1. Children’s
Enrollment Application
Date of Registration:______________
Date of Termination of Services:___________
Child’s Name:______________________
Child’s Primary language:__________________ Sex:___________
Date of Birth:___________________ Nickname:______________
Home Email Address:____________________________________
Child’s Home Address:___________________________________
Circle Days to Attend:
AM MON TUES WED THU FRI
Arrival Time:_______________
Departure Time:____________
PM MON TUES WED THU FRI
Arrival Time:_______________
Departure Time:____________

2. Meals: Breakfast______ AM Snack_____ PM Snack_____
Lunch_____
SCHOOL INFORMATION
Does your child attend school? Yes______ No______
Elementary School Name:________________________________
School Start Time:________________ School End
Time:_____________
EMERGENCY CONTACT AND RELEASE PERSONS
Child’s Name: Age: Date:
Date of Enrollment: Address:
Mother’s Name: Home Phone:
Home Address:
Mother’s Employer: Address:
Mother’s Work #: Mother’s Cell #:
Father’s Name: Home Phone:
Home Address:
Father’s Employer: Address:
Father’s Work #: Father’s Cell #:
Custody: Mother: Father: Both Other
Persons authorized to assume responsibility for your child if parents are
not available.
Guardian’s Name: Guardian’s Name:
Relationship: Relationship:

3. Address: Address:
Phone: Phone:
If you want a person who is not identified above to pick up your child,
you must notify in advance.
CUSTODIAL INFORMATION: If a non-custodial parent is not included
among those people authorized by a custodial parent to pick up the
child, please explain below and attach a copy of appropriate documents
(court order or other).
PARENTAL AUTHORIZATION FOR EMERGENCY TREATMENT
CHILD’S
NAME_________________________________________________
PARENT/GUARDIAN
NAME:______________________________________
CHILD’S MEDICAL INFORMATION
Medical
Problems:_______________________________________________
Allergies to drugs, foods or
other:___________________________________
Medicine(s) Child is
taking_________________________________________
If an event of an emergency requiring a physician’s care, do you
consent to call your family physician?

4. Yes _________ No___________
Physician’s Name: Phone
Number:_____________
CHILD’S INSURANCE:
Company/Policy Number: ________________________
Secondary Health Insurance Provider/Policy
Number:___________________
Please list any special
medications:__________________________________
__________________________________________________________
_____
I (we) state that we are the parent(s) guardian(s) having legal custody
of the child above and attest that the information above is correct. I
(we) authorize L.O.A. director or director’s designee to transport by
ambulance and obtain emergency treatment for my child. I consent to
an x-ray examination, anesthetic, medical or surgical diagnosis or
treatment, and hospital care to be rendered to the minor under the
general supervision of any physician or surgeon.
THE FOLLOWING STEPS WILL BE FOLLOWED IN AN EMERGENCY:
1. The parent/Guardian will be contacted immediately.
2. We will attempt to contact you through all of the emergency persons
listed on the child’s application form.
3. If we cannot contact you or your physician, we will do any or all of
the following.

5. (a)Call for emergency first aid assistance/transportation.
(b) Call another physician.
(c)Have the child transported to an emergency hospital in the
company of a staff member.
Parent/Guardian Signature:________________
Date:________________
MEDICAL HISTORY
Height:__________________ Weight:______________________
Allergies and another medical conditions:
Allergies: Yes No My child is allergic to Peanut Butter
Yes No My child is allergic to Strawberries
Yes No My child is allergic to Milk or Diary
Products
Yes No Explain:
Yes No My child is on a special
Explain:_____________________________
Asthma Yes ________ No________
Diabetes Yes________ No________
Other:___________________________________________________
____
-Medication that will be administered regularly at the academy:
-Is your child toilet trained?
-Medications will be administered in accordance with Florida State
Care licensing.-Prescription medication must include a prescription
label with specific dispensing instructions and a current date.
PERMISSION TO CHANGE CHILD’S CLOTHING

6. We at The Little Orange Academy would like your permission to
change your child’s clothes. During the day children do many
activities and sometimes they get wet or soiled and need to be
changed.
I____________________________________ give my permission for
the staff of The Little Orange Academy to change my child’s clothing
as needed.
Please be sure shoes are rubber-soled and closed-toe. Flip-flops,
sandals, are not appropriate in our environment. Shoes or secure
sneakers that slip on or fasten Velcro are required for all walking
children.
PERMISSION FOR YOUR CHILD TO BE PHOTOGRAPHED
At The little Orange Academy we photograph children during special
activities, daily routines and families as they arrive at our center. These
pictures will only be used to display in our center and in your child’s
classroom.
I ______________________________ give my permission for my child
_______________ to be photographed for The Little Orange Academy,
and picture should only be displayed in the Academy.