Child Care Registration

LAKA Childcare Center

4701 N 15th St, Tampa, FL 33610

PHONE: (813) 231.2040

Child's Information

First name*

Last name*

M.I.

Street address*

Street address line 2

City*

State*

Zip code*

Gender*

DCF Involved?*

Ethnicity*

Religious Affliation

Do you require before or after school care?

Before schoolAfter school

Parent's Information

Parent's/Guardian's name*

Phone number*

Place of work

Email address*

Parent's Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency Contact 1
In the event of an emergency, please contact:

First name*

Last name*

Primary phone number*

Secondary phone number*

Relationship*

Emergency Contact 2
In the event of an emergency, please contact:

First name*

Last name*

Primary phone number*

Secondary phone number*

Relationship*

Emergency Contact 3
In the event of an emergency, please contact:

First Name*

Last Name*

Primary phone number*

Relationship*

Authorize Pick-up

Name and Phone Number(s) of person(s) other than parents allowed to pick up your child

First name*

Last name*

Relationship*

Phone*

First name*

Last name*

Relationship*

Phone*

First name*

Last name*

Relationship*

Phone*

Any special instructions, such as custody or restraining orders must be attached to this application. All information will be kept confidential?

Drop Off and Pick up Agreement

Name

First NameLast Name

Agree to the following

I, the parent/guardian, agree to pick up, or make arrangements for my child to be picked up, as soon as possible, if the center program staff notifies me that my child has become ill during daycare hours.

Initials

Name

First NameLast Name

Agrees to allow the staff of Loving Arms Kidz Academy to drop of my child to school during the morning. I also agree to allow the staff of Loving Arms Kidz Academy to pick up my child from school and transport them back to the daycare.

Loving Arms Kidz Academy staff will sign in and out students that are being transported back and forth to school.

Child's full name

First NameLast Name

School

School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Medical information

Doctor

Doctor's phone number

Dentist

Dentist's phone number

Preferred hospital

Insurance/health coverage

Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.*

Parent's Signature

First NameLast Name

Date*

MonthDayYear

Enter the message as it's shown*