Child's Enrollment Form

Child's Enrollment Form
Upload Child's Current Physical and Immunization Record*
Drop files here or
Child’s Name*
First Name Last Name
Preferred Name
Child's DOB (mm/dd/yyyy)*
Date Enrolled (mm/dd/yyyy)*
Address
Street Address City State / Province / Region ZIP / Postal Code
Custodial Parent
- Mother
- Father
- Joint
Parent Information
Parent #1 Name*
First Last
Relationship*
Parent Email*
Home/Cell Phone*
Employer*
Work Phone*
Parent #2 Name
First Last
Relationship
Parent Email
Home/Cell Phone
Employer
Work Phone
Legal Guardian Name (If different than above)
Persons Authorized to Pick Up Child Other than Parents (Legal Identification Required)
Authorized person #1 Name
Relationship
Phone
Authorized person #2 Name
Relationship
Phone
Alternate Nutrition Plan
Alternate Nutrition Plan Agreement
I understand and approve the use of the alternate nutrition plan. I agree to provide the following meals and/or snacks to meet my child’s nutritional and dietary needs.
Indicate any special Dietary Requirements:
Mark “P” for Parent Provides or “C” for Center Provides
Breakfast AM Snack Lunch PM Snack Dinner Evening Snack Formula
HILLSBOROUGH COUNTY ORDINANCE requires that parents must receive a copy of the “KNOW YOUR CHILD CARE FACILITY/FCCH BROCHURE”, information on the INFLUENZA (FLU) VIRUS, and the parents are notified in writing of the “DISCIPLINARY PRACTICES” used by the Child Care Facility/FCCH. The parent’s/ legal guardian’s signature certifies receipt of the Child Care Facility/FCCH brochure, influenza information, discipline policies, alternate nutrition plan agreement and that all the information on this form is complete and accurate.
Signature of Parent or Legal Guardian*
Date*
Date Format: MM slash DD slash YYYY
Allergies/Dietary Restrictions
Medical Alert Information (i.e. medical and/or special needs/conditions)
List any additional information which would be beneficial for Launchpad Learning to know about your child
Preferred Physician*
Address*
Phone*
Preferred Hospital*
Emergency Contact (Other than parents)*
Name Relationship Phone
Authorization for Emergency Medical Treatment
Check the box beside the statement:*
If my child should become ill or injured at Launchpad Learning Center, I understand that the childcare provider will: 1. Contact me immediately and 2. Contact the person(s) I have designated if I cannot be reached.
Check the box beside the statement:*
Should the provider be unable to reach me and/or the person(s) designated, they are authorized to contact my child’s physician and/or arrange for immediate medical treatment.
Check the box beside the statement:*
The physician and/or medical facility are authorized to administer emergency medical treatment necessary to ensure the health and safety of my child.
Check the box beside the statement:*
I will accept responsibility for payment of medical services rendered.
Signature*
Date*
Date Format: MM slash DD slash YYYY
Please initial each of the following statements.
I HEREBY CONSENT for my child to ride in any vehicle authorized by Launchpad Learning Center. The parent releases Launchpad Learning Center of responsibility for any accident or injury resulting there from and will hold the center harmless from any liability for such accident or injury. (Pertains to field trips for VPK and School age students)*
I understand that Launchpad Learning Center reserves the right at its discretion to terminate the childcare of said child at any time.*
Payment for Launchpad Learning Center services are due by 9pm Sunday prior to service or if your child is a drop in it is due on the day of service. No refunds are given for advanced payments. Any changes in fees will be posted at least ten days in advance.*
I have access to Launchpad Learning’s website and Launchpad Learning Center, Inc’s Parent Handbook provided on Lineleader app and I have read and understand it.*
Launchpad Learning is required to serve a meal if the child is in attendance at the center entirely between 8:00-9:00, 11:00am- 1:30pm and 2:00pm-3:00pm. Your child will be provided with a meal off the posted menu, substitutions may only be provided by the family if accompanied by DOH medical form. If a DOH medical form is provided the meal sent must meet nutritional guidelines. We are required to ensure that meals are balanced and meet the recommended daily dietary allowances. Two meals and at least one snack is included for those who are on full time schedules.*
I have received a copy of the childcare facility brochures on the centers app, Lineleader, Know Your Child Care Facility and “The Flu Guide for Parents” and have also received in writing the (disciplinary practices in parent handbook) used by Launchpad Learning Center, Inc. (Available online in the Center’s Childcare App, Lineleader.)*
In order to assist Launchpad Learning Center in meeting all my child’s needs I give my permission for Developmental Screenings as well as other helpful assessments to be completed on my child.*
I hereby consent for my child to be included in school pictures and give permission for those pictures to be used by Launchpad Learning Center.*
Launchpad Learning is state licensed and must close on time. An initial fee of $10 will be accessed plus $1.25/minute/child after closing.*
I give permission for Launchpad Learning Center to apply insect repellant and sunblock appropriate for children, such as Natural Cutter Skinsations and Bug Soother! Family Care, as needed.*
I hereby agree to keep all information on this Child’s Enrollment/ Registration form current while my child is enrolled at Launchpad Learning Center.*
I will provide Launchpad Learning Center 2 weeks’ notice if withdrawing from a FT/PT program and will pay for 2 weeks even if my child does not attend.*
If my child takes vacation, I will notify the school at least 2 weeks in advance and pay $50 a week on the Friday prior to the vacation week in order to receive the reduced vacation rate.*
I give my child permission to have store brought snacks for celebrations and parties at Launchpad Learning Center.*
I have read the Rilya Wilson Act and will call or text the school each day my child will be absent.*
I have programed the non-emergency phone number of Launchpad Learning Center for attendance and texting phone to my cell phone, 813-519-9992.*
STATE OF FLORIDA LICENSING REQUIREMENTS: The Florida Department of Job and Family Services, Child Care Licensing unit shall have the right to enter and inspect the premises unannounced, and have access to children’s records, as well as the authority to contact staff, parents, and relatives of children in care, or other witnesses. The Administrator of Launchpad Learning Center and its employees are required, to report their suspicions of child abuse or neglect to the local public children’s services agency.*
The hours and days we have agreed that Launchpad Learning will provide care for my child are:
Primary Hours of Care:*

