ADMISSION INFORMATION

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

MonthDayYear
Date
Child Lives With

Both ParentsMomDadGuardian
Child's Home Address
Date of Admission

MonthDayYear
Date
Date of Withdrawal

MonthDayYear
Date
Name of Parent or Guardian Completing Form
Address of Parent or Guardian (if different from the child's)
List telephone numbers below where parents/guardians may be reached while the child is in care.
Parent 1 Telephone #
Parent 2 Telephone #
Guardian's Telephone #
Custody Documents on File

YesNo
EMERGENCY CONTACT PERSON

Give the name, address, and phone number of the responsible individual to call in case of an emergency if parents/ guardian cannot be reached
Name
Address
Phone Number
Please enter a valid phone number.
Relationship
Name
Phone Number
Name
Phone Number
Name
Phone Number
CONSENT FORM
1. TRANSPORTATION: I give consent for my child to be transported and supervised by the operation's employees: (Check all that apply)

for emergency careto and from hometo and from school
2. FIELD TRIPS:

I give consent for my child to participate in field trips.I do not give consent for my child to participate in field trips.
3. WATER ACTIVITIES: I give consent for my child to participate in the following water activities: (Check all that apply)

water table playsprinkler playsplashing/wading poolsswimming poolsaquatic playgrounds
4. RECEIPT OF WRITTEN OPERATIONAL POLICIES: I acknowledge receipt of the facility's operational policies, including those for: (Check All that Apply)

Discipline and guidanceProcedures for release of childrenSuspension and expulsionIllness and exclusion criteriaEmergency plansProcedures for dispensing medicationsProcedures to conduct health checksImmunization requirements for childrenSafe sleepMeals and food service practicesProcedures for parents to discuss concerns with the directorProcedures to visit the center without securing prior approvalProcedures for parents to participate in operation activitiesProcedures for parents to contact Child Care Licensing (CCL),DFPS, Child Abuse Hotline, and CCL website
5. Meals: I understand that the following meals will be served to my child while in care

NoneBreakfastMorning snackLunchAfternoon SnackSupperEvening Snack

6. DAYS AND TIMES IN CARE: My child is normally in care on the following days andtimes:

	Day of the week	Select Time

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:
Name of Physician
Name of Emergency Care Facility
Address
Address
Phone Number
Phone Number
Signature — Parent or Legal Guardian

Clear
CHILD'S 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 the 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?

YesNo
Plan Submitted on

MonthDayYear
Date
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
Signature — Parent or Legal Guardian

Clear
Date Signed

MonthDayYear
Date
SCHOOL AGE CHILDREN
My child attends the following school
School Phone Number
My child has permission to (check all that apply):

walk to or from school or homeride a busbe released to the care of his/her sibling under 18 years oldAuthorized pick up/drop off locations other than the child’s addressChild's required immunizations, vision and hearing screening, and TB screening are current and on file at their school.
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. Check only one option: Health Care Professional's Statement: I have examined the above named child within the past year and find that he or she is able to 1. take part in the day care program.
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. (Check only one option)

Health Care Professional’s Statement: I have examined the above named child within the past year and find that he or she is able totake 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 thisMy child has been examined within the past year by a health care professional and is able to participate in the day care program. Within12 months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.
Signature — Health Care Professional

Clear
Date Signed

MonthDayYear
Date
Upload signed and dated copy of a health care professional's statement

Cancelof
Upload signed and dated affidavit

Cancelof
Name Health Care Professional
Address of Health Care Professional
Signature Parent or Legal Guardian

Clear
Date Signed

MonthDayYear
Date
REQUIREMENTS FOR EXCLUSION
I have attached a signed and dated affidavit stating that I decline immunizations for reason of conscience, including religious belief, on theform 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 orreligious denomination that I am an adherent or member of.
VISION EXAM RESULTS
Right Eye 20/
Left Eye 20/
PassFail
HEARING EXAM RESULTS

6. DAYS AND TIMES IN CARE: My child is normally in care on the following days and times:

	Ear	1000 HZ	2000 HZ	Pass or Fail

Signature

Clear
Date Signed

MonthDayYear
Date
VACCINE INFORMATION

The following vaccines require multiple doses over time. Please provide the date your child received each dose.
Hepatitis B
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Rotavirus
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Diphtheria, Tetanus, Pertussis
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Haemophilus Influenza Type B
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Pneumococcal
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Inactivated Poliovirus
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Influenza
Vaccine Schedule
Yearly, starting at 6 months. Two doses given at least four weeks apart are recommended for children who are getting the vaccine for the first time and for some other children in this age group.
Dates Child Received Vaccine

MonthDayYear
Measles, Mumps, Rubella
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Varicella
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Hepatitis A
Vaccine Schedule
Dates Child Received Vaccine

MonthDayYear
Vaccine Schedule
The second dose should be given 6 to 18 months after the first dose.
Dates Child Received Vaccine

MonthDayYear
PHYSICIAN OR PUBLIC HEALTH PERSONNEL VERIFICATION

Signature or stamp of a physician or public health personnel verifying immunization information above:
Signature

Clear
Date Signed

MonthDayYear
Date
VARICELLA (CHICKENPOX)
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) and does not need varicella vaccine.
Signature

Clear
Date Signed

MonthDayYear
Date
ADDITIONAL INFORMATION REGARDING IMMUNIZATIONS
For additional information regarding immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm.
PositiveNegative
Date

MonthDayYear
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 offensesrelated to organized criminal activity are subject to harsher penalties.
PRIVACY STATEMENT
HHSC values your privacy. For more information, read our privacy policy online at: https://hhs.texas.gov/policies-practicesprivacy#security
SIGNATURES
Child's Parent or Legal Guardian

Clear
Center Designee

Clear
Date Signed

MonthDayYear
Date
Date Signed

MonthDayYear
Date
Should be Empty:

ADMISSION INFORMATION

GENERAL INFORMATION

EMERGENCY CONTACT PERSON

CONSENT FORM

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

CHILD'S ADDITIONAL INFORMATION SECTION

SCHOOL AGE CHILDREN

ADMISSION REQUIREMENT

REQUIREMENTS FOR EXCLUSION

VISION EXAM RESULTS

HEARING EXAM RESULTS

VACCINE INFORMATION

PHYSICIAN OR PUBLIC HEALTH PERSONNEL VERIFICATION

VARICELLA (CHICKENPOX)

ADDITIONAL INFORMATION REGARDING IMMUNIZATIONS

GANG FREE ZONE

PRIVACY STATEMENT

SIGNATURES