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  • Excel Kids Academy

    2025-2026 21st CCLC After School Enrollment Application
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  • Instructions

    1. Student's photograph* must be taken and saved to the tablet or electronic device used to complete this application BEFORE entering any information into the form below. 
    2. A photograph* of the signed and dated Influenza Virus DCF Form, complete with Parent/Guardian and Child's Name, must be taken and saved to the tablet or electronic device used to complete this application BEFORE entering any information into the form below. (Note: The upload button for the Influenza Virus DCF Form will appear on the last page of the application.)
    3. Any additional photographs* or documents* that need to be uploaded to this form must be saved to the tablet or electronic deviced used to complete this application BEFORE entering any information into the form below. Additonal photographs include photographs of persons not allowed to pick up student; additional documents include court orders or letters from doctor(s). 

    *Uploaded photographs must be less than 10 MB.

    ** Required fields are marked with an (*). 

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  • D.O.B
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  • Grade currently enrolled in for the 2025-2026 School Year*
  • Is your child proficient in English?*
  • Other languages spoken in the home*

  • Student's Gender*
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  • Does child have health insurance? (ex., private insurance, KidCare, Medicaid) (If none; you may be able to find affordable coverage – call 211 or visit www.thechildrenstrust.org/parents/health-connect/insurance.)*
  • Ethnic Origin of Student*

  • Is your child eligible for free or reduced lunch?*

  • We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child…

  • Is your child enrolled in LEP of ESOL program?*
  • What are the main ways in which your child communicates? (Mark all that apply)*
  • What, if any, help does your child receive at this time? (Mark all that apply)
  • What conditions does your child have that are expected to last for a year or more? (Mark all that apply)*

  • **If you marked “None of the above” on the previous question, please skip the next two questions and sign below. If you marked any other answer on the question above, please answer the remaining questions and sign below.

  • Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do?*
  • To support your child’s successful participation in this program, in what are as might s/he need extra assistance?*

  • Has your child been retained?*
  • Are any other siblings being registered?*

  • Family Information

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  • Emergency Contacts

    & Authorized Persons Allowed to Pick Up Your Child
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  • Is this contact authorized to pick up your child?*
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  • Is this contact authorized to pick up your child?
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  • Is this contact authorized to pick up your child?
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  • Is this contact authorized to pick up your child?

  • Is there any person NOT allowed to pick up your child?

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  • Medical Information

  • In case of emergency, Excel Kids Academy staff will call 911 and contact the parent/legal guardian and/or emergency contacts listed with Excel Kids Academy. 

    Please provide Excel Kids Academy with medical personnel contact information to obtain emergency medical care if warranted. 

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  • Does your child take any medication?*
  • I give consent to Excel Kids Academy staff to apply provided sunscreen and/or bug spray for my child.*

  • Privacy Rights & Authorizations

  • PRIVACY RIGHTS

  • I understand that pictures, and/or video will be taken during program activities/events. I give permission to Excel Kids Academy and/or its Community Partners to use said photos/videos of my child, family and myself to be used in educational, promotional or informational materials or press media for positive public relations purposes.*
  • I give consent to Excel Kids Academy to contact me via my email provided within this application for updates pertaining to my child and program activities. (Excel Kids Academy will not share your email address to third parties without your consent.)*

  • PERMISSION TO EVALUATE PROGRAMS AND TRACK STUDENT PROGRESS

  • I give permission for Excel Kids Academy staff to review my child's school data (test scores, report cards, attendance, and other performance indices), for the purpose of providing targeted support, academic instruction and assessing the effectiveness of Excel Kids Academy. I also give permission for the Excel Kids Academy staff to monitor my child's progress and to require my child to complete evaluation surveys for the purpose of determining program effectiveness.*

  • FLORIDA CHILD CARE STANDARDS AND STATUTES

    • Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility" (CF/PI 175-24). 
    • Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility. 

  • Program Expecations

  • Please read and check each program expectation, and initial each section. By initialing and signing at the bottom, you agree to comply with each requirement.

  • ATTENDANCE*
  • PARENT INFORMATION NIGHTS*
  • PICK-UP*
  • DISCIPLINE POLICY*
  • EMERGENCIES*
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  • Your signature below indicates that you have received the items on the Florida Child Care Standards & Statutes, all of the program expectations and that the information on this enrollment form is complete and accurate. 

  • I give my permission for this information to be submitted to 21st Century for program quality and evaluation purposes. The 21st Century provides funding for the program.

  • After-School Site (Select where your child will be attending our after school program)
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