Admission Information

Use this form to collect all required information about a child enrolling in day care.

Directions: The day care provider gives this form to the child’s parent or guardian. The parent or guardian completes the form in its entirety and returns it to the day care provider before the child's first day of enrollment. The day care provider keeps the form on file at the child care facility.

General Information

Operation's Name

Child's Full Name

Child's Date of Birth

Child Lives With?

Both Parents

Mom

Dad

Guardian

Child's Home Address

Date of Admission

Date of Withdrawal

Name of Parent or Guardian Completing Form

Address of Parent or Guardian (if different from the child's)

List phone numbers below where parents or guardian may be reached while child is in care:

Parent 1 Phone No.

Parent 2 Phone No.

Guardian's Phone No.

Custody Documents on File?

Yes

In case of an emergency, call:

Name of Emergency Contact

Relationship

Area Code and Phone No.

Address

I authorize the child care operation to release my child to leave the child care operation ONLY with the following persons. Please list name and phone number for each. Children will only be released to a parent or guardian or to a person designed by the parent or guardian after verification of ID.

Name

Area Code and Phone No.

Name

Area Code and Phone No.

Name

Area Code and Phone No.

Consent Information

Transportation:

I give consent for my child to be transported and supervised by the operation's employees (Check all that apply)

for emergency care

on field trips

to and from home

to and from school

Field Trips:

I give consent for my child to participate in field trips.

I do not give consent for my child to participate in field trips.

Comments

Water Activities:

I give consent for my child to participate in the following water activities (Check all that apply)

Is your child able to swim without assistance?

Yes

Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming?

Yes

Do you want your child to wear a life jacket while in or near a swimming pool?

Yes

Receipt of Written Operational Policies:

Meals:

Days and Times in Care:

My child is normally in care on the following days and times:

Monday (A.M. - P.M.)

Tuesday (A.M. - P.M.)

Wednesday (A.M. - P.M.)

Thursday (A.M. - P.M.)

Friday (A.M. - P.M.)

Saturday (A.M. - P.M.)

Sunday (A.M. - P.M.)

Receipt of Parent's Rights:

I acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility.

Signature - Parent or Legal Guardian

Signature field is empty.

Date Signed

Explain any needs selected above:

Does your child have diagnosed food allergies?

Yes

Food Allergy Emergency Plan Submitted Date:

Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit https:// www.ada.gov/resources/child-care centers/. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).

Signature - Parent or Legal Guardian

Signature field is empty.

Date Signed

School Age Children

My child attends the following school

School Area Code and Phone No.

My child has permission to (Check all that apply)

walk to and from school or home

ride a bus

be released to the care of his or her sibling under 18 years old

Authorized pick up or drop off locations other than the child's address

Child's required immunizations. vision and hearing screening, and TB screening are current and on file at their school.

Authorization For Emergency Medical Attention

In the event I cannot be reached to arrange for emergency medical care, I authorize the person in charge to take my child to:

Name of Physician

Address

Phone

Name of Emergency Care Facility

Address

Phone

I give consent for the facility to secure any and all necessary emergency medical care for my child.

Signature - Parent or Legal Guardian

Signature field is empty.

Date Signed

Requirements for Exclusion from Compliance

This is a I have attached a signed and dated affidavit stating that I decline immunizations for reason of conscience, including religious belief, on the form described by Section 161.0041 Health and Safety Code submitted no later than the 90th day after the affidavit is notarized.

I have attached a signed and dated affidavit stating that the vision or hearing screening conflicts with the tenets or practices of a church or religious denomination that I am an adherent or member of.

Vision Exam Results

Right Eye 20/x

Left Eye 20/x

Pass

Fail

Signature - Parent or Legal Guardian

Signature field is empty.

Date Signed

Hearing Exam Results

Right Ear 1000 Hz

Right Ear 2000 Hz

Right Ear 4000 Hz

Left Ear 1000 Hz

Left Ear 2000 Hz

Admission Information

General Information

Consent Information

Authorization For Emergency Medical Attention

Requirements for Exclusion from Compliance

Vision Exam Results

Hearing Exam Results

ACADEMY