APPLICATION FOR ENROLLMENT

STUDENT INFORMATION

Full Name: _____________________________________________________________________________________________________ Last First Middle Nickname

Date of Birth: Sex: Date of Enrollment:

Child’s Physical Address:

Full Time Program 3 Day Program (M/W/F) 2 Day Program (T/TH)

FAMILY INFORMATION

Child Lives With: Mother Father Both Other ____________________________________________________

Mother Father

Name

Home Address

Home Phone

Employer

Employer Address

Work Phone

Cell Phone

Cell Phone Network Carrier

Email Address

Legal Custody? Yes No Yes No

Name of Other Legal Custody

EMERGENCY CONTACTS

Child will be released only to the custodial parent or legal guardian and the persons listed below (picture id required). The follow-ing people listed as EMERGENCY CONTACTS 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.

Emergency Contact

Name: ________________________________________________ Yes

Address:______________________________________________ City/State: Zip Code: No

Emergency Contact

Name: ________________________________________________ Yes

Address:______________________________________________ City/State: Zip Code: No

Emergency Contact

Name: ________________________________________________ Yes

Address:______________________________________________ City/State: Zip Code: No

Emergency Contact

Name: ________________________________________________ Yes

Address:______________________________________________ City/State: Zip Code: No

Cell Phone: ___________________________________________

Work Phone: __________________________________________

Relationship:

Cell Phone: ___________________________________________

Work Phone: __________________________________________

Relationship:

Cell Phone: ___________________________________________

Work Phone: __________________________________________

Relationship:

Cell Phone: ___________________________________________

Work Phone: __________________________________________

Relationship:

MEDICAL INFORMATION

I hereby grant permission for the staff of StarChild Academy 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 any allergies (food, medications, insects, etc.) or special dietary needs:

Please list any special medical conditions or other areas of concern:

Please list any special procedures required in caring for your child:

Emergency Care Plan Instructions (If Applicable):

HELPFUL INFORMATION ABOUT YOUR CHILD:

_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________

YOUR SIGNATURE

My signature below indicates that:

The information on this enrollment form is complete and accurate.

I am aware that DCF regulations require a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment (Reference: Sections 7.1 and 7.2 of the DCF Child Care Facility Handbook). (Note: Not re-quired for school-age children who do not attend StarChild Academy’s Private Elementary School.)

I have received a copy of DCF’s Child Care Facility Brochure, “Know Your Child Care Facility” (CF/PI 175-24) (Reference: Section 7.3 of the DCF Child Care Facility Handbook). A copy of this brochure is also available on StarChild Academy’s web-site at www.StarChildAcademy.com.

I have received a copy of the Food & Nutrition Policies (Reference: Sections 2.8 and 7.3 of the DCF Child Care Facility Hand-book).

I have received a copy of the StarChild Academy Parent’s Handbook. This handbook includes StarChild Academy’s Disci-pline & Expulsion Policies and A copy of the StarChild Academy Parent’s Handbook is also available on StarChild Acade-my’s website at www.StarChildAcademy.com.

I hereby grant permission for StarChild Academy’s staff to have access to my child’s records. StarChild Academy has per-mission to assess my child’s developmental and educational milestones.

Some children in care might not have current immunizations.

I agree to abide by the terms in the StarChild Academy Parent’s Handbook and that I am responsible for the payment of tui-tion and other fees as explained on the StarChild Academy price schedule.

Be advise that our facility has a small fish tank at the reception area. __________________________________________ _________________________________________ ________________________ Signature of Parent/Guardian Name of Parent/Guardian Date

PHOTOS, VIDEOS & INTERNET IMAGES

As a service to its parents, StarChild Academy has installed a video camera system which allows parents and other family members who have passwords to view their child(ren) in their classrooms, the dining room and on the playgrounds remotely through the Internet.

I give my permission to display photos and videos of my child(ren) via StarChild Academy’s Internet video camera system. I also agree that StarChild Academy may use photos and videos of my child(ren) for in-print, online and other lawful advertis-ing and marketing purposes.

ENROLLMEMT-FORM-2019.12.4

We are excited to offer the safety, convenience and ease of Tuition Express ®—an automatic payment pro-

cessing system that allows on-time tuition and fee payments to be made from your bank account.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD

I (we) herby authorized STARCHILD ACADEMY LAKE MARY to initiate credit card charges to the below-referenced

credit card account (Section A) OR, initiate debit entries to my (our) checking/savings account (Section B). To

properly affect the cancellation of this agreement, I (we) are required to give 10 days written notice. Credit union

members: please contact your credit union to verify account and routing numbers for automatic payments.

Section A have a convenience fee of 2.5% and Section B is free of charge.

Automated Payment Processing

Safe - Convenient - Easy

For Official Use Only

Date Received :______________________________________ Employee Signature:_____________________________

_______________________________________________________________________________________________________________ Cardholder Name Phone Number

______________________________________________________________________________________________________________________________________________________________

Cardholder Address City State Zip

Card Number (Visa or Master Card Only) Expiration Date CVV

_____________________________________________________________________________________________________________________________________________________________

Cardholder Signature Date

COMPLETE ONE SECTION ONLY

SECTION A (Credit Card) (Visa or Master Card Only) I Choose to Participate in the Automatic Withdrawal of Founds.

