Little Munchkins Enrollment Agreement

Little Munchkins Enrollment Agreement

Please complete this form to enroll your child at Little Munchkins and acknowledge the terms of enrollment.
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ethnicity
Race (Choose one or More racial identities)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent / Guardian 2

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Days your child will Normally be in Care:
Meals your Child will Be Served:
Emergency Contacts (other than parent or Guardian) - REQUIRED per State Licensing
Emergency Contact 1

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Student
Emergency Contact 2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Student
Please read the following and acknowledge by selecting the box below:
Little Munchkins is authorized to release this child to these contacts. Under no circumstances will LMLC release this child to anyone other than a parent or guardian or to a person designated after verification of ID. Additions or changes to the list of persons appearing below will be made in written format only to LMLC. Would you like to use the emergency contact that you entered above as one of your release authorization contacts?
If you would like to authorize any additional individuals to pick up and release your child, please provide their information below.
Authorization Release Name 1

First NameLast Name
Authorization Release Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorization Release 2

First NameLast Name
Authorization Release 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Severe Allergy or Medical Condition

Please indicate below if your child has a severe allergy/medical condition ONLY if the allergy reaction/medical condition requires emergency medical treatment with medication, antihistamine or epinephrine: (this would include asthma or any medical condition that results in breathing difficulty requiring a breathing treatment apparatus such as an inhaler or nebulizer).**NOTE: Separate forms from your child’s health care professional will be required and must be complete and on file before your child’s first day of attendance and Must be from a provider in the State Of Texas.
Does your child have a severe allergy/medical condition diagnosed by a physician or health care professional
MILD ALLERGY/MEDICAL CONDITION:

Please indicate below if your child has any other allergy that has a body reaction that may or may not require treatment and is not classified as a severe allergy/medical condition.
Does your child have a mild allergy/medical condition diagnosed by a physician or health care professional?
FOOD RESTRICTION/PREFERENCE:

Please indicate below if your child has any food restrictions or specific personal preferences/requests - (i.e. vegetarian, wear hat outside, parent preference, religious preference, no milk, etc.)Note: A food restriction or preference would include a mild condition NOT diagnosed by a physician.
Does your child have any food restrictions or personal preferences/requests NOT related to a mild or severe allergy?
My child's food restriction or preference is:
Admission Requirements

*Please Read the Following*
Physician Name

First NameLast Name
Physicians Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physicians Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
*Please Read the Following*
HEALTH CARE PROFESSIONAL STATEMENT of HEALTH (The health statement must include child's name, he/she has been examined within the past 12 months and is able to take part in the childcare program along with the health care professional's signature.)

-OR-

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

**NOTE: Public school children are exempt from this requirement**
*Please read the Following
Immunization Records Authorization

I acknowledge and authorize Little Munchkins Learning Center to obtain my child’s immunization records through the Texas Immunization Registry (ImmTrac2). If my child’s immunization records are not available through the Registry, I agree to provide Little Munchkins Learning Center with a current copy of my child’s immunization records upon enrollment.

I understand that my child may not attend Little Munchkins Learning Center until the required immunization records have been provided and verified. I further acknowledge and authorize Little Munchkins Learning Center to enter and maintain my child’s immunization information in a third-party immunization tracking system used by the Center.
Legal or Custody issues
Does child have custody documents on file? (If yes, please provide an official copy of the current court order documentation to LMLC)*
Authorizations, Acknowledgments, and Agreements
LMLC May provide my child with emergency care and first aid when necessary and arrange transportation to an emergency medical facility. I further authorize ambulance/rescue personnel or medical providers to administer treatment and perform emergency medical care as deemed necessary.
LMLC May transport My child to and from School, On field trips, educational outings, and other center -sponsored activities.
My Child may participate in water activites
LMLC May photograph and/or videotape my child using such images for lawful purposes, including educational use,publicity, and posting on the LMLC Website or other social media platforms. I understand that I Relinquish all rights, titles, and interest in such media.
Receipt Of LMLC Policies
Please read the following and acknowledge by selecting the boxes below:
Please read the following and acknowledge by selecting the boxes below:
Please read the following and acknowledge by selecting the boxes below:
Parent/Guardian Signature
For Administration Only:

Enrollment Date______________ Classroom Upon Enrollment____________
Should be Empty:

Little Munchkins Enrollment Agreement

Emergency Contacts (other than parent or Guardian) - REQUIRED per State Licensing

Severe Allergy or Medical Condition

MILD ALLERGY/MEDICAL CONDITION:

FOOD RESTRICTION/PREFERENCE:

Admission Requirements

Legal or Custody issues

Authorizations, Acknowledgments, and Agreements

Receipt Of LMLC Policies