Day School Admission Information Form

General Information

*Required fields are indicated with a red asterisk. Please fill in all required fields. Failure to fill in all required fields will result in your form not being submitted.

Operation's Name*

Director's Name*

Child's Full Name:*

Child's Date of Birth*

Child lives with:

Both Parents
Mom
Dad
Legal Guardian

Child's Home Address*

Street Address City State ZIP Code

Date of Admission:

Date of Withdrawl:

Name of Parent or Guardian completing this form:*

Is your address the same as the child's above?*

Yes
No

Your Address*

Street Address City State ZIP Code

Dad's Phone Number*

Mom's Phone Number*

Guardian's Phone Number*

Custody Documents on File?*

Yes
No

Give the name, address, and phone number of the responsible individual to call in case of an emergency if the parents/guardian cannot be reached:*

Their relationship with the child:*

I authorize the child care operation to release my child to leave the child care operation ONLIN with the following persons.

Name	Telephone Number

Please list name and telephone numbers for each person, children will only be released to a parent or guardian or to a person designated by the parent/guardian after verification of ID.
Click the (+) icon for additional people.

Consent Information

Check all that apply:

1. Transportation

I give consent for my child to be transported and supervised by the operation's employees:

for emergency care
on field trips
to and from home
to and from school

2. Field Trips

Do you give consent for your child to participate in field trips?

Yes
No

3. Water Activities

I give consent for my child to participate in the following water activities

Water Table Play
Springler Play
Splashing/Wading Pools
Swimming Pools
Aquatic Playgrounds

4. Meals

I understand that the following meals will be served to my child while in care:

None
Breakfast
Morning Snack
Lunch
Afternoon Snack

5. Days and Times in Care

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

Day of the Week	AM	PM

Click the (+) for each new day/time combination

Authorization for Emergency Medical Attention

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

Physician

Name of Physician:*

Physician's Phone Number*

Physician's Address*

Street Address City State ZIP Code

Emergency Care Facility

Name of Emergency Care Facility:*

Emergency Care Facility Phone Number*

Emergency Care Facility Address*

Street Address City State ZIP Code

Additional Information Section

List any special needs that your child may have, such as environmental allergies, food intolerances, existing illness, previous serious illness, injuries and hospitalizations during that past 12 months, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:*

Does your child have diagnosed food allergies?*

Yes
No

If yes, plan submitted on:*

Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. 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).

School Age Children

My child attends the following school:

Name of School:

School 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 his/her sibling under 18 years old

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

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.*

A statement from a Health Care Professional stating that they have examined the above named child within the past year and find that he or she is able to take part in the day care program. You will be required to attached a signed statement from the Health Care Professional.
Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of. You will be required to attach 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

Upload the signed Health Care Professional's Statement:*

Accepted file types: jpg, png, pdf, txt, rtf, doc, docx, Max. file size: 50 MB.

Upload the signed and dated affidavit about your religious practices and medical treatment.*

Accepted file types: jpg, png, pdf, txt, rtf, doc, docx, Max. file size: 50 MB.

Requirements for Exclusion

Select all that apply:

I would like to submit a signed and dated affidavit stating that I decline immunizations for reasons of conscience, including religious belief, on the form described by Section 161.0041 Heath and Safety Code submitted no later than the 90th day after the affidavit is notarized.
I would like to submitt 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.

Upload the signed and dated affidavit about your religious practices regarding immunizations*

Accepted file types: jpg, png, pdf, txt, rtf, doc, docx, Max. file size: 50 MB.

Upload the signed and dated affidavit about your religious practices regarding hearing and vision screenings*

Accepted file types: jpg, png, pdf, txt, rtf, doc, docx, Max. file size: 50 MB.

Vision and Hearing Exam Results

Vision Exam Results

Right Eye

Left Eye

Did they pass?

Yes
No

Hearing Exam Results

Right Ear 1000 Hz

Right Ear 2000 Hz

Right Ear 4000 Hz

Did they pass?

Yes
No

Left Ear 1000 Hz

Left Ear 2000 Hz

Left Ear 4000 Hz

Did they pass?

Yes
No

Vaccine Information

Vaccines require multiple doses over time. Please provide the date your child received each dose in a document signed or stamped by a physician or public health personnel verifying that immunization record.*

Accepted file types: jpg, png, pdf, doc, docx, rtf, txt, Max. file size: 50 MB.

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement: My child had varicella disease (chickenpox) on or about (Date provided below) and does not need varicella vaccine.*

TB Test (If Required)

Positive
Negative

Date of Test

Gang Free Zone:

Under the Texas Penal Code, any area within 1,000 feet of a child care center is a gang-free zone, where criminal offenses related to organized criminal activity are subject to harsher penalties.

Signature*

First Last

Date*

Email*

Day SchoolAdmission Information Form

Fill out the form below!

General Information

Consent Information

1. Transportation

2. Field Trips

3. Water Activities

4. Meals

5. Days and Times in Care

Authorization for Emergency Medical Attention

Physician

Emergency Care Facility

Additional Information Section

School Age Children

My child attends the following school:

Admission Requirement

Requirements for Exclusion

Vision and Hearing Exam Results

Vision Exam Results

Hearing Exam Results

Vaccine Information

Gang Free Zone:

Day School
Admission Information Form