______________________________________________________________________________________________________________________________________________________________

Your Name Phone Number

______________________________________________________________________________________________________________________________________________________________

Address City State Zip

_______________________________________________________________________________________________________________________________________________________________

Bank or Credit Union Name Bank or Credit Union Address City State Zip

Routing Transit Number (see sample below) Account Number (see sample below) Checking Savings

_____________________________________________________________________________________________________________________________________________________________

Authorized Signature Date

SECTION B (Bank Account)

Student’s Name:_________________________________________

During the 2009 legislative session, a new law was passed that requires child care facilities, family day care homes and large family child care homes provide parents with information detailing the causes, symptoms, and transmission of the influenza virus (the flu) every year during August and September.My signature below verifies receipt of the brochure on Influenza Virus, The Flu, A Guide to Parents:

Name: ________________________________

Child’s Name: ________________________

Date Received: _______________________

Signature: ____________________________

Please complete and return this portion of the brochure to your child care provider, in order for them to maintain it in their records.

What should I do if my child gets sick?Consult your doctor and make sure your child gets plenty of rest and drinks a lot of fluids. Never give aspirin or medicine that has aspirin in it to children or teenagers who may have the flu.

CAll oR TAke youR ChIlD To A DoCToR RIGhT AWAy IF youR ChIlD:

• Has a high fever or fever that lasts a long time• Has trouble breathing or breathes fast• Has skin that looks blue• Is not drinking enough• Seems confused, will not wake up, does not

want to be held, or has seizures (uncontrolledshaking)

• Gets better but then worse again• Has other conditions (like heart or lung

disease, diabetes) that get worse

What can I do to prevent the spread of germs?The main way that the flu spreads is in respiratory droplets from coughing and sneezing. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and infect someone nearby. Though much less frequent, the flu may also spread through indirect contact with contaminated hands and articles soiled with nose and throat secretions. To prevent the spread of germs:

• Wash hands often with soapand water.

• Cover mouth/nose duringcoughs and sneezes. Ifyou don’t have a tissue,cough or sneeze into yourupper sleeve, not yourhands.

• Limit contact with peoplewho show signs of illness.

• Keep hands away from theface. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

When should my child stay home from child care?A person may be contagious and able to spread the virus from 1 day before showing symptoms to up to 5 days after getting sick. The time frame could be longer in children and in people who don’t fight disease well (people with weakened immune systems). When sick, your child should stay at home to rest and to avoid giving the flu to other children and should not return to child care or other group setting until his or her temperature has been normal and has been sign and symptom free for a period of 24 hours.

For additional helpful information about the dangers of the flu and how to protect your child, visit: http://www.cdc.gov/flu/ or http://www.immunizeflorida.org/

how can I protect my child from the flu? A flu vaccine is the best way to protect against the flu. Because the flu virus changes year to year, annual vaccination against the flu is recommended. The CDC recommends that all children from the ages of 6 months up to their 19th birthday receive a flu vaccine every fall or winter (children receiving a vaccine for the first time require two doses). You also can protect your child by receiving a flu vaccine yourself.

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“The Flu” A Guide

for Parents

For additional information, please visit www.myflorida.com/childcare or contact your

local licensing office below:

This brochure was created by the Department of Children and Families in consultation with the Department of Health.

CF/PI 175-70, June 2009

What is the influenza (flu) virus?Influenza (“the flu”) is caused by a virus which infects the nose, throat, and lungs. According to the US Center for Disease Control and Prevention (CDC), the flu is more dangerous than the common cold for children. Unlike the common cold, the flu can cause severe illness and life threatening complications in many people. Children under 5 who have the flu commonly need medical care. Severe flu complications are most common in children younger than 2 years old. Flu season can begin as early as October and last as late as May.

how can I tell if my child has a cold, or the flu? Most people with the flu feel tired and have fever, headache, dry cough, sore throat, runny or stuffy nose, and sore muscles. Some people, especially children, may also have stomach problems and diarrhea. Because the flu and colds have similar symptoms, it can be difficult to tell the difference between them based on symptoms alone. In general, the flu is worse than the common cold, and symptoms such as fever, body aches, extreme tiredness, and dry cough are more common and intense. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations.

STARCHILD ACADEMY’S FOOD AND NUTRITION POLICIES Lake Mary

Florida Administrative Code Chapter 65C-22.006 requires that there be signed statements from the custodial parents or legal guardian

that their child care facility has provided them with information on the child care facility’s food and nutrition policies that includes

language on food safety and food allergens. This information for StarChild Academy is shown below.

