Day SchoolAdmission Information Form Fill out the form below! General InformationOperation's Name*Director's Name*Child's Full Name:*Child's Date of Birth* Date Format: MM slash DD slash YYYY Child lives with:Both ParentsMomDadLegal GuardianChild's Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Admission: Date Format: MM slash DD slash YYYY Date of Withdrawl: Date Format: MM slash DD slash YYYY Name of Parent or Guardian completing this form:*Is your address the same as the child's above?*YesNoYour Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dad's Phone Number*Mom's Phone Number*Guardian's Phone Number*Custody Documents on File?*YesNoGive 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.NameTelephone 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 InformationCheck all that apply:1. TransportationI 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 TripsDo you give consent for your child to participate in field trips?YesNo3. Water ActivitiesI 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. MealsI 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 CareMy child is normally in care on the following days and times:Day of the WeekAMPM Click the (+) for each new day/time combinationAuthorization for Emergency Medical AttentionIn the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:PhysicianName of Physician:*Physician's Phone Number*Physician's Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Care FacilityName of Emergency Care Facility:*Emergency Care Facility Phone Number*Emergency Care Facility Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Information SectionList 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?*YesNoIf yes, plan submitted on:* Date Format: MM slash DD slash YYYY 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 ChildrenMy 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 RequirementIf 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 operationUpload the signed Health Care Professional's Statement:*Accepted file types: jpg, png, pdf, txt, rtf, doc, docx.Upload the signed and dated affidavit about your religious practices and medical treatment.*Accepted file types: jpg, png, pdf, txt, rtf, doc, docx.Requirements for ExclusionSelect 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.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.Vision and Hearing Exam ResultsVision Exam ResultsRight Eye*Left Eye*Did they pass?*YesNoHearing Exam ResultsRight Ear 1000 Hz*Right Ear 2000 Hz*Right Ear 4000 Hz*Did they pass?*YesNoLeft Ear 1000 Hz*Left Ear 2000 Hz*Left Ear 4000 Hz*Did they pass?*YesNoVaccine InformationVaccines 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.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.* Date Format: MM slash DD slash YYYY TB Test (If Required)PositiveNegativeDate of Test Date Format: MM slash DD slash YYYY 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* Date Format: MM slash DD slash YYYY Email* This iframe contains the logic required to handle Ajax powered Gravity Forms.
