Student’s Full Legal Name: - Broward Collegetest.broward.edu/studentresources/childcare/Documents/… · Web viewBroward College Early Childhood Demonstration Laboratory School

Broward College Early Childhood Demonstration Laboratory School 1000 Coconut Creek Boulevard Bldg. 63

Coconut Creek, FL 33066 (954) 201-2440

CHILD ENROLLMENT INFORMATION FORMStudent’s Full Legal Name: Date of Application /_ /_ __________________________________________________________________________________First Middle LastDate of birth: Sex: □Male □FemaleStudent’s home address:________________________________________________________________________________Street Address City State Zip

Days of the week in the center: M T W Th F Primary hours in the center: From_____To _____

Meals in the center: □Breakfast (8:00 am – 8:45 am) □Lunch □Snack

Parent is a Broward College Degree Seeking Student (Provide copy of schedule): □YES □NO Parent is a Broward College Employee □YES □NO

Email address(es) to be used for school communication:_____________________________________

Primary Language Spoken at Home: _____________________________________________________

Ethnicity:_____________________________________________________________________________

Primary Parent/Legal Guardian

Print First Name Print Last Name

Address (If different from Above) City State Zip

Home Phone: _________________________ Cell Phone:___________________________________ Name of Employer:___________________________________ Work Phone:___________________

Second Parent/Legal Guardian

Print First Name Print Last Name

Address (If different from Above) City State Zip

Home Phone: ___________________________ Cell Phone:___________________________________ Name of Employer:___________________________________ Work Phone:___________________

Custody: □Mother □Father □Both □Other (Legal documentation must be kept on file)Best way to get in touch with parent:___________________________________________________

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Child’s Physician:_ Phone:_ Address: May we call the above physician if parent/guardian cannot be reached? □YES □NO ____ InitialAllergies, health, or other concerns:_______________________________________________________________________________

Does your child take medication regularly: □YES □NO - If yes, please specify _______________________________________________________________________________

Does your child have any special needs: □YES □NO - If yes, please specify _______________________________________________________________________________

Other persons authorized to remove child from school or to be notified in case of illness or accident (if for some reason, the custodial parent or legal guardian cannot be reached:

Name: Relationship: Address:__________________________________________________________Cellular Number: Work: _ Home:_




Persons not permitted to remove child from the center (A copy of legal document i.e. court order must be on file and resubmitted each year)Name: Relationship: ________________

Identification Password Code: (Child Care Licensing requires a passcode. This password will be used when a new or unfamiliar individual must pick your child up from school. Please choose a code word that is less than 12 letters or numbers)

Mother/Guardian Signature Date Father/Guardian Signature Date

Application Updated:

Print Name Signature Date Print Name Signature Date

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AUTHORIZATION FOR EMERGENCY TREATMENT

To Whom It May Concern:

I hereby give my permission to the nearest hospital, to administer necessary treatment to my child, ______________________________ in the event of an emergency when I cannot be reached. Additionally, I Name of Child)

give consent for my child to be transported by ambulance if the situation warrants it.

Name of Child’s Physician: _________________________________ Phone: ____________________ My Child is Allergic To: _______________________________________________________________________________________________________

Date of last DPT or Tetanus:_________________________________________________________________

Insurance Company Covering My Child:_______________________________________________________

Policy Number:_________________________ Expiration Date:_______________________

(Signature of Parent or Legal Guardian) (Date)

Sworn to and subscribed before me this day of

by (Name of Parent Acknowledged)

My Commission Expires:

(Signature of Notary Public, State of Florida)

(Print or type name of Notary as commissioned)

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Personally Known: Produced Identification:

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EMERGENCY WEATHER RELEASE FORM

Child’s Name: _____________________________________________________________________

During a weather emergency, we rely on parents to assist in the safe evacuation of children from our facility. In the event of a weather emergency, decisions regarding site closings will be made by Broward College.

Information regarding school closings will be available via:- Radio – WAXY (FM 106.7), Y100 (FM 100.3), WIOD (AM 610) or WFTL (AM 1400)

- Television – please check your local television stations

- Website – www.broward.edu

- Telephone – (954) - 201-4900

In the event of a weather emergency, please indicate how your child will be picked up from our facility.

1. I will come immediately to school to pick up my child as soon as Broward College Early Childhood Demonstration Laboratory School closings are announced.

2. I give my child permission to ride home with any of the following people:

Parent Signature: _______________________________ Date:_____________________________

In the event of an unexpected emergency we will need to contact parents swiftly. Please provide one (1) primary telephone number to use to expedite this process. Other emergency contact numbers will be recorded and maintained in your child’s permanent record file.

Emergency Telephone Number:

This Primary Number Will Connect With:

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Coconut Creek, FL 33066 (954) 201-2440

BEHAVIOR MANAGEMENT

The policy of our program centers around protecting the rights and privileges of the children while fostering nurturance and warmth. We do not endorse or permit any physical or verbal abuse of any kind.

