For Children Only - Main Admission (And Annual Renewal) Form

For Children Only - Main Admission (And Annual Renewal) Form
Are you ENROLLING or filling out ANNUAL documents?*

I am ENROLLING my children at For Children OnlyI am completing ANNUAL required documentation
Renewal Text on PDF - Do not alter or remove
Renewal Date - Do not alter or remove

YearMonthDay
This form should take 10-20 minutes to fill out, and there are multiple parts. You will need to complete this form for each child you have in care. A copy of the signed form will be sent (via email) to you once it is complete.

Directions: 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: FOR CHILDREN ONLY

BASIC NECESSARY INFORMATION:
Which For Children Only location will/does your child attend?*
Which classroom will your child attend this year?*

Infant (6 weeks to 17 months)Pre-Toddler (17-23 months), Toddler (24-35 months), Three's (36 to 48 months), Pre-K (4 to 5 years)School age (5 years+)
Director's Name
Child's Full Name*
Date of Admission (when child will have their 1st day at FCO)

MonthDayYear
Date
Are there Custody Documents for this child?*

YesNo
Upload Custody Documents here:

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Child's Home Address*
Child's Date of Birth*

MonthDayYear
Date
Name of Parent or Guardian (1) Completing this form: *
Child lives with:*

Both ParentsMomDadGuardian
Address of Parent/Guardian 1 (if different from the child's)
Name of Parent or Guardian (2)
Address of Parent/Guardian 2 (if different from the child's)
List phone numbers below where parents or guardian may be reached while child is in care. Parent/Guardian (1) Phone No.*
Parent/Guardian 2 Phone No.
Parent/Guardian 1 Employer Phone:
Parent/Guardian 2 Employer Phone:
example@example.com
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 2 Email
example@example.com
Name of Emergency Contact (***MUST BE CONTACT OTHER THAN PARENT/GUARDIAN:***)*
Emergency Contact Relationship to Child*
Emergency Contact Area Code and Phone No.*
Emergency Contact Address*
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.
Drop off/Pick-up Contact Name 1
Drop off/Pick-up Contact 1 Area Code and Phone No.
Drop off/Pick-up Contact Name 2
Drop off/Pick-up Contact 2 Area Code and Phone No.
Drop off/Pick-up Contact Name 3
Drop off/Pick-up Contact 3 Area Code and Phone No.
1. Transportation: I give consent for my child to be transported and supervised by the operation's employees CHECK ALL THAT APPLY*

for emergency careon field tripsto 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.
Field Trip Comments
3. Water Activities: I give consent for my child to participate in the following water activities CHECK ALL THAT APPLY*

water table playsprinkler playsplashing or 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 no, your child is required to wear a life jacket while 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 a pool safely on their own, tread water or float on their back for one minute, and swim 25 yards with no assistance.
4. Receipt of Written Operational Policies:

I acknowledge receipt of the facility's operational policies, including those for (all apply and are in the Parent Handbook, you will sign this at the end of the document.).

Discipline and guidance Procedures for release of children

Suspension and expulsion Illness and exclusion criteria

Emergency plans Procedures for dispensing medications

Procedures for conducting health checks Immunization requirements for children

Safe sleep Meals and food service practices

Procedures for parents to discuss concerns with the director Procedures to visit the center without securing prior approval

Promotion of indoor and outdoor physical activity including

criteria for extreme weather conditions

Procedures for supporting inclusive services

Procedures for parents to participate in operation activities Procedures for parents to contact Child Care

5. Meals:

I understand that the following meals will be served to my child while in care:

Breakfast / Lunch / Afternoon snack
6. Days and Times in Care: My child is normally in care on the following days and times:
Monday*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Tuesday*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Wednesday*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Thursday*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Friday*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
7. Receipt of Parent's Rights

(here:https://www.hhs.texas.gov/sites/default/files/documents/2987.pdf):

I acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility. (This is in the Parent Handbook too - you will sign this at the end of the document.).
8. Childs 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
Food Allergy Emergency Plan - from Healthcare Provider

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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
9. School Age Children
My child attends the following school
Other - School Name (if not noted above)
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
School Held Information

Child's required immunizations, vision and hearing screening, and TB screening are current and on file at their school.
Authorization For Emergency Medical Attention
By signing below - I give consent for the facility to secure any and all necessary emergency medical care for my child.

