Student Application 2025

UNIVERSITY ACADEMY APPLICATION FOR ENROLLMENT
Password
Student Information:
Date of Birth*

MonthDayYear
Date
SEX:*
Date Of Enrollment:*

MonthDayYear
Date
Student Full Name:*

First NameLast Name
Primary Hours of Care:
From: to .
7:00AM 6:30PM
Days of the Week in Care*

MondayTuesdaywednesdayThursdayFriday
Child lives with:*

Family Information:

Parent 1
Parent 1 Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Employer
Parent 2 Name
Address
Cell Phone
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*
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.
Contact 1:
Name:*
Address:*
Work Number:*
Please enter a valid phone number.
Cell Number:*
Please enter a valid phone number.
Contact 2:
Name:
Address:
Work Number:
Please enter a valid phone number.
Cell Number:
Please enter a valid phone number.
- University Academy Handbook requires a current physical examination (Form 3040) and immunizationrecord (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 CareFacility 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 thedisciplinary and expulsion policies used by the childcare facility, orSection 2.3 of the Family Day Care Home/Large Family Child Care Home Handbook requires that parentsbe notified in writing of the disciplinary and expulsion policies used by the family day care provider.
Your signature below indicates that you have received the above items and that the information on thisenrollment form is complete and accurate. I hereby grant permission for the staff of this facility to haveaccess to my child’s records. Also, you have read and will follow University Academy (UA) policies asstayed in the handbook.
Parent name:*
Date*

MonthDayYear
Date
Parents signature*

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Board of County Commissioners, Broward County, Florida

HUMAN SERVICES DEPARTMENT

Community Partnerships Division

Child Care Licensing and Enforcement

AUTHORIZATION FOR EMERGENCY TREATMENT
Todays Date:*

MonthDayYear
Date
To Whom It May Concern:
I hereby give my consent toname of hospital * to administer necessary treatment to my child, name of child* 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*

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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

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.
ParentGuardian Signature*

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Date*

MonthDayYear
Date

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

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 -habitual late pick up -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*

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DATE*

MonthDayYear
Date

Preschool Hours of Operation Acknowledgment Form

We would like to inform you that the hours of operation for University Academy

Monday - Friday: 7:00 AM - 6:00 PM

It is important for the smooth operation of our school and the well-being of all children that these hours are respected. We kindly request that you ensure timely drop-offs and pick-ups in accordance with these hours. Please note that any pick-up after 6:00 PM will incur an additional fee of $2 per minute.

By signing below, you acknowledge and agree to the preschool's hours of operation

Acknowledgment:

I, the undersigned, acknowledge and agree to adhere to the preschool's hours of operation from 7:00 AM to 6:00 PM, Monday through Friday. I understand that any late pick-ups may result in additional fees.
Childs Name*
ParentGuardian Name*
Signature*

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Date*

MonthDayYear
Date

Know your Child Care Facility
I have received and read the "Know Your Child Care Center" brochure*
Parent Name
Childs Name*
Parent Signature*

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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 and September.

My signature below verifies receipt of the brochure on Influenza Virus, The Flu, A
Guide to Parents:
Name*
Childs Name*
Date Received*

MonthDayYear
Date
Signature*

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CALL OR TAKE YOUR CHILD TO A DOCTOR RIGHT AWAY IF YOUR CHILD:
What should I do if my child gets sick?

Consult your doctor and make sure your child gets plenty of rest and drinks a lot of fluids. Never give aspirin or medicine that has aspirin in it to children or teenagers who may have the flu.

Call or ta ke your child to a doctor rightaway if your child:

• Has a high fever or fever that lasts a long time
• Has trouble breathing or breathes fast
• Has skin that looks blue
• Is not drinking enough
• Seems confused, will not wake up, does not want to be held, or has seizures (uncontrolledshaking)
• Gets better but then worse again
• Has other conditions (like heart or lung disease, diabetes) that get worse

How can I protect my child from the flu?

A flu vaccine is the best way to protect against the flu. Because the flu virus changes year to year, annual vaccination against the flu is recommended. The CDC recommends that all children from the ages of 6 months up to their 19th birthday receive a flu vaccine every fall or winter (children receiving a vaccine for the first
time require two doses). You also can protect your child by receiving a flu vaccine yourself.

What can I do to prevent the spread of germs?

The main way that the flu spreads is in respiratory droplets from coughing and sneezing. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and infect someone nearby. Though much less frequent, the flu may also spread through indirect contact with contaminated hands and articles soiled with nose and throat secretions. To prevent the spread of germs:
• Wash hands often with soap and water.
• Cover mouth/nose during coughs and sneezes. If you don’t have a tissue, cough or sneeze into your upper sleeve, not your hands.
• Limit contact with people who show signs of illness.
• Keep hands away from the face. Germs are often spread when a person touches something that is contaminated with germs and then touches his or
her eyes, nose, or mouth.

When should my child stay home from child care?

A person may be contagious and able to spread the virus from 1 day before showing symptoms to up to 5 days after getting sick. The time frame could be longer in children and in people who don’t fight disease well (people with weakened immune systems). When sick, your child should stay at home to rest and to avoid giving the flu to other children and should not return to child care or other group setting until his or her temperature has been normal and has been sign and symptom free for a period of 24 hours.

