Busy Bumble Bees Learning Academy

Busy Bumble Bees Learning Academy Enrollment 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.
Operations Name
Directors Name
Childs Full Name
Childs Date of Birth

MonthDayYear
Date
Childs Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 childs

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List phone numbers below where parents or guardian may be reached while child is in care.
Parent 1 Number
Parent 2 Number
In case of emergency call
Name of Emergency Contact
Emergency Number
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / 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.
Name
Area Code and Phone No.
Name
Area Code and Phone No
Name
Area Code and Phone No.
Consent Information

1. Transportation: I give consent for my child to be transported and supervised by the operation's employees (Check all that apply for emergency care on field trips
Check all that apply

For emergency careOn field tripsTo and from homeTo and from school
I give consent for my child to be transported and supervised by the operation's employees
Check all that apply

I give consent for my child to participate in field tripsI do not give consent for my child to participate in field trips
Water Activities
I give consent for my child to participate in the following water activities
water table play    sprinkler play   splashing or wading pools   swimming pools   aquatic playgrounds

Is your child able to swim without assistance?
Yes   No

Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming?
Yes   No

Do you want your child to wear a life jacket while in or near a swimming pool?
Yes   No

I acknowledge receipt of the facility's operational policies, including those for (Check all that apply).
Discipline and guidance         Suspension and expulsion   Emergency plans   Procedures for conducting health checks   Safe sleep   Procedures for parents to discuss concerns with the director   Promotion of indoor and outdoor physical activity includingcriteria for extreme weather conditions   Procedures for parents to participate in operation activities   Procedures for release of children   Illness and exclusion criteria   Procedures for dispensing medications   Immunization requirements for children   Meals and food service practices   Procedures to visit the center without securing prior approval   Procedures for supporting inclusive services   Procedures for parents to contact Child Care Regulation (CCR), DFPS,Child Abuse Hotline, and CCR website

Meals
I understand that the following meals will be served to my child while in care (Check all that apply):
None   Breakfast      Morning snack   Lunch   Afternoon snack   Supper   Evening snack

Days and Times in Care
Monday Am:   Type a label   Pm:   Type a label
Tuesday Am:   Type a label   Pm:   Type a label
Wednesday Am:   Type a label      Pm:   Type a label
Thursday Am:   Type a label   Pm:   Type a label
Friday Am:   Type a label    Pm:   Type a label
I acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility.
Signature Parent or Legal Guardian

Clear
Date

MonthDayYear
Date
Please List Any Special Needs Your Child May Have
Does your child have diagnosed food allergies?Yes No Food Allergy Emergency Plan Submitted Date:
Does Your Child Have Any Food Allergies? If So Please Explain
Food Allergy Emergency Plan Submitted Date

MonthDayYear
Date
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

Clear
School Age Children
My child attends the following school
School Phone Number
Please enter a valid phone number.
My child has permission to

Walk to or from school or homeRide a busBe released to the care of his or her sibling under 18 years oldType option 4
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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone No.
Signature Parent or Legal Guardian I give consent for the facility to secure any and all necessary emergency medical care for my child.

Clear
Upload Vision Exam Results

Cancelof
Upload Hearing Exam Results

Cancelof
Upload Vaccine Information

Cancelof
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.
Date

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 or Legal Guardian

Clear
Date Signed

Clear
Physician or Public Health Personnel Verification Signature or stamp of a physician or public health personnel verifying immunization information above:
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Busy Bumble Bees Learning Academy Enrollment Form

List phone numbers below where parents or guardian may be reached while child is in care.

Consent Information

I give consent for my child to be transported and supervised by the operation's employees

School Age Children

In the event I cannot be reached to arrange for emergency medical care, I authorize the person in charge to take my child to: