New Child Enrollment Forms

New Child Enrollment Forms
Admission Information

Operation Name: Paradise Panther Cub Care Director's Name: Lanita Smith
Child's Name*

First NameLast Name
Child's DOB*

MonthDayYear
Date
Child Lives With?*

Both ParentsMomDadGuardianOther
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Admission*

MonthDayYear
Date
Date of Withdrawal (if applicable)

MonthDayYear
Date
Name of Parent/Guardian Completing Form*

First NameLast Name
Address of Parent/Guardian (if different from Child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/ Guardian 1 Phone Number*
Please enter a valid phone number.
Parent/ Guardian 2 Phone Number
Please enter a valid phone number.
Custody Documents on file?*

YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Grandparent, Family Friend, etc.
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I give consent for my child to participate in the following water activities:*

Splash PadSprinklerWaterslideKiddy Pool
I acknowledge receipt of the facility's operational policies, including those for (check all that apply)*

Discipline & GuidanceSuspension & ExpulsionEmergency PlansProcedures for conducting health checksSafe sleepProcedures for parents to discuss concerns with the directorPromotion 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 website
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:*

	A.M.	P.M.
Monday
Tuesday
Wednesday
Thursday
Friday

Child's Special Care Needs (Check all that apply):

Environmental allergiesFood intolerancesExisting illnessPrevious serious illnessInjuries & hospitalizations (past 12 months)Limitations or restrictions on child's activitiesReasonable accommodations or modificationsAdaptive equipment (include instructions below)Symptoms or indications of complicationsMedications 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
Child day care operations are public accommodations under the ADA, Title III. To learn more, visit www.ada.gove/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).

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Date Signed

MonthDayYear
Date
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's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone Number
Please enter a valid phone number.
Name of Emergency Care Facility
Emergency Care Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Care Facility Phone Number
Please enter a valid phone number.
I give consent for the facility to secure any and all necessary emergency care for my child.

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Date Signed

MonthDayYear
Date
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.
Vision Exam Results
Right Eye 20/ blank Left Eye 20/ blank
PassFail
Signature

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Date Signed

MonthDayYear
Date

Hearing Exam Results

	1000 Hz	2000 Hz	4000 Hz	Pass or Fail
Right Ear
Left Ear

Signature

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Date Signed

MonthDayYear
Date
If your child does not attend pre-k 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.*

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 health care professional's statement is attachedMedical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member 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 12 months of admission, I will obtain a health care professional's signed statement and submit to the child care operation.
Name of health care professional, if selected
Address of health care professional, if selected

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature- Health Care Professional

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Date Signed

MonthDayYear
Date
Signature- Parent or Legal Guardian

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Date Signed

MonthDayYear
Date
Immunization Record File Upload (signed by doctor, you can also just bring a hard copy to the daycare)

Cancelof
For additional information regarding immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm

Parent's Rights

This form provides the required information per Chapter 42 of the Human Resource Code Section 42.04271.
A parent or guardian of a child at a child care facility has the right to:

(1) enter and examine the child care facility during the facility’s hours of operation without advanced notice;

(2) review the child care facility’s publicly accessible records;

(3) receive inspection reports for the child care facility and information about how to access the facility’s online compliance history;

(4) obtain a copy of the child care facility’s policies and procedures;

(5) review, at the request of the parent or guardian, the facility’s:

(A) staff training records; and

(B) any in-house staff training curriculum used by the facility;

(6) review the child care facility’s written records concerning the parent’s or guardian’s child;

(7) inspect any video recordings of an alleged incident of abuse or neglect involving the parent’s or guardian’s child, provided that:

(A) video recordings of the alleged incident are available;

(B) the parent or guardian of the child does not retain any part of the video recording depicting a child that is not their own; and

(C) the parent or guardian of any other child captured in the video recording receives written notice from the facility before allowing a parent to inspect a recording;

(8) have the child care facility comply with a court order preventing another parent or guardian from visiting or removing the parent’s or guardian’s child;

(9) be provided the contact information for the child care facility’s local Child Care Regulation office;

(10) file a complaint against the child care facility by contacting the local Child Care Regulation office; and

(11) be free from any retaliatory action by the child care facility for exercising any of the parent’s or guardian’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.

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Date Signed*

MonthDayYear
Date

Child Release Form

List the names, relationships, identification numbers, and phone numbers of those who may pick your child up from this facility.

	Name	Relationship	ID #	Phone #
Person 1
Person 2
Person 3
Person 4
Person 5

I give my permission for Paradise Panther Cub Care to release my child to anyone listed on this release form. The staff of PPCC will not be responsible for my child once my child is signed out of the center by anyone who is listed on this release form.*

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Date Signed*

MonthDayYear
Date

Permission to Photograph
Child's Name*

First NameLast Name
Does Paradise Panther Cub Care have your permission to photograph your child?*

YesNo
Any photographs will be taken with a digital camera, cell phone, or a company hired to come in and take group or individual pictures of the children attending Paradise Panther Cub Care. Paradise Panther Cub Care sometimes uses companies such as Snapfish, Wal-Mart, Walgreens, and Shutterfly to print physical copies of pictures taken.

We may occasionally message you pictures of your child's activities throughout their day. Pictures taken will not be used for publications, websites, or public forms of social media. Parents will have access to any pictures taken at Paradise Panther Cub Care.
Signature*

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Date Signed*

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If a cell phone picture is taken of my child, with a friend, or in a group, I do/do not* allow the picture to be sent to all the parents of the child(ren) in that picture through cell phone messaging.
Signature*

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Date Signed*

MonthDayYear
Date
IDo/Do Not* allow Paradise Panther Cub Care employees to post pictures of my child in Paradise Panther Cub Care's private Facebook group (this group contains any parents or grandparents of children attending PPCC who wish to be in the group).
Signature*

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Date Signed*

MonthDayYear
Date
I Do/Do Not*allow Paradise Panther Cub Care to put pictures that include my child on their public website (www.paradise-panther-cub.com
Signature*

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Date Signed*

MonthDayYear
Date

Financial Agreement

Please discuss your payment options with our Office Manager before filling this out.
Child's Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Parent/Guardian 1 Name*

First NameLast Name
Parent/Guardian 2 Name

First NameLast Name
Payment for my child's program is due on the date that I set up with the Office Manager. If tuition is not paid within two weeks of the due date, then I understand that my child cannot return to care until the payment is made. I understand that I will be charged for days missed while I catch up and have two weeks to catch up from the specified date or my child will lose their enrollment.
Weekly Tuition Amount *
Signature*

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Due Date
Effective Date

MonthDayYear
Date
Should be Empty:

New Child Enrollment Forms

Admission Information

Vision Exam Results

Parent's Rights

Child Release Form

Permission to Photograph

Permission to Apply Products

Financial Agreement