State of Florida Department of Children and Families CHILD CARE APPLICATION FOR ENROLLMENT Date of Birth: Student Information: Sex: Date of Enrollment: Full Name: Last First Middle Nickname Child s Physical Address: Primary Hours of Care: From To Days of the Week in Care: M T Meals Typically Served While in Care: W Br Th F AM Snack Sa Lunch Su PM Snack Sup Eve Snack Family Information: Child Lives With: Mother s Name: Father s Name: Address: Address: Home Phone: Home Phone: Employer: Employer: Address: Address: Work Phone: /Cell: Work Phone:/Cell Custody: Both Mother Father Other 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..
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