My Story Application
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You can alternatively download the PDF for this application, fill it out and mail it to our Headquarters (2801 US Hwy 17-92 W. Haines City, Florida 33844)
My Story:
1.) Please complete entire application.
Today's Date:  
I attend the Pozee Playzle Center in:  
My Name Is:   First:   Middle:   Last: 
Family Calls Me:   Nickname: 
I Am A:   Boy        Girl
My Birthday Is:                                I am years old
I Live With:   Mommy        Daddy                    Other  (Explain):
I Have Lived Here For:    years     months         Before that I lived at:
Our Phone Number Is:  
Mommy's Name Is:   First:   Middle:   Last: 
Daddy's Name Is:   First:   Middle:   Last: 
Mommy's Email Address:  
Daddy's Email Address:  
Brother's and Sister's:   Name:       Age:
Name:       Age:
Name:       Age:
Name:       Age:
Name:       Age:
Work Information:
Mommy Works At:  

(Name of business)
(Occupation)

(Address)

(Business phone #)
(Push this to talk to my Mommy)

(Her email address at work)
Daddy Works At:  

(Name of business)
(Occupation)

(Address)

(Business phone #)
(Push this to talk to my Daddy)

(His email address at work)
  *Please list a phone number where mommy / daddy can easily be reached.
Authorization To Release Your Child:
 
Name Relationship To Child Address Phone Number Photo ID
Provided
 
Information About Your Child


Are there custody arrangements for your child? Yes     No
(A court order with supporting documentation describing custody arrangements and restrictions must be provided prior to enrolling your child/children.)
I speak (language) at home.
I sleep (for children under 36 months)1   2 naps per day.
I use the potty (for children under 36 months)Yes     Not yet
I go to this preschool
My favorite food is
My favorite toy is
Emergency Contact (other than parents):
 
Name Relationship
To Child		 Phone Number
Authorization for Emergency Medical Treatment:
 

If my child should become ill or injured at the facility named
I understand that the:

Facility will: (1) Contact me immediately and (2) Contact the person(s) I have designated if I cannot be reached. Should the facility be unable to reach me and/or the person(s) designated, they are authorized to contact my child's physician and/or arrange for immediate medical treatment.

The physician and/or medical facility are authorized to administer emergency medical treatment necessary to ensure the health and safety of my child.

Digital Signature         Date (mm/dd/yy):

Consent To Participate In Activities:
 
Transportation:
Field Trips: I consent for my child to be transported on field trips. 		Consent Do Not Consent
Water Activities: Sprinkler Play Splashing water tables Consent Do Not Consent
Bus Transport to/from elementary school for before/after school care Consent Do Not Consent
Registration Agreement

I understand and agree to the following:

Completion of Registration and other Information. Registration information must be fully completed prior to enrolling my child. I will provide updated medical and family information to The Land of Pozee Playzle in a timely manner. Medical, family and other information may be shared by employees on a "need to know" basis.

Payments. All registration and enrollment fees must be paid in full before my child can be enrolled. A deposit of one week's care will be paid with registration. I understand that an electronic funds transfer in the amount of one weeks' care for my child will occur each Friday, and that I will be assessed $50 for any insufficient funds transaction. I further understand that I may be assessed late fees for payments received after the Friday cut-off day.

Fees are based on five days of care. Your child care fee is payable for each week whether or not your child is present for the entire week, or any part of the week.

Parent Handbook; use of the center: I have received and reviewed the Pozee Playzle Parent Handbook and other information regarding the center that was provided to me. I agree to the terms and conditions contained in these materials, and I will use the center in accordance with those terms and conditions. I understand that access to the services provided by Pozee Playzle, and use of the center, may be denied should I fail to comply with the terms of this agreement, or if determined by the center that it is in the best interest of my child. The discipline policy must be read and accepted by signature prior to my child/children's enrollment.

Solicitation of Services: I agree that I will not solicit, employ or enter into any contract with any employee of Pozee Playzle to provide child care, tutoring, or similar services under any circumstances without the express written consent of Pozee Playzle.

Release of Liability: I release Pozee Playzle from claims, losses, damages or costs (including attorney's fees) caused by or arising from my child's registration, use of the center, or participation in programs and activities.


Digital Signature         Date (mm/dd/yy):