Enrollment Form

Please fill out the Enrollment Form in its entirety below.

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Child(ren) Information
Parent/Guardian Information
Authorization
Authorization
Foreign Language Immersion Early Childhood Center Health/Emergency Information
Disclaimer

Child(ren) Information

Child's Full Name*

Male or Female*

Male

Female

Date of Birth*

Date of Birth ×

Nickname (if any)

Child's Full Name

Male or Female

Male

Female

Date of Birth

Date of Birth ×

Nickname (if any)

Child's Full Name

Male or Female

Male

Female

Date of Birth

Date of Birth ×

Nickname (if any)

Child(ren) Live(s) With*

Mother

Father

Both Parents

Guardian

Desired Start Date*

Actual Start/Enrollment Date

(Leave Blank)

Approximate Drop-Off and Pick-Up Times*

Meals Typically While In Care

Brkf

AM Snack

Lunch

PM Snack

When Will Your Child(ren) Attend?*

Saturday Parents Night

Parent/Guardian Information

Parent/Guardian Full Name*

Street Address*

Address line one

City

Zip

Home Phone

Cell Phone

Personal Email*

Employer/Business Name*

Employer/Business Name

Address line one

City

Zip

Employer/Business/Work Phone*

Please include extension if applicable

Work Email

Typical Work Days & Hours*

Parent/Guardian Full Name

Street Address

Address line one

City

Zip

Home Phone

Cell Phone

Personal Email

Employer/Business Name

Address line one

City

Zip

Employer/Business/Work Phone

Please include extension if applicable

Work Email

Typical Work Days & Hours

Child Lives With*

Custody*

Mother

Father

Both

Other

If Other, Then Please List

Authorization

Person(s) Authorized To Pick Child(ren) Up

A child or children will be released only to the custodial parent(s) or legal guardian and additional persons listed below. By listing an individual below, said person(s) will also be contacted and are authorized to remove the child from the Center in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:

Full Name*

Streen Address*

Address line one

City

Zip

Home Phone

Cell Phone

Work Phone

Relationship to Child*

Full Name

Streen Address

Address line one

City

Zip

Home Phone

Cell Phone

Work Phone

Relationship to Child

Authorization

Person(s) Specifically NOT Authorized To Pick Child(ren) Up

Please Note: The Foreign Language Immersion Early Childhood Center must have a certified copy of any legal custody/restraining order in order to prevent a parent from picking up his or her child(ren).

Persons NOT AUTHORIZED TO PICK UP:

Full Name

Streen Address

Address line one

City

Zip

Home Phone

Cell Phone

Work Phone

Relationship to Child

Full Name

Streen Address

Address line one

City

Zip

Home Phone

Cell Phone

Work Phone

Relationship to Child

Foreign Language Immersion Early Childhood Center Health/Emergency Information

By listing the healthcare provider(s) information requested below, you hereby authorize the Foreign Language
Immersion Early Childhood Center to contact said providers and obtain emergency medical care if warranted.

Child's Name

Date of Birth

Height

Weight

Date of Last Medical Exam

Social Security Number

Date of Last Tetanus Shot

Primary Insurance Company

Name

Address

City

State

Zip

Telephone Number

Policy Number

Secondary Insurance Company

Name

Address

City

State

Zip

Telephone Number

Policy Number

Medications Taken On A Long-Term Continuous Basis

Name

Dose

Time Dispensed

Purpose/Condition Treated

Name

Dose

Time Dispensed

Purpose/Condition Treated

Name

Dose

Time Dispensed

Purpose/Condition Treated

Allergies

Medicine

Food

Insect

Other

Any existing illness or injuries?

Yes

If yes, please explain

Any previous illness or injuries?

Yes

If yes, please explain

Any hospitalization during the past 12 months?

Yes

If yes, please explain

Any restrictions on normal physical activities?

