Enrollment Form | Stepping Stones

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

Director's name

Child's full name

Child's date of birth

Month

Day

Year

Child live with

Both parents

Mom

Dad

Guardian

Child's home address

Date of admission

Date of withdrawal

Name of parent or guardian 1 and address (if different from the child's)

Name of parent or guardian 2 and address (if different from the child's)

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

Parent 1 area code & phone number

Parent 2 area code & phone number

Guardian's area code & phone number

Custody documents on file

Yes

Name of emergency contact

Relationship

Area code & phone number

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 designated by the parent or guardian after verification of ID.

Name

Area code & phone number

Name

Area code & phone number

Name

Area code & phone number

Consent information

1. Transportation - I give consent for my child to be transported and supervised by the operation's employee. Check all that apply.

For emergency care

On field trips

To and from home

To and from school

2. Field trips

I give consent for my child to participate in field trips

I don't give consent for my child to participate in field trips

Comments

3. 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

If no, your child is required to wear a life jacket while in or near a swimming pool

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

Yes

If yes, your child is required to wear a life jacket while in or near a swimming pool

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

Yes

*A competent swimmer can enter and exit a pool safely on their own, tread water or float on their back for one minute, and swim 25 yards with no assistance.

6. Days and time 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.)

7. Receipt of parent's rights - I acknowledge I received a written copy of my rights as a parent or guardian of a child enrolled in this facility.

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Signature - Parent or Legal Guardian

Date signed

Explain any needs selected above:

Does your child have diagnosed food allergies?

Yes

Food allergy emergency plan submitted date:

Month

Day

Year

Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit www.ada.gov/resources/child-care-centers/. If you believe that such an operation may be practicing discrimination in viol

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Signature - Parent or Legal Guardian

Date signed

9. School age children - My child attends the following school.

School area code and phone number

My child has permission to. Check all that apply.

Walk to or from school or home

Ride a bus

Be released to the care of their siblings younger than 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 that I cannot be reached to arrange for emergency medical care, I authorize the person in charge to take my child to:

Name of physical & address

Area code and phone number

Name of emergency care facility & address

Area code and phone number

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

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Signature - Parent or Legal Guardian

Date signed

Requirements for Exclusion from Compliance

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

Pass

Fail

Left Eye 20/x

Pass

Fail

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

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Signature - Parent or Legal Guardian

Date signed

Hearing Exam Results

Right Ear 1000 Hz

Right Ear 2000 Hz

Right Ear 4000 Hz

Right Ear

Pass

Fail

Left Ear 1000 Hz

Left Ear 2000 Hz

Left Ear 4000 Hz

Left Ear

Pass

Fail

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

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Signature - Parent or Legal Guardian

Date signed

Admission Requirement - If your child does not attend pre-kindergarten or school away from the child care operation, one of the following must be presented when your child is admitted to the child care operation or within one week of admission.

Health Care Professional's Statement: I have examined the above named child within the past year and find they are able to take part in the day care program.

A signed and dated copy of a health care professional's statement is attached.

Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.

My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.