Childcare Application of Enrollment

- Step 1 of 21

Childcare Application of Enrollment

Student Information

Secret Code

Date of Birth

Gender

Date of Enrollment

Full Name

First

Last

Middle

Child’s Home Address

Address Line 1

City

State

Zip Code

Primary Hours of Care: Form

Parent/Legal Guardian Information

Parents/Guardian

DOB

Phone Number

Parents/Guardian

DOB

Phone Number

Florida Department of Health Child Care Food Program

CHILD CARE APPLICATION FOR ENROLLMENT

Student Information :

Date Of Birth

Sex

Date of Enrollment

Full Name:

Last

First

Middle

Nickname

Child’s Physical Address:

Primary Hours Of Care: From

Days Of the Week in Care:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Meals Typically Served Whose In Care: Br AM Snack Lunch PM Snack Supper Eve Snack

Family Information

Parent 1 Name:

Parent 2 Name:

Address:

Home Phone:

Employer:

Address:

Work Phone :

Cell:

Work Phone :

Child Live With: Parent 1

Parent 2

Both Parents

Other

Medical Information:

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

Doctor:

Address:

Phone

Doctor:

Address:

Phone

Doctor:

Address:

Phone

Hospital Preference:

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

conern:

Emergency Care Plan Instructions (if applicable):

Emergency Contacts :

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 are authorized to remove the child from the facility. In case of illness, accident or emergency, If for some reason the custodial parent or legal guardian cannot be reached:

Name

Address

Work#

Home#

Name

Address

Work#

Home#

Name

Address

Work#

Home#

Helpful Information about Child:

Sections 7.1 and 7.2 of the child Care facility handbook require to a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.
Section 7.3 of the child Care facility handbook Requires that parents receive a copy of the Child Care facility Brochure, “Know Your Child Care Facility” (OF/PI 175-24), or
Section 8.3 of the Family Day Care Home/Large Family Child Care Home handbook requires that parent(s) receive a copy of the family day care home brochure, “Selecting a Family Day Care Home Provider (CF/PI 175-28.
Section 2.8 of the Child Care Facility handbook requires that parents are notified in writing of the disciplinary and expulsion policies used by the child care facility , or Section 2.3 of the Family Day Care Home/Large Family Child Care Home Handbook requires that parents are notified in writing of the disciplinary and expulsion policies used by the family day care provider.

Your signature below indicates that you have received the above items and that the information all on this enrollment form is complete and accurate. I hereby grant permission to the staff of this facility to have access to my child’s records.

1st year:

Parent/Guardian Name

I hereby consent and digitally sign this enrollment document

Updated Date

Parent/Guardian Name

I hereby consent and digitally sign this enrollment document (copy)

Updated Date

Parent/Guardian Name

I hereby consent and digitally sign this enrollment document (copy)

Updated Date

Parent/Guardian Name

I hereby consent and digitally sign this enrollment document (copy)

Updated Date

Days of Service please check

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

Child’s Name

Date of Birth

Hours. Time of Arrival

Time of Departure

Payment Schedule Tuition amount’s Weekly

Monthly

Weekly Tuitions is one Every Monday or first business day of the start week
Monthly Tuitions is due the first business day of each Month
Late pickups are not permitted encase of emergency please call in advance so we make proper arrangements More then 3xs of late pick up Expression of Love will have to discontinue the services.

I have read the above financial responsibility agreements and fully understand and agree to my financial obligations.

Parent/Guardian Name

I hereby consent and digitally sign this enrollment document

Date

EOL Director and or Owner Name

I hereby consent and digitally sign this enrollment document (copy)

Date

Days of Week In Care:

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

Primary Hours of Care: Form:

call

STEP 1: Complete the following table for all INFANTS and CHILDREN through age 18 that reside in the household, even if not related (include child listed at top of form)

Child’s Name (Last Name, First)	Date of Birth	Attends this center? (circle)	Migrant? (circle)	Homeless/Runway? (circle)
		Yes No	Yes No	Yes No
		Yes No	Yes No	Yes No
		Yes No	Yes No	Yes No

STEP 2: Do any household members (children or adults) receive Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) benefits?

If NO, go to STEP 3 If YES, enter one of the following case numbers, then go to STEP 6 FAP/SNAP

Case Number

or TANF Case Numbers:

STEP 3: Children’s Income Information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)

Children’s Income – sometimes children earn or receive income. Enter the total income received by all children listed in STEP 1, then check how often the income is received.

