University Academy Student Application

UNIVERSITY ACADEMY APPLICATION FOR ENROLLMENT

Student Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex:*
Date of Enrollment:*

MonthDayYear
Date
Emergency Code:*
Child's Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Hours of Care: From: 7:00AM To 6:00PM .
Days of the Week in Care:*

MondayTuesdayWednesdayThursdayFriday
Child lives with:*

Family Information:

Parent 1
Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number:*
Please enter a valid phone number.
Employer
Parent 2
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Employer
Child Lives With:*

Parent 1Parent 2Both ParentsOther

Medical Information
I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.
Doctor: *
Address:*
Phone:*
Please enter a valid phone number.
Hospital Preference:
Please list allergies, special medical or dietary needs, or other areas of concern:*
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:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
Please enter a valid phone number.
Work Number:
Please enter a valid phone number.
Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
- University Academy Handbook requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 10 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/PI175-28
- Section 2.8 of the Child Care Facility Handbook requires that parents be notified in writing of the disciplinary and expulsion policies used by the childcare facility, or
- Section 2.3 of the Family Day Care Home/Large Family Child Care Home Handbook requires that parents be 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. Also, you have read and will follow University Academy (UA) policies as stated in the handbook.
Parent Name:*

First NameLast Name
Date*

MonthDayYear
Date
Parent’s signature:*

Clear

AUTHORIZATION FOR EMERGENCY TREATMEN
Today’s Date*

MonthDayYear
Date
To Whom It May Concern:

I hereby give my consent to name of Hospital* to administer necessary treatment to my child, child name* in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance if situation warrants it.
Name of Physician*
Phone*
Allergies of Child
Date of Last DPT or Tetanus*

MonthDayYear
Date
Insurance Company Covering Child*
Policy Number*
Expiration Date*

MonthDayYear
Date
Signature of Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date

Discipline Policy
Children shall not be subjected to discipline that is severe, humiliating, or frightening. No child shall be delegated or permitted to discipline another child. No physical restraints, equipment, device, or furniture shall be used to confine a child, including, without limitation, swing, walkers and spinners. No child shall be confined in an enclosed area, such as a closet, looked room, box or bathroom. No child should be subjected to profane languages, threats, derogatory remarks, or other verbal abuse. No child shall be punished for failure to eat or sleep, or toileting accident. No child shall be punished by with-holding food, rest, or use of the toilet. No physical punishment shall be used, such as, but not limited to, spanking, hitting, striking, biting, or pinching.

Please read the following written policies regarding disciplinary action for when the behavior becomes inappropriate:

We will make every attempt to redirect the child from their inappropriate behavior by talking to them about the behavior.

The child will be taken to the office for a cooling off period and to speak with the director.

A note to parent(s)/guardian(s) will be sent home making them aware of the inappropriate behavior.

If the negative behavior persists, a conference will be scheduled with parent(s)/guardian(s), teachers and a Director to unite insights and provide the best possible solution to the situation. Both parents and/or guardians must be present.

Immediate cancellation of enrollment will occur, if the child is a danger to herself/himself or others. The immediate disenrollment under the above condition(s) is at the complete discretion of the Director for maintaining the safety of all children under our care.

University Academy reserves the right to remove a child at any time due to our discretion.
Parent/Guardian Signature: *

Clear
Date*

MonthDayYear
Date

Know your Child Care Facility
I parent name* have received and read the “Know Your Child Care Center” brochure.
Child's Name*

First NameLast Name
Parent Signature:*

Clear
Date:*

MonthDayYear
Date

During the 2009 legislative session, a new law was passed that requires child care facilities, family day care homes and large family child care homes provide parents with information detailing the causes, symptoms, and transmission of the influenza virus (the flu) every year during August andSeptember. My signature below verifies receipt of thebrochure on Influenza Virus, The Flu, A Guide to Parents.
Parent Name:*
Child's Name:*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear

Expulsion Policy
University Academy is committed to providing a warm, inviting, and calming space to learn and grow.

It is our policy to redirect a child from inappropriate behaviors with strategies that are appropriate. It is our responsibility to help children make proper behavior choices and to help them successfully communicate their needs. By modeling and teaching positive social skills, mediating difficulties between children, and offering alternatives to aggression, we hope to manage behaviors appropriately. Providing children with an introduction to the concept of choices and communicating the natural rewards and consequences of those choices will create an environment which the need for discipline is greatly lessened.

Our philosophy is to positively redirect children and to help them find strategies and solutions to their conflicts. Verbal redirection is used along with positive reinforcement.

Unfortunately, there would be a few occasions that could require us to enforce our Expulsion policy, either on a short term or permanent basis.

IMMEDIATE CAUSES FOR EXPULSION:

-the child is at risk of causing serious injury to him/herself or others

-the parent threatens physical action towards children, staff, or another family or exhibits intimidating or verbally abusive behaviors

-failure to submit up-to-date required forms (i.e.: immunization, physicals)

-failure to pay, habitual unauthorized late payments

In the event any of the above situations occur, all measures will be taken to work together to remedy the issue between the parent and University Academy Administration. Expulsion will always be last resort when all other options have been exhausted.

Certify below with your signature that you have fully read, understand, and agree to comply with the above policy.
Signature:*

Clear
Date*

MonthDayYear
Date

Physical Activity Participation Policy
All children at University Academy shall have a minimum of 40 minutes of combined indoor and outdoor physical activity for every three and a half hours in care per day.

All After School Students shall have a minimum of forty minutes of physical activity for every three hours in care.

All Campers shall have a minimum 40 minutes combined indoor and outdoor physical activity for every three and one-half hours in care.