For additional helpful information about the dangers of the flu and how to protect
your child, visit: http://www.cdc.gov/flu/ or http://www.immunizeflorida.org/

Food Participation Policy

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

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 teacherMy 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).
Yes Child name:
No Child name:
Child Name
Please list restrictions here:
ParentGuardian Signature*

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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:*

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Date:*

MonthDayYear
Date

Parental Consent for Access to Child Records

Dear Parents/Guardians,

In order to provide the highest quality of care for your child, it is sometimes necessaryfor our childcare personnel to have access to your child’s records. These records mayinclude, but are not limited to, enrollment forms, medical information, emergencycontact details, and any other pertinent information that will assist us in ensuring yourchild’s well-being and safety while in our care.By signing this form, you are giving consent for our preschool staff to access and reviewthese records as needed to provide appropriate care for your child.We take the confidentiality of your child’s records seriously and will only allowauthorized personnel access to these files in accordance with our privacy and securitypolicies. This information will not be shared with anyone outside the preschool withoutyour explicit written consent, except as required by law.

Consent Acknowledgment:

I, the undersigned, hereby give consent for the staff University Academy to have accessto my child’s records in order to provide appropriate care and meet the needs of mychild.
Childs Name*
ParentGuardian Name*
Signature*

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Date*

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Date

Distraction Prevention Tips:

• Never leave your child alone in a car and call 911 ifyou see any child locked in a car!

• Make a habit of checking the front and back seatof the car before you walk away.

• Be especially mindful during hectic or busy times,schedule or route changes, and periods ofemotional stress or chaos.

• Create reminders by putting something in theback seat that you will need at work, school orhome such as a briefcase, purse, cell phone oryour left shoe.

• Keep a stuffed animal in the baby’s car seat andplace it on the front seat as a reminder when thebaby is in the back seat.

• Set a calendar reminder on your electronicdevice to make sure you dropped your child offat child care.

• Make it a routine to always notify your child’s childcare provider in advance if your child is going to belate or absent; ask them to contact you if your childhasn’t arrived as scheduled.

It only takes a car 10 minutes to heat up 20 degrees and become deadly.

Even with a window cracked, the temperature inside a vehicle can cause heatstroke.

The body temperature of a child increases 3 to 5 times

Never leave your child alone in a car and call 911 if you see any child locked in a car! Make a habit of checking the front and back seat of the car before you walk away. Be especially mindful during hectic or busy times, schedule or route changes, and periods of emotional stress or chaos.

Keep a stuffed animal in the baby's car seat and place it on the front seat as a reminder when the baby is in the back seat. Set a calendar reminder on your electronic device to make sure you dropped your child off at child care.

Create reminders by putting something in the back seat that you will need at work, school or home such as a briefcase, purse, cell phone or your left shoe.

Make it a routine to always notify your child's child care provider in advance if your child is going to be late or absent; ask them to contact you if your child hasn't arrived as scheduled.

Facts About Heatstroke:

It only takes a car 10 minutes to heat up 20 degrees andbecome deadly.Even with a window cracked,the temperature inside avehicle can cause heatstroke.

Even with a window cracked,the temperature inside avehicle can cause heatstroke.

The body temperature of achild increases 3 to 5 times faster than an adult’s body.
During the 2018 legislative session, a new law was passed that requires child care facilities, family day care homes and large family child care homes to provide parents, during the months of April and September each year, with information regarding the potential for distracted adults to fail to drop off a child at the facility/ home and instead leave them in the adult's vehicle upon arrival at the adult's destination.
Parents/Guardians Name:*
Signature*

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IMAGE RELEASE
I give permission for my childs photos to be used on University Academy's web sites
Parent's name
Childs Name
Parent Signature

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Date

MonthDayYear
Date

Parent Contact Information
Full Name:*
Date of Birth*

MonthDayYear
Date
Address*
How Your Child Gets Home*
Allergies/Medical Information:*
Mother/Guardian:*
Email:*
example@example.com
Home/Phone
Cell Phone Number:*
Please enter a valid phone number.
Work:*
Please enter a valid phone number.
Mother/Guardian Name:
Email
example@example.com
Home/Phone:
Cell Phone:
Work:
Prefer Email Address (for classroom reminders/non urgent matters): Please Check one.*

Mother’s EmailFather’s Email
Emergency Contact Name:*
Relationship to Student*
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
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
Please initial:*

I have carefully and thoroughly read, understand, and have a typed copy of the parent handbook for University Academy. | will follow University Academy policies as stated in the handbook and understand that | am responsible for the information included in the handbook.
Childs Name:*
Guardian Name:*
Signature:*

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Date*

MonthDayYear
Date

Signature:*

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Should be Empty:

Family Information:

Medical Information:

Contact 1:

Contact 2:

Discipline Policy

Expulsion Policy

CALL OR TAKE YOUR CHILD TO A DOCTOR RIGHT AWAY IF YOUR CHILD:

Food Participation Policy

IMAGE RELEASE

Parent Contact Information