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A Kid's World of Fun & Learning

Child Care Application for Enrollment

Student Information

Date of Enrollment

Date of Birthday*

Sex (Gender)

First name*

Last name*

Middle name

Nickname

Address*

Primary Hours of Care: From _______

Primary Hours of Care: to ________

Days of the week in Care*

Monday

Tuesday

Wednesday

Thursday

Friday

Meals Typical Served in Care*

Breakfast

Am Snack

Lunch

Pm Snack

Bring my own

Family Information

Mother's Name*

Father's Name*

Address*

Home Phone

Employer*

Employer Address*

Employer Address *

Work Phone*

Cell Phone*

Custody*

Medical Information

I hereby grant permission for the staff of this facility, AKWOFL, to contact the following medical personal to obtain emergency medical care if warranted.

Name of Doctor, address, and phone number*

Name of Doctor, address, and phone number

Name of Dentist, address, and phone number

Hospital Preference*

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

Contacts

The child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and authorized to remove the child from the facility, AKWOFL, in case of illness accident, or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:

Emergency Contact: Name Address, Work Phone # and Cell Phone #*

Emergency Contact: Name Address, Work Phone # and Cell Phone #

SAFETY FIRST We're taking extra measures to ensure your children are safe in our nursery. Learn More

Phone: (561) 967-0844

Email: akw2616@yahoo.com

2616 Kirk Rd West Palm Beach, FL 33406

Monday - Friday 7:00 am - 5:00 pm

Licensed 50-51-0006

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