(Not to exceed 10 hours per day)

From to
Days of the week in care:*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Meals Typically Served While in Care:*
- Br
- Lunch
- PMSnack
Please notify us in writing if there’s any changes to be made to your hours.

Two weeks’ notice and approval is required before changes are made.
Check the box beside statement:*
Parents agree to pay according to schedule.
We have agreed to pay $
Select the appropriate option:
- Weekly
- Bi-weekly
- Monthly
- Hourly
- VPK only
Other Charges
b. There will be no charge for meals served for children FT/PT programs. c. There will be a charge for in house and traveling field trips. The cost will be posted prior to the field trip. d. There will be an hourly charge for full time students attending over 50 hours a week and part time students attending over 25 hours a week. e. There is an annual $85 supply fee for FT/PT students every October 1st. f. There will be a late pick up for any student not picked up by the daily close of business. Please see fee schedule listed below. Overtime rate: NSF Checks: Late payment: Enrollment: $1.25/minute $40.00/item $30.00/week $100 /child or $175/siblings PaymentsaredueonMondayby9amevenifthestudentisnotattendancewhenpaymentisdue. Tuitionratesare subject to change at anytime.
RELEASE
Launchpad Learning Center, as a State of Florida licensed Child Care Facility, provides a safe, clean and fun environment for children. However, in any childcare program, injuries may occur. For Launchpad Learning Center to be able to provide childcare services to you, it is necessary that you assume certain risks. Signing this release is necessary to receive services. I, on behalf of myself, my spouse, and each child designated on the Admission Form Agreement (my “Child”), waive and release all rights, causes of action and claims against Launchpad Learning Center., A Florida Cooperation, its Officers, Directors, Administrators, Agents, and Employees, for any and all loss of damage to property or injuries suffered by my Child during the time my Child is visiting at Launchpad Learning Center, including the possible negligence of Launchpad Learning Center, but excluding gross negligence and intentional property misconduct. I understand that the provision of childcare contains risk of injury to persons and damage to property, and that by signing this release, I engage Launchpad Learning Center to provide temporary childcare for my Child at my own risk. I have been given an opportunity to ask questions and obtain answers to my satisfaction regarding any and all aspects of Launchpad Learning Center and the Release, including, but not limited to, future risks, complications, and costs. By signing this Release, I have not relied on any promises or statements made by Launchpad Learning Center other than those contained in the written information supplied to me by Launchpad Learning Center. I understand that this Release will be kept on file at Launchpad Learning Center and will continue in effect for this and any future visits my child may make to Launchpad Learning Center. I agree to pay all costs and attorney fees arising out of my action relating to the Agreement, the Registration Form, or the release for collection purposed or otherwise.
Check the box beside the statement:*
I HAVE READ THE ABOVE CAREFULLY AND HAVE FULLY UNDERSTOOD THE CONTENT AND CONSEQUENCES OF THIS AGREEMENT BEFORE SIGNING.
Parent/Legal Guardian Name*
Signature of Parent/Legal Guardian*
Date*
Date Format: MM slash DD slash YYYY

Launchpad Learning Center

Child’s Enrollment Form

Parent Information

Persons Authorized to Pick Up Child Other than Parents (Legal Identification Required)

Alternate Nutrition Plan

Authorization for Emergency Medical Treatment

Please initial each of the following statements.

The hours and days we have agreed that Launchpad Learning will provide care for my child are:

@

Breakfast	AM Snack	Lunch	PM Snack	Dinner	Evening Snack	Formula

Name	Relationship	Phone

From	to