Roots & Shoots Enrollment

This ENROLLMENT form is for ONE child, if you are enrolling multiple children you will need to fill out this form for each child.

First Parent First Name

First Parent Last Name

First Parent Phone

First Parent Email

First Parent Occupation

If stay at home parent please list prior occupation

First Parent Employer

If stay at home parent please list prior employer

If there is no second parent please put N/A in the following fields.

Second Parent First Name

Second Parent Last Name

Parent Two Phone

Parent Two Email

Parent Two Occupation

If stay at home parent please list prior occupation

Parent Two Employer

If stay at home parent please list prior employer

Address 1

Address 2

City

State

Zip code

Child's First Name

Child's Last Name

Name child goes by (given or nickname)

Child's Birth Date

If you have any questions, comments or concerns, Ashley or Susan would be happy to speak with you. You can get in touch with them by email or calling 561 501-6615.

You will receive an email confirmation if you do not receive one please contact us
email: [email protected] - phone: 561 501-6615

Child’s Physician:

Phone:

Practice:

May we call another physician if unable to contact the above?

Yes

No

(NOT A PARENT/GUARDIAN) Persons to be contacted in case of illness, accident or emergency, if for some reason the parents or guardians cannot be reached, and authorized to remove the child from the facility.
This cannot be either parent one or two, and should be someone within driving distance of Sunflower.

Emergency Contact One NAME

(Other than parents)

Phone

Relationship

Emergency Contact Two NAME

(Other than parents)

Phone

Relationship

Please help us get to know your family better by providing the following details. Thank you

First Name of sibling number one

younger or older sibling of child you are enrolling

Birth Date of sibling number one

First Name of sibling number two

younger or older sibling of child you are enrolling

Birth Date of sibling number two

First Name of sibling number three

younger or older sibling of child you are enrolling

Birth Date of sibling number three

Is there anyone else that you haven't already listed above who is important to your child that we should know about?

May we share your contact info (emails and phone numbers) with other current families in your class?

Yes No

Permissions

Permission for Food-related Activities & Special Occasion Food Consumption
Pursuant to 65C-22.005(1)(c)2., F.A.C., licensed child care facilities must obtain written permission from parents/guardians regarding a child’s participation in food related activities. These activities include such things as: classroom cooking projects, gardening, school wide celebrations, and birthdays.

I

give/decline permission for my child,

to participate in food related activities and special occasions wherein food is consumed, subject to the conditions indicated below.

Permission Options: (Select one of the options below)

My child DOES NOT HAVE a food allergy or dietary restriction. He or she may participate in activities.

My child DOES NOT HAVE a food allergy or dietary restriction. He or she may not participate in activities.

My child HAS a food allergy or dietary restriction. He or she may not participate in activities.

My child HAS a food allergy or dietary restriction. He or she may participate in activities, but must not eat or handle the following items (please list below):

Permission for Application of Topical Lotions, Sprays and Ointments

I

give permission for Sunflower Creative Arts Staff to apply the following to my child

Sunscreen

Yes

No

Insect repellant

Yes

No

Sting Stop

Yes

No

What is Sting Stop?

Topical Arnica

Yes

No

What is Arnica?

Permission for Administration of Oral Arnica and Benadryl

I

give permission for Sunflower Creative Arts Staff to administer the following to my child,

Oral Arnica

Yes

No

What is Arnica?

Liquid Benadryl

Yes

No

I understand that Sunflower Creative Arts is a nut-free environment. No nuts, nut products or nut oils are allowed in the facility, including any and all food that I provide and send with my child.

I understand that Sunflower Creative Arts is a non-smoking environment.

Sunflower Creative Arts Photo/Video Release

I/We hereby give to Sunflower Creative Arts, and any of its associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees, the right to reproduce in any of its printed and online publications (such as newsletters, annual reports, websites, social media posts and blog posts), as well as any media that has yet to be created, all pictures, audio and video that it has produced of myself and/or my child(ren).

I/we authorize Sunflower Creative Arts to use all such pictures, audio and video and duplicates thereof, in perpetuity, for its publicity purposes and dispose of them as they may see fit. I/we hereby release Sunflower Creative Arts, from all claims of every kind on account of such use.

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select the "I Accept" button constitutes your signature acceptance and agreement as if actually signed by you in writing.

Questions should be directed to Sunflower Chief Operating Officer, Ashley Caskill, at [email protected] or 561 501-6615.

Photo/Video Release

I accept

I do NOT accept

Sunflower Creative Arts Release and Waiver of Liability

“Sunflower” means Sunflower Creative Arts, Inc., a Florida not-for-profit corporation, its officers, directors, volunteers, employees, representatives, agents and assigns. “Sunflower Activities” means any and all events, classes, programs, and/or services, formal and informal, offered and/or provided by Sunflower.

In consideration of participation in any Sunflower Activities, you, as a parent or guardian, on behalf of yourself and your child/children, waive, release and forever discharge any and all rights and claims for injuries, damages, losses, demands, recoveries, suits, payments, actions, and judgments of every nature and description, against Sunflower for injuries sustained or suffered by you and/or your child/children during any Sunflower Activities.

You hereby agree to hold Sunflower harmless and faultless for any harms or injuries that arise out of or are in any way related to Sunflower Activities and/or your participation and/or your child’s/children’s participation in Sunflower Activities, even if arising from the actions, acts of omission, negligence and/or gross negligence of Sunflower.

You on behalf of yourself and/or your child/children hereby knowingly and freely assume any and all risks of injury, known or unknown, from participating in any Sunflower Activities including but not limited to: physical injury, psychological or emotional injury, paralysis, or death.

You hereby certify that you are legally capable and competent to understand and execute this release and waiver of liability agreement without coercion on behalf of yourself and/or your child/children.

You hereby represent that you and/or any child or children in your care who will participate in any Sunflower Activities are physically, mentally and emotionally fit to participate in Sunflower Activities.

You hereby certify that you have read and fully understand this release and waiver of liability agreement and you understand that you are giving up important rights for yourself and/or your child/children.

You are free to agree or not agree to this agreement by choosing not to participate and/or to not permit your child/children to participate in Sunflower Activities. You have the right to discuss this agreement with Sunflower prior to participation.

You and/or your child/children, by participating in Sunflower Activities, consent to and grant Sunflower Creative Arts, Inc. license to use your and/or your child’s/children’s likeness(s), voice(s), and/or name(s), without compensation, for use in any and all media, whether now known or hereafter devised, in perpetuity, and you release Sunflower Creative Arts, Inc., its successors, assigns and licensees from any and all liability in relation to all of said uses.

You agree to follow and adhere to all Sunflower rules and understand and agree that you may be asked to leave at any moment and for any reason without any effect to the validity of this agreement.

You understand and agree that your and/or your child’s/children’s participation in Sunflower Activities indicates that you hereby waive your rights and/or the rights of your child/children to sue or bring other legal action against Sunflower as stated above and to hold Sunflower harmless as stated above.

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select the "I Accept" button constitutes your signature acceptance and agreement as if actually signed by you in writing.

I Accept

Parent One Signature

Parent Two Signature

Please allow 10 to 60 seconds for the form to transmit after you click the submit button.

Your enrollment form has not been recieved until you have been redirected to the next page.

You will receive an email confirmation if you do not receive one please contact us
email: [email protected] - phone: 561 501-6615

This ENROLLMENT form is for ONE child, if you are enrolling multiple children you will need to fill out this form for each child.

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