Learning Tree Academy Enrollment Form

Enrollment Form
General Information
Child's Full Name

First Name and Middle InitialLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Lives With?
Child's Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Admission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Withdrawal

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent 1/Guardian 1

First NameLast Name
Parent 1/Guardian 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address of Parent of Guardian 1 if different from the child's:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2/Guardian 2

First NameLast Name
Parent 2/Guardian 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address of Parent or Guardian 2 if different from the child's:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Custody Documents on File?
Name of Emergency Contact (other than Parents)

First NameLast Name
Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address of Emergency Contact

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization to release child

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.
Name

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

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

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Consent Information
1. Transportation: I give consent for my child to be transported and supervised by Learning Tree Academy employees (Check all that apply - MUST CHECK AT LEAST ONE)
2. Field Trips (MUST CHECK AT LEAST ONE):
Comments:
3. Water activities (MUST CHECK AT LEAST ONE):
Is your child able to swim without assistance? A competent swimmer can enter and exit a pool safely on their own, tread water or float on their back for one minute, and swim 25 yards with no assistance. *If your child is not a competent swimmer, 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 yes, your child is required to wear a life jacket while in or near a swimming pool.
4. Receipt of Operational Policies: I acknowledge receipt of Learning Tree Academy's operational policies, including those for (Check all that apply - MUST CHECK ALL).
5. Meals: I understand that the following meals will be served to my child while in care (Check all that apply):
6. Days and Times in Care: My child is normally in care on the following days and times:
7. Receipt of Parent's Rights: I acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility. (See Operational Policies)
8. Children's Special Care Needs
Child's Special Care Needs (check all that apply)
Explain any needs selected above:
Does your child have diagnosed food allergies? (Yes or No)
Food Allergy Emergency Plan Submitted Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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).
Signature - Parent or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School Age Children
My child attends the following school:
School Area Code and Phone Number:
My child has permission to (check all that apply):
Authorized pick up or drop off locations other than the child's address.
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 of Physician

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Emergency Care Facility
Address of Emergency Care Facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I give consent for the facility to secure any and all necessary emergency medical care for my child. (Signature of parent or Legal Guardian)
I have received information regarding WIC, Agricultural Risk Protection, and the Parent Letter Informational Letter. Please initial below.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Additional Information About Immunizations

For more information about immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm.
Privacy Statement

HHSC values your privacy. For more information, read our privacy policy online at https://hhs.texas.gov/policies-practices-privacy#security
Signatures
Signature of Child's Parent or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Enrollment Form

General Information

Authorization to release child

Consent Information

8. Children's Special Care Needs

School Age Children

Authorization for Emergency Medical Attention

Gang Free Zone

Additional Information About Immunizations

Privacy Statement

Signatures