Children’s income – Total: $

How often received? (check only one):

Weekly
Bi-Weekly
Twice a Month
Monthly
Annually

STEP 4: household income and adult household member information (see reverse side for what types of income to report) (skip this step if you listed a case # in STEP 2)

Adult Household Members and Income – list all adult household members (age 19 and up) even if they do not receive income. For each adult, list the total gross income (before taxes & deductions) from each source in whole dollars only (no centers) and how often it is received { i.e, weekly, bi- weekly, twice a month, month monthly or annually) , For an adult that does not receive income from any source, write “none” or “0” if you enter “none” or “0” or leave any income fields blanks, you are certifying that there is no income to report.

Adult Household Member’s Name (Last Name, First Name)	Earnings From Works ($ Amount/How often?)	Public Assistance/Child Support/Alimony ($ Amount /How often?)	Pensions/Retirement/All Other Income ($ Amount/ How often?)

Total Household Members (Add Step 1 & 4) :

Last four digits of Social Security Number (SSN) of adult household member :

If no SSN, write “none”

STEP 5 : Contact information and adult signature

By signing below, I am certifying (promising) that all information on this application is true and that all income is reported. I understand that this information is being given in connection with the receipt of federal funds and that insults on officials may verify (check) the information. I am aware that if I purposely give false information. I may be prosecuted under applicable state and federal laws.

Home address (If available) :

Printed name :

Date signed :

OPTIONAL Child’s ethic and racial identities We are required to ask for information about your child’s. This information is important and helps make sure that we are fully serving the community.

Responding to this action is optional and does not affect your child’s eligibility for free or reduced- per meals. Ethnicity (check one) :

Hispanic or Latino
Not Hispanic or Latino

Race (check one or more) :

American or Alaskan Native
Asian
Black or African American
Native Hawallan or Other Pacific Islander
White

FOR CONTRACTOR USE ONLY:

Categorical Eligibility:
FAP/SNAP or TANF Household
Foster Child

Total Household Size:

Total; Household income: $

Eligibility Determination :
Free
Reduced Price
Non-needy
How Often Income is

Received (Frequency):
Weekly
Biweekly
Twice a Month
Monthly
Annually

NOTE : If different income frequencies are listed, convert all income to an annual amount. Annual Income Conversion: Weekly x 52. Biweekly x 26, Twice a Month x 24, Monthly x 12

Reason for Non-needy status:

Income too High
Incomplete Application
Other Reason

Determining Official’s Name

I hereby consent and digitally sign this enrollment document

Date

EOL Director and or Owner Name

I hereby consent and digitally sign this enrollment document

Date

Revised 6/2019

INSTRUCTIONS for completing the Free and Reduced Price Meal Application (use a pen and print all information other than signature)

Print the name of the child you are applying for the top of the form. Print the name and the address of the child care centre the child attends, If not already pre-printed. Print the primary hours of care for your child, Circle the days of the week your child primarily attends the child care and the meals that you expect your child to receive whole in care: breakfast (BR), morning snacks (MS), lunch (LU), afternoon snack (AS), supper (SU), and / or evening snacks (ES).

IF ANY MEMBER OF YOUR HOUSEHOLD RECEIVES FOOD ASSISTANCE PROGRAM (FAP/SNAP) OR TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) BENEFITS.

FOLLOW THESE INSTRUCTIONS: STEP 1: List all children age 16 and under that are supported with the household income even if they are not related to you. Be sure to include the columns, circle Yes or No to answer each question for each child listed. STEP 2 Enter either the FAP/SNAP or TANF case number in the designated space. The case number will be on your letter of eligibility; It is not the number on your EBT card. STEP 3: Skip this step. STEP 4: Skip this step. STEP 5: Enter your address and phone # (If available) An adult household member must sign the form. Print the name of the person ho signed the form, then enter the date signed.

IF YOU ARE APPLYING FOR A FOSTER CHILD,

FOLLOW THESE ISNSTRUCTIONS: With appropriate documentation, foster children are automatically eligible for free meals regardless of the income of the household where they. You have the option to provide the child care centre with official documentation from the foster care agency or court that placed the child in the household, rather than completing this application. Should you choose to complete this application, and you are applying only for a foster child(ren), then only complete STEPS1 and 5. If you are applying for foster and non-foster children, complete STEPS 1, 3, 4 and 5. If completing STEP 3. Do not include payments to the households for the care of the foster child(ren). See the instructions listed below for the applicable steps.

