Admission Form

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

Date

Child Lives With

Child's Home Address

Street address, City, State, Zip Code

Date of Admission

Date

Date of Withdrawal

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.Format: (000) 000-0000.

Parent 2 Phone No.

Format: (000) 000-0000.

Guardian's Phone No.

Format: (000) 000-0000.

Custody Documents on file

Name of Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone

Format: (000) 000-0000.

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

Format: (000) 000-0000.

Authorized person 2

Phone

Format: (000) 000-0000.

Authorized person 3

Phone

Format: (000) 000-0000.

Transportation

I give consent for my child to be transported and supervised by the operation's employees (Check all that apply)

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).

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.

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.

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

*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).

I understand that the following meals will be served to my child while in care (Check all that apply).

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)

Explain any needs selected above

Does your child have diagnosed food allergies?

Food Allergy Emergency Plan Submitted Date

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.

Format: (000) 000-0000.

My child has permission to (check all that apply):

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.

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

Format: (000) 000-0000.

Name of Emergency Care Facility

Address

Phone No.

Format: (000) 000-0000.

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:

Vision Exam Results

Right Eye 20/

Left Eye 20/

Parent or Guardian Signature

Hearing Exam Results

Rows	1000 Hz	2000 Hz	4000 Hz
Right Ear
Left Ear

Right Ear

Left Ear

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.)

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)

Date of TB test

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

Admission Form

Consent Information

Requirements for Exclusion from Compliance

Vision Exam Results