These activities may include but not limited to the playground equipment, ball games, teacher lead small group games and teacher directed large group games. If weather is not permitting a rainy-day activity schedule is posted in each classroom on the parent information board. All teachers shall promote teamwork and fair and honest behavior in sports.

Proper clothing and footwear attire must be worn. Closed toe shoe is required at all times. No flip flops, sandals, or Crocs are permitted. In cold water we ask that an over garment be supplied for each child.

By signing below, you agree that you have been notified of the Physical Activity Participation Policy at University Academy.
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date

Dear University Academy Parents:

For our school to be in compliance with the Child Care Standards of the Florida Administrative Code, we must keep your written permission on file for your child to participate in any food-related activities that occur at our school. To meet this requirement, we have complied a list of our food-related activities items are brought into the classroom as part of an instructional activity, daily classroom reward (candy or pretzels), or birthday/holiday (cupcakes, cookies, potato chips) celebration. Please read the list carefully and note the statements at the bottom of this permission slip.

FRUITS:	VEGETABLES:	DAIRY:	STARCH:	SWEETS:	MEALS:
Apples	Carrots	Cream Cheese	Bread	Cupcakes/Cakes	Pizza
Melons	Celery	Cheese	Popcorn	Cookies	Chicken Nuggets
Grapes	Cucumber	Yogurt	Pretzels	Sprinkles & Jimmies	Pasta
Lemons	Turnips	Butter	Cheese Doodles	Hot Fudge Sauce	Hotdogs
Strawberries	Spinach	Milk	Pita Bread/Chips	Maraschino Cherries	Mac & Cheese
Raisins	Hummus	Ice-cream	Crackers	Marshmallows
Oranges	Mushrooms	Whipped Cream	Potatoes	Chocolate
Bananas	Tomatoes	Eggs	Rice Cakes	Donuts
Pears	Snap Peas		Muffins	Jelly
Pineapples				Tea/Lemonade
Berries				Frosting/Icing

**

YES, my child has permission to participate in food activities under the direction of the classroom teacher.NO, my child may not participate in food activities under the direction of the classroom teacher.My child may participate in food activities under the direction of the classroom teacher with the exception of the following foods (due to allergies or religious restrictions).
Child name
Please list restrictions here
My child, the classroom teacher with the exception of the following foods (due to allergies or religious restrictions

may participate in food activities under the direction of
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date

IMAGE RELEASE

Parent Contact Information
I parent name give permission for my child’s photos to be used on University Academy’s web sites.
Child’s Name:

First NameLast Name
Parent Signature:

Clear
Date

MonthDayYear
Date

Parent Contact Information
Full Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Your Child Gets Home: *
Allergies/Medical Information:*
Mother/Guardian:*

First NameLast Name
Email*
example@example.com
Home/Phone:
Please enter a valid phone number.
Cell:*
Please enter a valid phone number.
Work:*
Please enter a valid phone number.
Father/Guardian:*

First NameLast Name
Email*
example@example.com
Home/Phone: *
Please enter a valid phone number.
Cell:*
Please enter a valid phone number.
Work:*
Please enter a valid phone number.
Emergency Contact: *
Relationship to Student:*
Phone Number:*
Please enter a valid phone number.
Siblings at our school (name/grade):
Is there Anything else you would like me to know about your child?
I give permission for my student’s photo and class work to be used on the classroom website for the purpose of showcasing our hand work and fun activities:*

YesNo
Prefer Email Address (for classroom reminders/non urgent matters): Please Check one*

Mother’s EmailFather’s Email
Please initial here:*

I have carefully and thoroughly read, understand, and have a typed copy of the
parent handbook for University Academy.

I will follow University Academy policies as stated in the handbook and
understand that I am responsible for the information included in the handbook.
Child’s Name: *
Parent Name:*
Signature:*

Clear
Date*

MonthDayYear
Date

Facts About Heatstroke:
My signature below verifies receipt of the Distracted Adult brochure
Parent/Guardian:*

First NameLast Name
Child's Name :*

First NameLast Name
Date:*

MonthDayYear
Date

SAFE SLEEP FOR YOUR BABY
Parent Initial:*

Automated Payment Processing

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We are excited to offer the safety, convenience and ease of Tuition Express®—a payment processing system that allows
secure, on-time tuition and fee payments to be made from either your bank account or credit card

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT AND CREDIT CARD

I (we) hereby authorize University Academy to initiate credit card charges to the below-referenced credit card account (Section A) OR, initiate debit entries to my (our) checking or savings account, indicated below (Section B). To properly affect the cancellation of this agreement, I (we) are required to give 10 days written notice. Credit union members: please contact your credit union to verify account and routing numbers for automatic payments. Check with the center for accepted credit card types.
Please select which section you will be providing.*

SECTION A (Credit Card)Section B (Bank Account)
Cardholder Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Card Number
Expiration Date
Signature

Clear
Date

MonthDayYear
Date
Your Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank or Credit Union Name:
Bank or Credit Union Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Routing Transit Number
Account Number
Checking or Saving

ChekingsSavings
Authorized Signature

Clear
Date

MonthDayYear
Date

Should be Empty:

UNIVERSITY ACADEMY APPLICATION FOR ENROLLMENT

Family Information:

Medical Information

Emergency Contacts

AUTHORIZATION FOR EMERGENCY TREATMEN

Discipline Policy

SWIM Central Water Safety Education Questionnaire

Know your Child Care Facility

Expulsion Policy

Physical Activity Participation Policy

IMAGE RELEASE

Parent Contact Information

Facts About Heatstroke:

SAFE SLEEP FOR YOUR BABY

Automated Payment Processing