ALL OTHER HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS: STEP 1 :

List all children age 16 and under that are supported with the household’s income, even if they are not related to you. Be sure to include the child listed at the top of the form. If there is not enough space to list all children, use a second form and attach the forms together. List the date of birth of each child. In the next three columns, circle Yes or No to answer each question for each child listed. STEP 2: Skip this step, STEP 3: Enter the total income received by all children listed in STEP 1, then check how often the income is received. STEP 4: List all adults age 19 and older that are supported with the household’s income, even if they are not related to you and even if they receive no income. If there is not enough space to list all adults, use a second form and line forms together. For each adult, list the amount of income regularly receives before taxes or anything else is taken cut and circle how often the income is received (frequency) in the appropriate columns. If self-employed, list not income. See examples below for sources of income to report. For any adult with no income, while “none” or. Any income fields that are blank will also be counted as a zero (0). Enter the total number of household members (all children and adults), then list the last four digits of the social security number (SSN) o f the adult completing/signing the application (or write NONE if he/she has no SSN). STEP 5: Enter your address and phone # (if available). An adult household member must sign the form. Print the name of the person who signed the form, then enter the date is signed.

Sources of Income for Children

Earnings from work wages
Social Security(Disability payments/Survivors Benefits Social Security benefits. )
Income from person the household spending money
Income from any other source or trust

Sources of income for Adults

A child has a regular full or part-time job where they earn salary or wages
A child is bind or disabled and receives Social Security benefits.
A parent is disabled, retired, or deceased and their child receives. Social Security benefits
A friend or extended family member regularly gives a child
A child receives regular income from a private fund, annuity

Earning for work

salary wages, cash, bonuses
Net income from self employment ( or business)
If you are in the US Military:
Basic pay and cash bonuses NOT include pay, FSSA private housing allow
Allowance for off housing food and clothing

Public Assistance/Alimony child support

Unemployment benefits
Supplemental Security Income (JSS)
Cash assistance from State or local government
Alimony payments
Child support payments
Veteran’s benefits
Strike benefit

Pensions/Retirement All Other Income

Social Security (including retirement and benefits;
Private pensions or disability benefits
Regular income from estates
Investment income
Earned interest
Rental income
Regular cash payments from outside household

The Richard B. Russell National School Lunch Aot requires that, unless you list a current: Food Assistance Program (FAP/SNAP) or Temporary Assistance for Needy Families (TANF) case number or are applying for a foster child, you must include the last four digits of the Social Security Number (SSN) of the adult household member signing the application or indicate that the signer does not have a SSN. Providing the last four digits of a SSN is not mandatory, but if this information is not given or an indication is not made that the signer does not have a SSN, the application cannot be approved. The information provided on this form may be verified through programs reviews, audits and investigations and may include contacting employees to determine income, contacting a welfare office to verify receipt of FAP/SNAP or TANF benefits, contacting the state employment security office to determine the amount of benefits received, and checking any documentation produced by the household to prove the amount of income received. These verifications efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported. We may share your eligibility information with education, health, and nutrition programs to help them evaluate fund or determine fits for their programs: auditors for program reviews; and law enforcement officials to help them investigate violations of program rules. The institution is an equal opportunity. Please refer to the accompanying Parent Letter to read the full Nondiscrimination Statement.

Child Care Food Program

Infant Feeding Form

Child care Facility: Please fill in facility name and formulas offered before distributing to parents.

Child Care Facility Name:

*formulas offered at this facility:

Milk-based:

Soy-based:

This child care facility participates in the Child Care Food Program (CCFP) and is required to offer infant formula and food to your baby.

We welcome breastfeed babies and support and encourage moms to continue breastfeeding when returning to work or school. For formula fed infants, we offer the iron-fortified infant formulas listed above to babies in our care. To qualify for reimbursement, infant meals and snacks must include, at a minimum, the following food components at appropriate age and development stages:

Breastmilk or iron-fortified infant formula (or a combination of both)
Iron-fortified infant cereal
A variety of texture-appropriate vegetables and fruits such as sweet potatoes, bananas, and peas.
A variety of texture-appropriate meat and meat alternates such as chicken, yogurt, and cheese
Bread, crackers, Florida WIC-approved ready-to-eat cold cereals

Please be aware this child care facility:

Will offer all food components to each infant that is developmentally ready to accept them. Parent do not have to bring in any foods for their children.
Can feed solid foods to infants in a bottle only when a medical statement is provided.
May request to supply clean, sanitized and labeled bottles on a daily basis.
Requires the parent to label bottles of breastmilk or formula and containers of food that they provide with baby’s name, date, and time of bottle or food preparation.

Parents please complete the following:

Baby’s full name:

Date of Birth:

Please check this box

if your baby is breastfeed.

Please check if you plan to do one or both:

Provide pumped breast milk
Visit facility to nurse

I understand that this child care facility will supply that above iron-fortified formulas for formula-fed infants up to 12 months of age and infant cereal and baby food for infants 6 months and older, according to the CCFP requirements.