StarChild Academy provides nutritious meals and snacks of a quantity and quality to meet the daily nutritional needs of the children. The USDA My- Plate, June 2011, is used to determine what good groups to serve at each meal or snack and the serving size of the

selected foods for children ages two and older. The categories “oils” and “discretionary calories” are not considered food groups. Copies of the USDA MyPlate may be obtained from USDA website at http://www.chossemyplate.gov or from the following link http://www.lfrules.org/Gateways/reference.asp?no=Ref-03036. Using the USDA MyPlate, breakfast consist of at least three different food groups, lunch consist of at least four different food groups, and snacks consist of at least two different food groups.

Food provided by StarChild Academy directly, or by contract with an outside source such as a caterer, will be served only if in sound conditions, free from spoilage and contamination, and safe for human consumption. All food is stored and handled in a sanitary manner at all times.

StarChild Academy has adequate equipment available to maintain food safety.

1. Meat, poultry, fish, dairy products, and processed foods are inspected under the United States Department of Agriculture

requirements.

2. No raw milk or unpasteurized juice is served without the written consent of the parent of legal guardian.

3. No home-canned food is served.

4. No home-grown eggs are served.

5. No recalled food products are served.

6. All raw fruits and vegetables are washed thoroughly before being served or cooked.

7. To prevent food from becoming potentially hazardous, hot goods are maintained at a temperature of 135 degrees Fahrenheit or above, and cold foods are maintained at a temperature of 41 degrees Fahrenheit or below. The facility supplies adequate equipment to maintain temperature requirements.

8. Food is thoroughly cooked and/or reheated.

If StarChild Academy provides or makes available food to children in care from an outside source such as a caterer, or as the result of a learning activity provided by our child care program, such as a garden, it is the responsibility of StarChild Academy to ensure all food

intended for consumption by a child in care is in sound condition, green from spoilage and contamination, and safe for human

consumption. A copy of the license or permit for caterers is kept on file at StarChild Academy.

StarChild Academy maintains a food acceptance log for all pre-prepared meals being transported into the facility.

Parents or legal guardians are advised in advance of each food-related activity, such as special occasion and learning activities,

which include food consumption. Written parental permission may be obtained in the form of a general or specific permission slip. Documentation of parent permission for food activities in maintained for a minimum of four months for the date of each activity.

Parents are informed of food-related activities as follows:

Regular Meals and Snacks—Through Weekly Menus in the Parent Information Center, in the Dining Room, and Online

Classroom Holiday Parties—Through Sign Up Sheets in Each Classroom

Field Trips—Though the Field Trip Schedule

Parent’s Night Out—Through the Parent’s Night Out Sign Up Sheet

Birthday Parties—Will Occur on Various Dates Throughout the School Year Based on the Children’s Birthdates

Learning Activities and Other—Through Daily Reports Provided to Parents

If a special diet is required for a child by a physician, a copy of the physician’s order, a copy of the diet, and a sample meal plan for the special diet is maintained in the child’s file and followed. If the custodial parent or legal guardian notifies StarChild Academy of any

known food allergies, written documentation is maintained in the child’s file for as long as the child is in care. Special food restrictions

are shared with staff and are posted in a conspicuous location.

Meal and snack menus are planned, written, dated, and posted at the beginning of each week in a conspicuous place accessible to

parents. Any menu substation is noted on the menu. All meals and snacks prepared outside of the facility’s kitchen or designated food

preparation area, such as catered food, is listed along with the source of the prepared food. Daily meal and snack menus are maintained for a minimum of four months.

Documentation of parental permission for field trips and food activities/special occasions is retained for a minimum of

four months. Written documentation of known allergies (if applicable) is maintained for a long as the child is in care.

I have received a copy of StarChild Academy’s Food and Nutrition Policies and give my permission in the form of this general permission slip for my child to participate in food-related activities, including regular meals and snacks, classroom holiday parties, field trips, Parent’s Night Out, birthday parties, learning activities, and other food related activities.

____________________________________________________ ___________________________________________________ ____________________________________________ __________________________

Child’s Name Parent’s Name Parent’s Signature Date

200 Longwood Lake Mary Road Info@StarChildLakeMary.com 407-333-8901 T

Lake Mary, Florida 32746 407-333-890 F

TRANSPORTATION AGREEMENT

School Year: 2020-2021

PARENT FORMS\TRANSPORTATION AGREEMENT 01

TRANSPORTATION AGREEMENT

I, , agree for my child, ,

to ride on the bus or van provided by StarChild Academy.

My child is to be delivered to in the morning.

(School)

My child is to be picked up from in the afternoon. (School)

The following rules apply:

1. If StarChild Academy is transporting your child to school in the morning, please check with

the front desk regarding departure times.

2. All of our vehicles are equipped with seat belts, and all children are expected to remain

buckled up while being transported. 3. Please advise StarChild Academy if your child will not be picked up after school.

4. If your child is not at the school pick-up point when the StarChild Academy vehicle is ready to

depart, we will not be able to wait for your child. Please let your child know that he/she should

go to the school office if they miss our vehicle.

Parent’s Signature Date

FIELD TRIP GENERAL PERMISSION AGREEMENT