2017-18 Preschool Application


Student Information

Full Name:_______________________________________________________________________

Date of Birth: ____________   Sex: ___ Date of Enrollment:___________ 

Child's Physical Address:____________________________________________________________

 Email address(es) to reach parents:________________________________________________

Family Information:  Child Lives With: ______________________________

Mother's Name: _________________________       Father's Name: _________________________      

Address:  ____________________________________________________        

Work Phone: ___________/Cell:___________  Work Phone: ___________/Cell:___________

Custody:     Mother ________ Father ________ Both ________  Other ________

Name of Church attended by parents_____________________________________________

I agree to receiving VPK care Monday, Wednesday, Friday from 8:30 AM – 1:30 PM

I agree to provide an AM snack and a healthy lunch for my child each school day

I give permission for my child to take part in all school activities

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:    _______________

Dentist:__________________      Address: _____________________     Phone:   _______________

Hospital Preference:  ______________________________________________________________________        

Please list allergies, special medical or dietary needs, or other information we should know about your child:   



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_________________________    Phone #_________________

Name _____________________   Address_________________________    Phone #_________________

Name _____________________   Address_________________________    Phone #_________________


• 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 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility
Brochure, "Know Your Child Care Facility” (CF/PI 175-24), or

  • 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 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.

Parent’s Signature_____________________________________________Date_____________________

ADMINISTRATIVE: Registration Paid___________________ Supply Fee Paid______________