Museum School Medical Documentation & Release Form 2022-2023

Child's Name *

First Name Last Name

Child's Date of Birth *

Date

Please check all that apply to your child:

My child was enrolled in a Fall/Spring 2021-2022 Museum School class this past school year. My child is enrolled in Summer 2022 class(es). My child is enrolled in a Fall/Spring 2022-2023 class.

Please upload a current headshot of your child. Please be sure your child is the only subject in the photo. Thank you! *

Children who attended Museum School in the Fall/Spring 2021-2022 school year have all required forms on file for Summer 2022. No further action is required.

Students Enrolled in BOTH Summer 2022 and Fall/Spring 2022-2023 Classes:

As specified by the Texas Health and Human Services Child Care Licensing, Museum School requires the following records be submitted 7 days prior to the first day of summer class. These forms will only be submitted once for both Summer and Fall/Spring. A child may not attend Museum School until all records below have been submitted.

Please submit the following:

1. Current Immunization Records or a signed, dated and notarized Official Exemption Affidavit from the Texas Department of State Health Services

Please click HERE to see examples of acceptable immunization records. Please do not submit your child's health record from their medical portal.

Information about immunization requirements can be found HERE.
Information about Exemption Affidavit requirements can be found HERE.

2. Statement of Health

Please click HERE to download the Health Statement form. Museum School will accept the doctor's office statement of health or the form from another licensed preschool. The form must be signed and dated by the physician with the physician's address, printed name and signature. It must state the child has been seen in the past 12 months and is healthy to participate in the program.

3. Vision and Hearing Screening

The screening results must be submitted for children who will be 4, 5 or 6 years of age by September 1, 2022. These records are ONLY required for children who are enrolled in Fall/Spring 2022-2023; they are not required to be submitted for summer classes.

2021-2022 Students Enrolled in BOTH Summer 2022 and Fall/Spring 2022-2023 Classes:

Children who attended Museum School in the Fall/Spring 2021-2022 school year have all required forms on file for Summer 2022. No further action is required for Summer. Please see the notes below for the 2022-2023 records that are due by August 8, 2022.

As specified by the Texas Health and Human Services Child Care Licensing, Museum School requires the following records be submitted each school year. Fall/Spring 2022-2023 forms are due by August 8, 2022. Exception for Children with an August Birthday: Forms must be submitted by September 2, 2022. A child may not attend Museum School until all records below have been submitted.

Please submit the following:

1. Current Immunization Records or a signed, dated and notarized Official Exemption Affidavit from the Texas Department of State Health Services

Please click HERE to see examples of acceptable immunization records. Please do not submit your child's health record from their medical portal.

Information about immunization requirements can be found HERE.
Information about Exemption Affidavit requirements can be found HERE.

2. Statement of Health

Please click HERE to download the Health Statement form. Museum School will accept the doctor's office statement of health or the form from another licensed preschool. The form must be signed and dated by the physician with the physician's address, printed name and signature. It must state the child has been seen in the past 12 months and is healthy to participate in the program.

3. Vision and Hearing Screening

The screening results must be submitted for children who will be 4, 5 or 6 years of age by September 1, 2022. These records are ONLY required for children who are enrolled in Fall/Spring 2022-2023; they are not required to be submitted for summer classes.

Students Enrolled in Summer 2022 Classes:

As specified by the Texas Health and Human Services Child Care Licensing, Museum School requires the following records be submitted 7 days prior to the first day of class. A child may not attend Museum School until all records below have been submitted.

Note: If a preschool or school-age child attends another school away from Museum School where the immmunization records are on file, the school was noted on the enrollment form; therefore, no further action is required.

If a preschool or school-age child does not attend another school away from Museum School, please submit a Current Immunization Record or a signed, dated and notarized Official Exemption Affidavit from the Texas Department of State Health Services

Please click HERE to see examples of acceptable immunization records. Please do not submit your child's medical history from their health portal.

Information about immunization requirements can be found HERE.
Information about Exemption Affidavit requirements can be found HERE.

Fall/Spring 2022-2023 Classes:

As specified by the Texas Health and Human Services Child Care Licensing, Museum School requires the following records be submitted each school year. Fall/Spring 2022-2023 forms are due by August 8, 2022. Exception for Children with an August Birthday: Forms must be submitted by September 2, 2022. A child may not attend Museum School until all records below have been submitted.

