the parent(s) or legal guardian as shown above and/or the persons listed below. The following persons will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency. Name Home/Work/Cell Phone Number(s) Relationship to Child

Emergency Contact 1 (Name AND Number)

Emergency Contact 2 (Name AND Number)

Emergency Contact 3 (Name AND Number)

FLORIDA DCF REQUIREMENTS

• Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. • Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the 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). Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate.

Florida DCF Requirements Signature

Florida DCF Requirements Signature Date

YYYY

HANDBOOK/DISCIPLINARY PROCEDURES ACKNOWLEDGEMENT

Parents are required to be notified in writing of the disciplinary practices used by the childcare facility. By signing below I acknowledge receipt of the school handbook, which includes this policy.

Handbook / Disciplinary Procedures Signature

Handbook / Disciplinary Procedures Signature Date

YYYY

FIELD TRIP/ACTIVITIES AGREEMENT

I give permission for my child to participate in any and all school activities, which may include, but is not limited to trips away from Good Shepherd.

I further absolve Good Shepherd and/or all Good Shepherd Employees from liability because of any and all injuries that may occur at Good Shepherd or during any and all activities away from Good Shepherd.

Field Trip / Activities Signature

Field Trip / Activities Signature Date

YYYY

Please check the box to give permission to take pictures of your child/children throughout the year for classroom for projects, school/classroom newsletter, and/or social media (i.e. website/Facebook) etc.

I give permission to take pictures of my child for the reason listed above.

I DO NOT give permission to take pictures of my child for the reasons listed above.

Primary parent/guardian

Secondary parent/guardian

Enrollment Form