I prefer to supply my own formula (write in name of *formula):

This facility has not requested or required me to provide infant formula or food

Parent Name

I hereby consent and digitally sign this enrollment document

Date:

Printed Name of Parent:

*Please note: Forty Head Start facilities provide the brand of formula you currently give your infant as well as ago appropriate food

Revised 8/2019 infant Fooding Form Services

PARENT LETTER FOR NO-PRICING PROGRAMS

Dear Parent/Guardian:

We participate in the Child Care Food Program (CCFP), which provides reimbursement for serving nutritious meals to enrolled children. All meals served must meet pattern requirements established by the U.S Department of Agriculture (USDA). In the operation of USDA child feeding programs, no person will be discriminated against because of race, color, national origin, sex, age, or disability.

The information requested on the attached Free and Reduced-Price Meal Application is necessary so that we may receive reimbursement for meals served to your child while in care. The amount of reimbursement we receive from the CCFP depends on the household income status of the enrolled children. Please complete the attached application, sign, date, and return it to the address listed below. Please refer to the back of the application for full instructions. Your application will be placed in our files and kept confidential.

Children from households that receive Food Assistance Program (formerly known as the Food Stamp Program) or TANF (Temporary Assistance for Needy Families) benefits are eligible for free meals. Children enrolled in Head Start of Early Head Start (HS/EHS) are eligible for free meals, subject to the submission of official, acceptable HS/EHS enrollment documentation. With proper documentation, HS/EHS children will not need Free and Reduced-Price Meal Application. Foster children are eligible for free meals regardless of the income of the household with whom they reside, subject to the submission of official, acceptable foster care agency/court documentation or a Free and Reduced-Price Meals Application. Children from households with total income less than or equal to the levels listed below are eligible for either free or reduced-price meals.

INCOME ELIGIBILITY GUIDELINES (Effective July 1, 2021 – June 30, 2022)

HOUSEHOLD SIZE	ANNUAL	MONTHLY	TWICE PER MONTH	BIWEEKLY	WEEKLY
1	23,828	1,986	993	917	459
2	32,227	2,686	1,343	1,240	620
3	40,628	3,386	1,693	1,583	782
4	49,025	4,085	2,043	1,886	943
5	57,424	4,786	2,393	2,209	1,105
6	65,823	5,486	2,743	2,532	1,266
7	74,222	6,188	3,093	2,855	1,428
8	82,621	6,886	3,443	3,178	1,589

For each additional family member add +8,399 +700 +350 +324 +162

HOW TO COMPLETE:

If any member of your household currently receives Food Assistance Program (FAP) or TANF benefits, then any child in the household is eligible for free meals. The application must include the child’s name, the FAP or TANF case number, and the signature of an adult household member.

If completing a Free and Reduced-Price Meal Application for a foster child, the application must identify the child as a foster child, and include the child’s name, any “personal use” income, and an adult’s signature. Households wishing to apply for meals benefits for foster children should contact us if they have any questions.

If you do not list a FAP or TANF case number, or if the child is not a foster child, the application must include:

The child’s name;
The names of all household members, including spouse , children, parents or other persons who live with you in the same household;

Revised 6/2021
1-023-20

The amount of income each person usually receives (before deductions for taxes, social security, etc). how often it is received, and when it is form, such as wages, retirement, or public assistance. For self-employed persons, list net income. Net income is defined as gross receipts less operating expenses. For persons who do not receive any income, write “0” or “NONE”;
The signature of an adult household member; and
The last four digits of the social security number of adult household member who signed the application or the word “none” if that adult does not have a social security number.

VERIFICATION: Your application may be reviewed by the child care center of other officials at any time during the year to determine if it has been correctly approved. CONFIDENTIALITY: The information that you report will be used only to determine eligibility for free or reduced-price meals in the CCFP, REAPPLICATION: You may apply for free and reduced-price meals at any time during the year. If you are not eligible now but your household experiences a change, such as, a decrease in household income, an increase in household size, unemployment or receipt of Food Assistance Program or TANF benefits, then complete a new application.

Sincerely,

Expressions of Love Academy
call now! (954) 786-9544
address: Lorem Ipsum, 4586 Street

In accordance with Federal civil rights law and U.S Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, Offices, and employees, and institutions participating in or administrating USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.) , should contact the Agency (State or local) where they applied for benefits individuals who are deaf, hard of hearing or have speech disability may contact USDA through the Federal Relay Service at (800)877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete

the USDA Program Discrimination Complaint Form, (AD-3027) found online at:

and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866)632-9992. Submit your completed form or letter to USDA by:

Mail: U.S Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
Fax: (202) 690-7442; or
Email: progress

This institution is an equal opportunity provider.