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*
Physician Address*
Phone No.*
Name of Emergency Care Facility*
Emergency Care Facility Address*
Emergency Care Facility Phone Number*
Requirements for Exclusion from Compliance
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.
Attachments for Exclusion from Compliance above

Cancelof
Vision Exam Results / Hearing Exam Results
Attach Hearing and Vision Exam Results here:

Cancelof
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 yourchild 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 takepart 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
Health Care Professional's Statement Attachment / Signed Letter / Signature Here:

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Vaccine Information - upload vaccine documentation here:

Cancelof
Date your child had varicella (chickenpox) - if necessary

MonthDayYear
Date
FCO Required Questions:
Photo/Video Release: For Children Only may occasionally use photos/videos of students for promotional purposes, including the school website, Facebook page, or advertisements. If an image is shared, only the student's first name and age (if anything) will be included, and compensation will not be provided for the use of these photos/videos. Please select ONE option*

Public Display Approved: I authorize For Children Only to use my child’s photos/videos internallyand externally for promotional purposes, including print/web ads, the school website,Facebook/Instagram page, newsletters, and newspaper articles.Media Restrictions: I do not authorize For Children Only to use my child’s photos/videos for anyexternal promotional purposes.
Diaper Rash Ointment Permission:*

Yes - I give For Children Only permission to apply Diaper Rash ointment to my child as needed.No, I do not give For Children Only permission to apply Diaper Rash ointment to my child.
Teething Ointment Permission:*

Yes, I give For Children Only permission to apply teething ointment to my child as needed.No, I do not give For Children Only permission to apply teething ointment to my child.
Sunscreen/Insect Repellent Permission:*

Yes, I give For Children Only permission to apply sunscreen/insect repellent my child as needed when going outside. I understand that I must provide the sunscreen/insect repellent for my childNo, I do not give For Children Only permission to apply sunscreen/insect repellent to my child
Almost there! Did anyone (teacher, director, etc.) refer you to our school?*

No, I found you on my ownYes, A teacher or director at our schoolsGoogle MapsFacebook/InstagramOther parentSomething else
Tell us who or how you were referred - we give them prizes!
Review/Parent or Guardian Signature

Now you will sign this form all at once. Please review the following as this will apply to all signature areas in this document, including:
- that you have received the Parents Rights document (located here: https://www.hhs.texas.gov/sites/default/files/documents/2987.pdf, also in Parent's Handbook which will be provided to you.)
- Completed the Child’s special needs area
- That you have authorized emergency medical care
- That you have provided Hearing/Vision Test information (if necessary)
- That you have completed the Health Care provider admission statement
- That you completed the Varicella statement
- That you have signed the entire form
- That you attest the following
“I have received, read, and understood the most up to date Parent Handbook (here: https://www.forchildrenonlydayschool.com/enroll - click PARENT HANDBOOK), including all policies, procedures, and rates. I have received all information on how to contact the local regulation office, state abuse hotline(s), and online information. I have had the opportunity to ask questions and agree to abide by all statements and policies within the handbook, including but not limited to, payment policies, holiday schedules, and health policies. I have filled out all sections of this admission paperwork and signed in all required areas.”
Parent Handbook:
League City Addendum:
Friendswood Addendum:
Pearland Addendum:
Parent or Legal Guardian Signature Here - *

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Date Signed*

MonthDayYear
Date
Should be Empty:

For Children Only - Main Admission (And Annual Renewal) Form

9. School Age Children

Authorization For Emergency Medical Attention

Requirements for Exclusion from Compliance

Vision Exam Results / Hearing Exam Results

Admission Requirement

FCO Required Questions:

Review/Parent or Guardian Signature