Admission Form

Admission Form

D's Heart to Heart
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.
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 *
Street address, City, State, Zip Code
Date of Admission*

MonthDayYear
Date
Date of Withdrawal

MonthDayYear
Date
Parent or Guardian 1:*
Parent or Guardian 2:*
Address of Parent of Guardian 1: (if different from the child's)
Street address, City, State, Zip Code
Address of Parent of Guardian 2: (if different from the child's)
Street address, City, State, Zip Code
List phone numbers below where parents or guardian may be reached while child is in care.
Parent 1 Phone No.*
Please enter a valid phone number.
Parent 2 Phone No.
Guardian's Phone No.
Custody Documents on file

YesNo
Name of Emergency Contact*
Emergency Contact Relationship*
Emergency Contact Phone*
Emergency Contact Address*
Street address, City, State, Zip Code
I authorize the child care operation to release my child to leave the child care operation ONLY with the following persons. Please list name and phone number for each Children will only be released to a parent or guardian or to a person designated by the parent or guardian after verification of ID.
Authorized person 1
Phone
Authorized person 2
Phone
Authorized person 3
Phone
Consent Information
Transportation
I give consent for my child to be transported and supervised by the operation's employees (Check all that apply)*

Emergency CareField TripsTo and From HomeTo and From School
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.
Comments
Water Activities
I give consent for my child to be transported and supervised by the operation's employees (Check all that apply).

Water table playSprinkler playSplashing and wading poolsSwimming poolsAquatic playgrounds
Is your child able to swim without assistance? If no, your child is required to wear a life jacket while in or near a swimming pool.*

YesNo
Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming? If not, your child is required to wear a life jacket whkle in or near a swimming pool.

YesNo
Do you want your child to wear a life jacket while in or near a swimming pool?

YesNo
*A competent swimmer can enter and exit the pool safely on their own, tread water or float on their back for one minute, and swim 25 yards with no assistance.

Receipt of Written Operational Policies:
I acknowledge receipt of the facility's operational policies, including those for (Check all that apply).*

Discipline and guidanceSuspension and expulsionProcedures for conducting health checksEmergency plansSafe sleepPromotion of indoor and outdoor physical activity including criteria for extreme weather conditionsProcedures for parents to participate in operation activitiesProcedures for release of childrenIllness and exclusion criteriaProcedures for dispensing medicationsImmunization requirements for childrenMeals and food service practicesProcedures to visit the center without securing prior approvalProcedures for supporting inclusive servicesProcedures for parents to contact Child Care Licensing (CCL), DFPS, Child Abuse Hotline, and CCL websiteProcedures for parents to discuss concerns with the director
I understand that the following meals will be served to my child while in care (Check all that apply).*

NoneBreakfastMorning SnackLunchAfternoon SnackSupperEvening Snack

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

Rows	A.M.	P.M.
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

I acknowledge I have received a written copy of my rights as a parents or guardian of a child enrolled at this facility.*

Parent or Guardian Signature
Child's Special Care Needs (check all that apply)

Environmental allergiesLimitations or restrictions on child's activitiesFood intolerancesReasonable accommodations or modificationsExisting illnessAdaptive equipment (include instructions below)Previous serious illnessSymptoms or indications of complicationsInjuries and hospitalizations (past 12 months)Medications prescribed for continuous long-term useOther
Explain any needs selected above
Does your child have diagnosed food allergies?

YesNo
Food Allergy Emergency Plan Submitted Date

MonthDayYear
Date
Signature- Parent or Legal Guardian*

Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit https://www.ada.gov/resources/child-care-centers/. 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
School Area Code and Phone No.
My child has permission to (check all that apply):

walk to or from school or homeride a busbe released to the care of his or her sibling under 18 years old
Authorized pick up or drop off locations other than the child's address
Child's required immunizations, vision and hearing screening, and TB screening are current and on file at their school.*

YesNo
Authorization For Emergency Medical Attention

In the event I cannot be reached to arrange for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician
Address
Name of Emergency Care Facility
Name of Emergency Care Facility
Address
Phone No.
I give consent for the facility to secure any and all necessary emergency medical care for my child*

Parent or Guardian Signature
Requirements for Exclusion from Compliance
Select all that apply:

I have attached a signed and dated affidavit stating that I decline immunizations for reason of conscience, including religious belief, on the form 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 or religious denomination that I am an adherent or member of.
Vision Exam Results
Right Eye 20/
Left Eye 20/
PassFail
Parent or Guardian Signature

Hearing Exam Results

Rows	1000 Hz	2000 Hz	4000 Hz
Right Ear
Left Ear

Right Ear

PassFail
Left Ear

PassFail
Signature
Additional 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. (Select 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 take 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 amember of. I have attached 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 12months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.
Signature*

The following vaccines require multiple doses over time. Please provide the date your child received each dose.

Rows	Date Received
Hepatitis B (birth, first dose)
Hepatitis B (1-2 months, 2nd dose)
Hepatitis B (6-18 months 3rd dose)
Rotavirus (2 months, 1st dose)
Rotavirus (4 months, 2nd dose)
Rotavirus (6 months, 3rd dose)
Diphtheria, Tetanus, Pertussis (2 months, 1st dose)
Diphtheria, Tetanus, Pertussis (4 months, 2nd dose)
Diphtheria, Tetanus, Pertussis (6 months, 3rd dose)
Diphtheria, Tetanus, Pertussis (15-18 months, 4th dose)
Diphtheria, Tetanus, Pertussis (4-6 yrs, 5th dose)
Haemophilus Influenza Type B (2 months, 1st dose)
Haemophilus Influenza Type B (4 months, 2nd dose)
Haemophilus Influenza Type B (6 months, 3rd dose)
Haemophilus Influenza Type B (12-15 months, 4th dose)
Pneumococcal (2 months, 1st dose)
Pneumococcal (4 months, 2nd dose)
Pneumococcal (6 months, 3rd dose)
Pneumococcal (12-15 months, 4th dose)
Inactivated Poliovirus (2 months, 1st dose)
Inactivated Poliovirus (4 months, 2nd dose)
Inactivated Poliovirus (6-18 months, 3rd dose)
Inactivated Poliovirus (4-6 years, 4th dose)
Influenza (annually from 6 months)
Measles, Mumps, Rubella (12-15 months, 1st dose)
Measles, Mumps, Rubella (4-6 yrs old)
Varicella (12-15 months, 1st dose)
Varicella (4-6 yrs, 2nd dose)
Hepatitis A (12-23 months, 1st dose)
Hepatitis A (6-18 months after 1st dose)

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
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.
TB Test (if required)

PositiveNegative
Date of TB test

MonthDayYear
Date
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.
Privacy Statement

HHSC values your privacy. For more information, read our privacy policy online at: https://hhs.texas.gov/policies-practices-privacy#security
Child's Parent of Legal Guardian
Please enter your email address:
example@example.com
Should be Empty:

Admission Form

Consent Information

Requirements for Exclusion from Compliance

Vision Exam Results