Form CF-FSP5241 "Child Care Application for Enrollment in Specialized Child Care Facilities for Mildly Ill Children" - Florida

What Is Form CF-FSP5241?

This is a legal form that was released by the Florida Department of Children and Families - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the Florida Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CF-FSP5241 by clicking the link below or browse more documents and templates provided by the Florida Department of Children and Families.

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Download Form CF-FSP5241 "Child Care Application for Enrollment in Specialized Child Care Facilities for Mildly Ill Children" - Florida

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State of Florida
Department of Children and Families
CHILD CARE APPLICATION FOR ENROLLMENT
IN SPECIALIZED CHILD CARE FACILITIES
FOR MILDLY ILL CHILDREN
Student Information:
Date of Birth: ____________ Sex: ___ Date of Enrollment:___________
Full Name:_______________________________________________________________________
Last
First
Middle
Nickname
Child's Physical Address:____________________________________________________________
Primary Hours of Care:
From __________________ To _________________
Days of the Week in Care:
M
T
W
Th
F
Sa
Su
Meals Typically Served While in Care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Family Information:
Child Lives With: ______________________________
Parent/Guardian Name:
_____
Parent/Guardian Name:
Address:
Address:
Home Phone:
Home Phone:
Employer:
Employer:
Address:
Address:
Work Phone: ___________/Cell:___________
Work Phone: ___________/Cell:___________
Relationship to the child:__________________
Relationship to the child: _________________
Custody:
Mother ________
Father ________
Both ________ Other ________
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:
Doctor:
Address:
Phone:
Hospital Preference:
________________
Present Illness:____________________________________________________________________
Allergies/Reaction:_________________________________________________________________
Present Medications and Dosages:____________________________________________________
Current Diet:______________________________________________________________________
Diapering Requirements (If Applicable):_________________________________________________
Symptoms Requiring Parent or Health Care Provider Notification/Special Instructions:
_____
___________________________________________________________________________
Past Medical History
CF-FSP 5241, Child Care Application for Enrollment in Specialized Child Care Facilities for Mildly Ill Children, Dec 2019, 65C-25.003, F.A.C.
Page 1 of 2
State of Florida
Department of Children and Families
CHILD CARE APPLICATION FOR ENROLLMENT
IN SPECIALIZED CHILD CARE FACILITIES
FOR MILDLY ILL CHILDREN
Student Information:
Date of Birth: ____________ Sex: ___ Date of Enrollment:___________
Full Name:_______________________________________________________________________
Last
First
Middle
Nickname
Child's Physical Address:____________________________________________________________
Primary Hours of Care:
From __________________ To _________________
Days of the Week in Care:
M
T
W
Th
F
Sa
Su
Meals Typically Served While in Care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Family Information:
Child Lives With: ______________________________
Parent/Guardian Name:
_____
Parent/Guardian Name:
Address:
Address:
Home Phone:
Home Phone:
Employer:
Employer:
Address:
Address:
Work Phone: ___________/Cell:___________
Work Phone: ___________/Cell:___________
Relationship to the child:__________________
Relationship to the child: _________________
Custody:
Mother ________
Father ________
Both ________ Other ________
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:
Doctor:
Address:
Phone:
Hospital Preference:
________________
Present Illness:____________________________________________________________________
Allergies/Reaction:_________________________________________________________________
Present Medications and Dosages:____________________________________________________
Current Diet:______________________________________________________________________
Diapering Requirements (If Applicable):_________________________________________________
Symptoms Requiring Parent or Health Care Provider Notification/Special Instructions:
_____
___________________________________________________________________________
Past Medical History
CF-FSP 5241, Child Care Application for Enrollment in Specialized Child Care Facilities for Mildly Ill Children, Dec 2019, 65C-25.003, F.A.C.
Page 1 of 2
Other Illnesses or Childhood Diseases:
_____
Past Medications:
________________________________________________________________
Emergency Contacts:
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:
Name
Address
Work#
Cell/Home#
Name
Address
Work#
Cell/Home#
Name
Address
Work#
Cell/Home#
Helpful Information About Child:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
• 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).
• 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.
• Chapter 65C-25.003(14)(b), Florida Administrative Code, requires that parents receive copies of
the facility’s admission policy; infection control procedures; daily care procedures; plan for the
care of children exhibiting worsening symptoms, and referral for medical evaluations, including a
listing of the symptoms; policy and procedure for staff communication with parents and health
providers; and discipline and expulsion policies.
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.
_________________________________________________
_____________________
Signature of Parent/Guardian
Date
CF-FSP 5241, Child Care Application for Enrollment in Specialized Child Care Facilities for Mildly Ill Children, Dec 2019, 65C-25.003, F.A.C.
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