Please submit the following:

Current Immunization Records or a signed, dated and notarized Official Exemption Affidavit from the Texas Department of State Health Services

Please click HERE to see examples of acceptable immunization records. Please do not submit your child's health record from their medical portal.

Information about immunization requirements can be found HERE.
Information about Exemption Affidavit requirements can be found HERE.

2. Statement of Health

Please click HERE to download the Health Statement form. Museum School will accept the doctor's office statement of health or the form from another licensed preschool. The form must be signed and dated by the physician with the physician's address, printed name and signature. It must state the child has been seen in the past 12 months and is healthy to participate in the program.

3. Vision and Hearing Screening

The screening results must be submitted for children who will be 4, 5 or 6 years of age by September 1, 2022.

Immunization Records *

I am submitting a copy of my child's current Immunization Record. I am submitting a copy of my child's current Immunization Record WITH the Vision and Hearing screening results listed on the Immunization Record (for children who will be 4, 5 or 6 years of age on September 1, 2022). I claim an exemption for my child from Texas Immunization requirements based on medical contraindications or other reasons of conscience, including a religious belief. A signed, dated and notarized affidavit (issued by the Texas Department of State Health Services) supporting this exemption is attached to this form.

Please upload your child's Immunization Records or Exemption Affidavit. (Please upload a scanned file versus a photograph.) *

Statement of Health and Vision and Hearing Screening *

I am submitting a Statement of Health signed and dated by a medical professional. The Vision and Hearing screening results are reported on the Statement of Health (or the Immunization Records) for my child who will be 4, 5 or 6 years of age by September 1, 2022. I am submitting a Statement of Health signed and dated by a medical professional. My child will NOT be 4, 5 or 6 years of age by September 1, 2022 and does not require the Vision and Hearing screening. I claim an exemption for my child from the Vision and Hearing screening based on medical contraindications or other reasons of conscience, including a religious belief. A signed, dated and notarized affidavit supporting this exemption is attached to this form.

Please upload your child's Statement of Health. (Please upload a scanned file versus a photograph.) *

Please upload Vision and Hearing results (if not found on the Immunization Record or Statement of Health) for children turning 4, 5 or 6 years of age by 9/1/2022.

FARE Allergy Action Plan *

I am submitting a FARE Allergy Action Plan dated, with a PARENT/GUARDIAN AND a MEDICAL PROFESSIONAL SIGNATURE. I will bring my child's Epi Pen and/or Benadryl on his/her first day of class. My child does not have any known allergies.

Please upload your child's FARE form, if applicable.

Are there any special needs not indicated on your child's original enrollment request form (specialized therapy, food intolerances, existing illness, previous injuries, hospitalizations in the past 12 months, medications prescribed for long-term continuous use, etc.)?

FALL/SPRING CLASS LISTS

Please indicate if you DO or DO NOT consent to releasing your child's first and last name, your family's primary email address and phone number to other families in your child's class for play opportunities, birthday invitations, etc.

I * consent to releasing my child's first and last name, our family's primary email address and phone number to other families in my child's class for play opportunities, birthday invitations, etc.

Statement of Health *

My child has been examined within the past 12 months by a health care professional and is able to participate in Summer 2022 Museum School.

PARENT/GUARDIAN SIGNATURE

I verify the following:

My child may participate in field trips to the Fort Worth Science and History Museum.
I authorize the individuals submitted on the enrollment form to pick up my child from Museum School. I understand I must email museumschool@fwmsh.org to make changes to my child's authorized pick up list.
I authorize the Fort Worth Museum of Science and History to secure any and all necessary emergency medical treatment and transport for my child to Cook Children's Medical Center.
My child has permission to participate in water table play.
Please click to access the Summer 2021 and the Fall/Spring 2022-2023 Parent Handbooks, as applicable. I have read, understand and agree to:
- The Museum School Parent Handbook: Operational Policies and Notice Regarding COVID-19
- The Tuition, Refund and Withdrawal Policy (page 5)
- The Museum School Discipline and Guidance Policy (page 14)
- The Museum School Acknowledgment and Waiver (page 14)
All medical information is correct.

Parent/Guardian Signature *

Clear

Please select Parent or Guardian

Name of Parent/Guardian Completing Form

First Name Last Name

Today's Date

Date