Enrollment - Blossom Preparatory School

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Parent’s
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Contact

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Child's Name *

First

Last

Child's Date of Birth *

Sex *

Date of Enrollment

Child's Primary Residence *

Address Line 1

City

State

Zip Code

Primary Hours of Care: From

Primary Hours of Care: To

Days of the Week in Care:

Parent/Guardian Name *

First

Last

Email *

Phone *

Notification Preference

Does the child reside with you (at least part-time in cases of custody arrangements) *

Primary Parent/Guardian Name *

First

Last

Parent/Guardian Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please note: if you are not a resident of this county, a library card will cost $20.

Primary Email *

Employer

Work Phone

Relationship to the child

Custody

Mother
Father
Both
Other

Primary Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Doctor Name

First

Last

Doctor Address

Layout Hours of

Doctor Phone Number

Hospital Preference

Please list allergies, special medical or dietary needs, or other areas of concern

Emergency Care Plan instructions including symptoms, medication and notification in the event of an actual emergency (if applicable)

Emergency Contact Name *

First

Last

Emergency Contact Address

Emergency Contact Phone Number

Select a 4-digit PIN number

If no PIN is entered here, your library card PIN will be set to the last 4 numbers of your phone number.

File Upload

Click or drag a file to this area to upload.

Date

Signature of Parent/Gardian

LICENSE NUMBER

Contact us

239-961-5306

blossomprepk@gmail.com

Hours of Operation
Monday- Sunday 24 hours care

Come Say Hello!

Ocoee FL,34761

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