Enrollment | R Excel School of Learning

Date of Enrollment( Today's Date)*

Child's Full Name*

Other Names for Child

Date of Birth(XX/XX/XXXX)*

Sex*

Male

Female

Child's Physical Address*

Primary Hours of Care*

Time of day for Care*

AM

PM

AM & PM

Child Lives With*

Parent/Guardian Name: *

Address*

Phone Number ( Home)

Phone Number ( Cell) *

Phone Number (Work)*

Current Employer *

Relationship to Child*

Mother

Father

Grandparent

Guardian

Who has custody of the Child?*

Both- No Custody Order

Mother

Father

Neither

Child will be released only to the custodial parent(s) or legal guardian(s) 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(s) or legal guardian(s) cannot be reached:*

I agree

I don't agree

Emergency Contact (4+) as listed below*

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

Yes

No

Child's Doctor*

Hospital Preference *

Northwest Florida Community Hospital - Chipley

Doctors Memorial Hospital - Bonifay

Jackson Hospital - Marianna

Studer Family Children's Hospital - Panama City Beach

HCA Florida Gulf Coast Hospital - Panama City

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

Emergency Care Plan instructions including symptoms, medication, and notification in the event of an actual emergency (if applicable)*

Please add any other helpful information about your Child.

PLEASE READ CAREFULLY: Sections 7.1 and 7.2, of the Child Care Facility Handbook, require 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” (CF/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 7.3, C.3 of the Child Care Facility Handbook, requires that parents are provided food and nutrition policies used by the child care facility. • 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, requiresthat parents are notified in writing of the disciplinary and expulsion policies used by the family daycare provider. Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate. I hereby grant permission for the staff of this facility to have access to my child’s records. *

I agree

I don't agree

Signature of Parent/Guardian*

Please enter the Current Date*

Please Fill out the form below for Enrollment for R Excel School of Learning

Please Email us at enrollnow@rexcelschooloflearning.com to submit (PDF) Application.

DCF Required Information (As Listed Below)

Sections 7.1 and 7.2, of the Child Care Facility Handbook, require a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.

Know Your Child Care Facility

Enrollment Form PDF

Selecting A Family Day Care Home Provider

School Entry Health Exam Forms

Disciplinary and Expulsion Policies

Food and Nutrition Policies

Safe Sleeping Policy

Parents Handbook