After School Care Application
Child Care Enrollment
Please fill out all information.
What is your child’s first name?
What is your child’s last name?
What grade was your child in for the 20-21 school year
- Select -
Pre K
K
1
2
3
4
5
What is your Childs date of birth
What is your childs age
What is the sex of your child?
- Select -
Female
Male
Last 4 digits of your child’s social security number
What school does your child currently attend?
Miami-Dade Public Schools ID Number? (if applicable)
Is your child proficient in English
- Select -
YES
NO
Other languages spoken in your home
- Select -
Haitian
Creole
Spanish
Other
Which race/ethnicity best describes your child?
- Select -
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Haitian
Hispanic
White / Caucasian
Other
What is your street address?
In what city do you live?
Does the child have health insurance?
YES
NO
What is the name of your medical insurance carrier?
What is the medical insurance carrier number?
List any allergies, illnesses, medicines, behaviours, or other important medical issues that we should know about concerning your child. If there are none, write none
Primary Parent/Guardian's Full Name
Secondary Parent's Cell Number
Primary Parent/Guardian's email address
Is the either parent or guardian a 1st responder or health care professional?
YES
NO
Other
Secondary Parent's Name
Primary Parent/Guardian's Cell Number
Emergency Contact Name
Emergency Contact Relationship to Child
Emergency Contact Number
We want to help your child in the best way possible and grant the best experience. Please tell us the way your child communicates. Check all that apply
Speaks and is easily understood
Speaks but is difficult to understand
Uses communication devices like pictures or a board
Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking
Uses sign language
Using signs that are not words like laughing or grunting
What, if any, help does you child receive at this time? Check all that apply
Behavioral therapy or services
Counseling or emotional concerns
Daily medication (not including vitamins)
Occupational Therapy
Physical Therapy
Special Educational Services in school
Speech/Language Therapy
None of the above
What conditions does your child have that are expected to last for a year or more? Check all that apply
Autism spectrum disorder
Problems with aggression or temper
Problems with attention or hyper activity (ADHD)
Developmental delay (only if under age 5)
Intellectual/Developmental disability (if over age 5)
Hearing impairment or deaf
Learning disability (school age)
Medical condition or illness
Physical disability or impairment
Problems with depression or anxiety
Speech or Language condition
Vision impairment or blind
None of the above
Do any of the conditions marked above make it harder for your child to do things that other children can't do?
- Select -
YES
NO
Who referred you to the program? (PLEASE STATE THE PERSON'S NAME IF APPLICABLE)
Typing your name in the box below constitutes an electronic signature
Submit
