Enrollment Application

Thank you for your interest in Chapel Academy. This application helps us learn more about your child and your family as we prepare for the upcoming school year.

Please complete each section as accurately as possible. Once your application is submitted, our team will review it and follow up with next steps. Submitting an application does not guarantee enrollment, but it does begin the review process.

Student Information

Name(Required)

First Middle Last

Child's Age(Required)

Date of Birth

Sex(Required)

Male

Female

Date of Enrollement(Required)

Which care you will need:(Required)

Primary Hours of Care: FROM

Primary Hours of Care: TO

Family Information

Child lives with:(Required)

Custody

Mother's Name

First Middle Last

Father's Name

First Middle Last

Mother's Address

Street Address City ZIP Code

Father's Address

Street Address City ZIP Code

Parent's Address

Street Address City ZIP Code

Father Employer Address

Street Address City State

Mother Employer Address

Street Address City State

Mother's Drivers License #

Mother's Phone(Required)

Mother's Email

Father's Drivers License #

Father's Phone(Required)

Father's Email

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's Name(Required)

Doctor's Office Address(Required)

Street Address City ZIP Code

Doctor's Phone(Required)

Hospital Preference(Required)

Dentist Name(Required)

Dentist Phone(Required)

Please list allergies, special medical or dietary needs, or other areas of concern:

Emergency Contacts and Authorization for Pick-Up and Drop-Off:

Child/Children 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 pick up your child from the facility in case of illness, accident or emergency, if for some reason the custodial parent or legal guardian cannot be reached. Please request additional pages if necessary.

Contact

Name	Address	Relationship to Student	Driver's License State & Numer	Work Phone	Home Phone	Mobile Phone	Actions

There are no Entries.

Chapter 65-22.006(2), Florida Administrative Code, requires a current physical examination (HRS-H Form 3040) and immunization record (DH Form 680 or 681) within 30 days of enrollment. *Blue and yellow Cards*

Section 402.3125(5) “Know Your Child Care Facility”, Florida Statutes, requires that parents receive a copy of the Child Care Facility Brochure as well as a copy of Influenza Virus, “The Flu” A Guide for parents.

Chapter 65c-22.006(4)2., Florida Administrative Code, requires that parents are notified in writing of the disciplinary practices used by the child care facility. Please see Parent Handbook Policy 2.9 & 2.9A regarding the discipline and expulsion policies.

There is a late pick up fee of $5.00/minute for any child picked up after 6:00 p.m.

By signing below, you verify that you have received the above items and the Parent Handbook explaining theChapel Academy VPK policies and procedures, and that all information on this enrollment form is complete and accurate.