Yes

If yes, please explain

Hospital Preference

(to be taken in case of emergency)

Name

Address

City

State

Zip

Phone Number

Physician Preference

(to be contacted in case of emergency)

Name

Address

City

State

Zip

Phone Number

Dentist

(to be contacted in case of emergency)

Name

Address

City

State

Zip

Phone Number

Individuals To Be Contacted In Case of Emergency if Parent(s) Cannot Be Reached

Name

Cell Phone

Home Phone

Work Phone

Relationship To Child

Name

Cell Phone

Home Phone

Work Phone

Relationship To Child

Name

Cell Phone

Home Phone

Work Phone

Relationship To Child

Disease History

Whooping Cough

Select Date ×

Rubella

Select Date ×

Chicken Pox

Select Date ×

Mumps

Select Date ×

Measles

Select Date ×

Diphtheria

Select Date ×

Tetanus

Select Date ×

Petussis

Select Date ×

Hepatitis B

Select Date ×

Varicella

Select Date ×

Scarlet Fever

Select Date ×

T.B.

Select Date ×

Operation History

Tonsillectomy

Select Date ×

Adenoidectomy

Select Date ×

Appendectomy

Select Date ×

Mastoidectomy

Select Date ×

Ear Tubes

Select Date ×

Heart Surgery

Select Date ×

Other

Input Operation & Date

Other

Input Operation & Date

Other

Input Operation & Date

Other

Input Operation & Date

Other

Input Operation & Date

Other

Input Operation & Date

Disabilities

Vision Impairment*

Yes

Hearing Impairment*

Yes

Speech Impairment*

Yes

Other

Input Disability

Other

Input Disability

Other

Input Disability

Other

Input Disability

Other

Input Disability

Other

Input Disability

Other

Input Disability

Other

Input Disability

Other

Input Disability

Disclaimer

I acknowledge I have received and had the opportunity to review the documents indicated below and had the opportunity to ask for explanations of any issues regarding my child’s enrollment at the Center, and I have been satisfied with the explanations. I also acknowledge the enrollments conditions and policies established by the Center as set out Family Handbook and agree to abide by the same. I am aware and agree that I must give thirty (30) days advance notice of my intent to withdraw or alter my child(ren)’s enrollment from full day to half days (part time) with the Center, and I remain responsible for four (4) weeks of tuition at the current rate or schedule rate increase, regardless of whether my child attends the Center during said thirty day period. I am aware a part-time, “half-day” enrollment space may not be available. In that case, my child will have to remain in a full-time enrollment position or withdraw with the required notice and payment of four (4) weeks of full time tuition. I understand and agree that tuition is due the first day of the week before 6:00 p.m. and that I agree to pay all costs associated with collecting any tuition, late tuition payment fees (currently $10.00 per week), returned check bank fees (currently $36 for Suntrust) in addition to a $25.00 service charge by FLECC, LLC, and/or any similar charges and costs. I also specifically agree to pay any attorneys fees, FLECC, LLC and/or the Owner(s) of the Center may incur in the collection of monies from me as it relates to my child’s enrollment with the Center.

I further acknowledge receipt of, understand and agree the following provisions apply to my child(ren)’s enrollment with the Center:

Section 65C-22.006(2), F.A.C. requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within thirty (30) days of enrollment.
Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, “Know Your Child Care Facility” (CF/PI 175-24). I have received said brochure.
Section 65C-22.006(3)(x)2., F.A.C. requires that parents are notified in writing of the disciplinary practices used by the childcare facility. I have received a summary copy of the 1-2-3 Magic Disciplinary practices by Dr. Thomas Phelan.
I have received, read, understand and agree to the policies, practices and conditions of enrollment set out in the Family Handbook.

Parent/Guardian Signature

Date*

Select Date ×

Parent/Guardian Signature

Date

Select Date ×

Your Enrollment Form Has Been Submitted

Thank you for submitting the Enrollment Form!

We have received your submission and will be getting in touch with you shortly if need be. Thank you!

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CONTACT US

Do you have a question or inquiry? Then please feel free to contact us at (321) 939-4177, email at contact@languageimmersionschool.com or feel free to use the contact form on this page.