In accordance with the Broward County Child Care Ordinance we will assure that:

Children will not be subjected to discipline that is severe, humiliating or frightening

Children will not be subjected to cruel, harsh, physical or unusual punishment

Children will not be permitted to discipline another child

Physical restraints of any sort, including but not limited to, swings, walkers and spinners shall NOT be used to confine a child

Children shall not be subjected to profane language, threats or any other verbal abuse

Children will never be confined in enclosed areas, such as closets, locked rooms or bathrooms

Children will never be punished for failure to eat or sleep or for toileting accidents

Children will never be punished by withholding food, rest or toileting

Children will never be disciplined with the use of spanking, hitting, biting or pinching.

Children will not be threatened with any punishment that is prohibited within this form

Name (Print):

Date:

Signature:

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Coconut Creek, FL 33066 (954) 201-2440

PHYSICAL ACTIVITY POLICY

The Broward College Early Childhood Demonstration Laboratory School will provide your child with planned physical activities during regularly scheduled times. A typical day will include 40 minutes of gross-motor outdoor/indoor play for every 3 hours your child is in school. The Broward County ORDINANCE NO. 2014-28 OF THE BOARD OF COUNTY COMMISSIONERS OF BROWARD COUNTY, FLORIDA states that allchildren are required to participate in daily outdoor play and gross-motor activities. Please make sure that your child is healthy and able to participate in all activities.

Send your child to school in comfortable clothing appropriate for weather conditions outdoors. All children must wear sneakers/closed-toed shoes with rubber soles every day. Flip flops, open-toed shoes, heels, sandals, boots, Crocs, etc., are not safe for these activities.

Gross-motor activities will include, but are not limited to, the following:

1. Dance, parachute, ball play, sack races2. Outdoor/Indoor obstacle course3. Bicycle riding, riding toys, push toys4. Climbing, crawling, stretching, sliding, exercising, balancing, tossing, throwing, jumping,

etc.

During inclement weather, gross-motor activities will take place indoors.

If the College makes a decision to close North campus, then the Broward College Early Childhood Demonstration Laboratory School will close. Parents must register their cellular numbers with the school. Our office is equipped with an emergency radio that will alert us to any emergency weather situations.

By signing below you acknowledge that you have read, understand and abide by the Physical Activity Policy of the Center.

Print Child’s Name Print Parent’s Name

Parent’s Signature Date

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Coconut Creek, FL 33066 (954) 201-2440

BLANKET FIELDTRIP PERMISSION FORM

Dear Parent or Guardian,

On occasion, as weather permits, we will be taking your child (3 and 4 year-olds only) on walking trips to various locations on the North Broward College Campus (i.e.: Library, Omni Auditorium, Breezeway, etc.). All walking trips will be supervised appropriately. By signing below, you are giving permission for your child to participate in these trips on the college campus.

_____________________________________________________ Print Child’s Name

Parent/ Guardian Print Name:__________________________________ Phone:____________________

Parent/Guardian Signature: ____________________________ Date: ____________________

FOOD PERMISSION FORM

I 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, birthday parties, learning activities, and other food related activities at the Broward College Early childhood Demonstration laboratory School.

Child’s Name (Print)

Parent’s Name (Print)

Parent/ Guardian Signature Date

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Coconut Creek, FL 33066 (954) 201-2440

PROGRAM DISMISSAL

The Broward College Early Childhood Laboratory School may dismiss a child form the program at their discretion. The Lab School strives to provide a safe and nurturing environment for ALL of the children enrolled in the program. Program staff and administration will make every effort to first resolve behavioral occurrences with children through discussion, problem solving, redirection, verbal communication, parent conferences etc. Program staff and administration will take the following steps prior to program dismissal:

1. Initial ConferenceProgram staff will record child’s behavior through written reports. Program administrator/ teacher will contact the child’s parents to inform them of the incident and what measures are being taken to rectify the situation. A conference will be scheduled with the child’s parent(s) to discuss behavioral concerns. A written plan of action will be created during the conference to discuss corrective action methods.

2. Second ConferenceProgram administrators will schedule a follow-up conference if the behavioral occurrences continue. The second conference will include an administrator, the child’s teacher(s), and the child’s parent(s). Parents will be given information and/ or referrals to Florida Diagnostic and Learning Resources System (FDLRS) and a time frame will be established to improve the behavior. If the behavior is not rectified or improved within this time frame, the child may be dismissed from the Lab School.

3. Dismissal Children may be temporarily suspended or permanently dismissed from the program if there is no improvement after the previous steps have been taken. Parents will be required to pick up their child during the day if their child exhibits any form of physical or verbal abuse which places their child or others in danger. Parents will be responsible for program fees during the suspension period.

