Select the Center You're Enrolling In:
*
Please Select
Veteran's Location (Center 1)
Rankin Location (Center 2)
Admission Information
Use this form to collect all required information about a child enrolling in day care. The day care provider gives this form to the child's parent or guardian. The parent or guardian completes the form 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.
Section 1 – General Information
Operation's Name
*
Please Select
Little Laughter's Child Care Center
Director's Name
*
Please Select
Elizabeth Jones
Lakendra Moore
Child's Date of Birth
*
Child Lives With:
*
Both parents
Mom
Dad
Guardian
If Guardian, Do you have custody documents on file?
*
Yes
No
Child's Home Street Address, City, State and Zip Code.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Admission
*
-
Month
-
Day
Year
Date
Name of Parent or Guardian 1
*
Parent 1 Area Code and Phone No.
*
Address of Parent or Guardian 1, if different from the child's
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Parent or Guardian 2
*
Parent 2 Area Code and Phone No.
*
Address of Parent or Guardian 2, if different from the child's
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Emergency Contact, when the parent or guardian cannot be reached, call:
*
Relationship
*
Area Code and Phone No.
*
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / 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
Full Legal Name
Area Code and Phone Number
Person 1
Person 2
Person 3
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1. Transportation
I give consent for my child to be transported and supervised by the operation's employees. Check all that apply.
Transportation Options
For emergency care
On field trips
To and from home
To and from school
2. Field Trips
Field Trip Consent
I give consent for my child to participate in field trips.
I do not give consent for my child to participate in field trips.
Comments
3. Water Activities
I give consent for my child to participate in the following water activities. Check all that apply.
Water Activities
Water table play
Sprinkler play
Wading pools
Swimming pools
Aquatic playgrounds
1. Is your child a competent swimmer?
Yes
No
If no, your child is required to wear a life jacket while in or near a swimming pool.
2. Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming?
Yes
No
If yes, your child is required to wear a life jacket while in or near a swimming pool.
Note: 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 the following. Check all that apply.
Operational Policies
Discipline and guidance
Suspension and expulsion
Emergency plans
Procedures for conducting health checks
Safe sleep
Procedures for parents to discuss concerns with the director
Procedures for parents to participate in activities
Promotion of indoor and outdoor physical activity including criteria for extreme weather conditions
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
5. Meals
I understand the following meals will be served to my child while in care. Check all that apply.
Meals Served
None
Breakfast
Morning snack
Lunch
Afternoon snack
Supper
Evening snack
6. Days and Times in Care
My child is normally in care on the following days and times.
6. Days and Times in Care
A.M.
P.M.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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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.
Parent or Legal Guardian Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
8. Child's Special Care Needs
Check all that apply.
Special Care Needs
*
Environmental allergies
Limitations or restrictions on child's activities
Food intolerances
Reasonable accommodations or modifications
Existing illness
Adaptive equipment, include instructions below
Previous serious illness
Symptoms or indications of complications
Injuries and hospitalizations in the past 12 months
Medications prescribed for continuous long-term use
Other
Explain any needs selected above.
*
Does your child have diagnosed food allergies?
*
Yes
No
Food Allergy Emergency Plan Submitted Date:
*
-
Month
-
Day
Year
Date
Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit 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).
Parent or Legal Guardian Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
9. School-Age Children
My child attends the following school
*
School Area Code and Phone No.
*
My child has permission to:
*
walk to or from school or home
ride a bus
be released to the care of their sibling younger than 18 years old
Authorized pick up or drop off locations other than the child's address.
Child's required immunizations, vision and hearing screening are current and on file at their school.
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Section 3 - 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
*
Area Code and Phone No.
*
Street Address, City, State and ZIP Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Emergency Care Facility
*
Area Code and Phone No.
*
Street Address, City, State and ZIP Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Parent or Legal Guardian Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Section 4 - 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 Health and Safety Code Section 161.0041 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.
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Section 5 - Vision & Hearing Exam Results
Section 5 - Vision Exam Results
20/
Pass or Fail
Right
Left
Section 6 - Hearing Exam Results
1000 Hz
2000 Hz
4000 Hz
Pass or Fail
Right:
Left:
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Complete Section 7-14 on FORM 2935 PDF File and Upload Here before Submitting this Form.
You can save this form for later and resume, upload and submit when the required sections are completed.
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