FACTS ABOUT HEATSTROKE:

It only takes a car 10 minutes to heat up 20 degrees and become deadly

Even with a window cracked, temperature inside a vehicle can

The body temperature child increases 3 to 5 times faster than an adult’s body

PREVENTION TIPS:

Never leave your child alone in a car and call 911 if you see any child locked in a car
Make a habit of checking the front and the back seat of the car before you walk away cause heatstroke
Be especially mindful during hectic or of a busy times, schedule or routine changes, periods of emotional stress or chaos.
Create reminders by pulling something in the back seat that you will need at work, school or home such as a briefcase purse cell phone or your left shape
Keep a stuffed animal the baby’s car seat and place it on the front seat as reminder when the baby is in the back seat
Set a calendar reminder on your electronic device to make sure you drooped your child off at child care
Make it routine to always notify your child’s child care provider in advance your child is going to be late or absent ask them to contact you if your child hasn’t arrived as scheduled

During the 2018 legislative session,

a new law was passed that requires child care faculties family day care homes and large family child care homes to provide parents, during the months of April and September each year with information regarding the potential for distracted adults to fail to drop off a child at the facility home and instead leave them in the adults vehicle upon arrival at the adult’s destination

Parents/Guardian:

Child’s Name:

Date:

Please complete and return this portion of the brochure to your child care provider to maintain the reception their records

PHOTO RELEASE FORM

the parent of a child/children at Expressions Of Love Academy agree to the following.

I understand that my child(ren) whose name(s) are listed below may be photographed/Videoed By the Staffs, Teachers or Directors at the Academy during normal school hours, field trips, or activates, I understand that these photographs/videos may be used in promoting child care services, Students Learning and etc either in print on the kinder lime app or on the internet.

The child(ren) are known as:

With my signature for print or electronic use in promoting the Academy services or achievements. I understand that if is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child’s enrollment. I understand that there will be no payment for me or my child’s participation in this release.

Parent/Guardian Name

I hereby consent and digitally sign this enrollment document

Date

Relationship To Child

(copy)

I hereby consent and digitally sign this enrollment document (copy)

Acknowledgement
Parent

I acknowledge that I have read the parent manual and understand the rules and regulations of Expression of Love Academy of Excellence. I also understand the appropriate Uniform requirements and foot wear i must place on my children each day. I have also read over the amount of physical activates indoors and outdoors play my children will participate in I also understand if is my duty to communicate any questions comments or concerns I may have as an active Parent of EOL I also understand that I play a major role in my child’s education and safety outside and classroom

I also understand this is a Christian environment and we would not tolerate certain words or action around the facility

Thank you for your cooperation

Parent Name

Signature

I hereby consent and digitally sign this enrollment document

Date

Assumption of Risk and Waiver of Liability Relating to Corona virus/ Covid 19

Expressions Of Love Academy had put in place preventative measures to reduce the spread of COVID-19: however, we cannot guarantee in participating in any indoor or outdoor field trips that you, your children, or any person, will not become infected with COVID-19. Further attending or agreeing to allow your child to attend any field trip activities could increase your risk and your child risk of contracting COVID-19. Although we will take all extra precautions, wearing our mask, washing our hands, taking temperatures, and continuing to practice social distance.

Therefore, if you choose to participate and allow your child in any of the Field Trips, events, or activates with our program you are required to acknowledge and execute this Waiver for yourself, household, child/ and or children.

Acknowledgement

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child or children and I may be exposed to or infected by COVID-19 by attending a field trip, event or activity.

I voluntarily agree to assume all the foregoing risks and accept sole responsibility for any injury to my child or children or myself including but not limited to personal injury, disability, death, illness, damage, loss, claim, liability, costs or expenses of any kind arising out of or relating thereto, I understand and agree that this is a release form includes any claims based on the actions, omissions, or negligence of the Expressions of Love Academy, Staff, School Board or an affiliated with the organization weather a COVID-19 infection occurs before, during, or after participating in our Field Trips, Events, or Activities.

This is also a release and agreements form that you are allowing your child(ren) to attend our assigned Field Trips, Events, and Activities.

Even if we use reasonable care in providing these activities, there is a chance your child may be seriously injured by participating in this activity because there are certain dangers inherent in the activity which cannot be avoided or eliminated, By signing the form you are giving up your child’s right and your right to recover from Expressions Of Love Academy in a lawsuit for any personal injury that results from the risks that are a natural part of the activity.

Student(s) Name:

Parent Name:

Parent Signature

I hereby consent and digitally sign this enrollment document

Date:

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