_______________________________ _________________________ _________________

Print Parent Name Parent Signature Date

_______________________________ _________________________ _________________

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Coconut Creek, FL 33066 (954) 201-2440

Print Administrator Name Administrator Signature Date

PAYMENT AGREEMENT

Weekly per pupil fee payments are due each Monday in the form of debit/credit card, check, or money order. If payment is not received on the first day of weekly service (Monday), your child will not be accepted until the weekly per pupil fees are paid. A daily late fee of $10.00 per child will be charged if per pupil fees are not paid on Monday of each week. If your child is absent on a Monday, per pupil fees may be paid upon your child’s return to school without penalty. Registration fees are nonrefundable and are charged upon enrollment and each year during the month of August. Once registration fees are paid, they only secure or “hold” a spot for a maximum of two weeks. Operational school expenses are incurred whether or not your child is in attendance. Therefore, per pupil fees must be paid regardless of your child’s absence, for whatever reason (i.e.: illness, vacations, holidays, etc.). There will be no refunds or discounts granted for absences. Please note Broward College is closed during winter and spring break; the Lab School will also be closed and the weekly per pupil fees will only be waived during these weeks. If you chose not to have your child in the Lab School program after per pupil fees are paid, refunds will only be issued for weekly payments that were paid in advance, prior to your child’s first day of attendance. All fees are subject to change.

It is your responsibility to let us know in advance if your child is going to be out for more than two days in a row. If you are withdrawing your child from the Lab School, a two-week advanced written notice is required or you will be charged for an additional two weeks per pupil fees.

When a child is withdrawn, we immediately fill the spot with a child on our “wait list.” Should you wish to re-enroll your child and space is available, you will be charged a new registration fee.

I understand that if my account is delinquent for more than one week, I may be asked to withdraw my child until my account is made current. The school cannot guarantee a child’s spot will be held when a child is withdrawn due to non-payment of per pupil fees. Any unpaid per pupil fees may be sent to a third-party collection agency.

By signing below I acknowledge that I have read the above information and understand my obligation to

Broward College Early Childhood Demonstration Laboratory School to pay the weekly per pupil fee for

the current fee schedule.

____________________________________ ________________________

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Parent/Guardian Printed Name Date

_____________________________________ _______________________ ______Parent/Guardian Name (Signature) Child’s Name D.O.B

ALTERNATE NUTRITION PLAN

Human Services Department/ Bureau of Children’s ServicesChild Care Licensing and Enforcement Section

Control Form 6091-5 (Rev.7/93)

Date:_____________________

Dear Parent:

In accordance with the Broward County Child Ordinance/ Family Central Ordinance, Parents and the Childcare Facility are urged to work cooperatively where lunches are not provided by the facility.

Please read the following and sign. This facility agrees to provide a nutritious: ____X____ Breakfast ____X____ Lunch ____X____ Mid-Afternoon Snack

The parent agrees to provide a nutritious: ________ Breakfast ________ Lunch ________ Mid-Afternoon Snack

I have read the preceding and agree to meet the child’s nutritious needs as defined below.

Parent/ Guardian’s Signature:_______________________________

Parents-- keep this bottom portion

Meals provided by the parent shall consist of the following:

Meals provided by the parent shall consist of the following: A. Meat / Poultry / Fish 2 ounces

Or cheese 2 ounces Or eggs 2 ounces

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Coconut Creek, FL 33066 (954) 201-2440

Or dried beans and peas 2 ounces B. Fruits (2 or more) ½ cup

Vegetables ½ cup Or fruit and vegetables ½ cup

C. Bread 1 slice D. Butter 1 teaspoon E. Milk 1 cup

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Parent Signature Date


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SWIM CENTRAL WATER SAFETY EDUCATION QUESTIONNAIRE

Child Care Program: Date:

Child’s Name: Age:

Parents Address:

YES NO1 Has your child ever taken swim lessons?2 Can your child roll over and float on his/her back?3 Can your child swim to the side of the pool?4 Have you taken a Community Water Safety Course?5 Is anyone in your household certified in CPR?

Additional Comments:

3700 NW 11 Place Lauderhill, FL 33311 Fax: 954-357-8077Phone: 954-357-SWIM (7946)

PROVIDERS: You must have documentation that this form has been submitted.If you faxed this form, write the date you faxed it here: If you mailed the original form, this one should be a COPY. Write date mailed here:

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Coconut Creek, FL 33066 (954) 201-2440

NEW PARENT CHECKLIST

□ Medical records:Yellow form (physical)Blue form (shot records)

□ Completed enrollment packet: Make sure to read and sign all pages and fill in the password section on the front page. Food program form must be filled out.

□ 2 blankets:One fitted crib sheet (not a portable crib sheet) to cover the cot and one blanket to cover up your child.

□ Change of clothes:Bring in spare clothing just in case your child has an accident (If they are potty training bring in a couple of sets of spare clothes.)

□ Pull-up, Diapers, and Wipes:If your child uses pull-ups or diapers, you will need to bring in a daily supply for your child including wipes.

□ A family picture and a picture of your child

□ A close up picture of your child’s face

Please make sure ALL items are labeled with your child’s full name.

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