Enrollment Form

Retta Christian Learning Center

13201 Rendon Road Burleson, TX 76028 -- 817-473-9002 -- www.retta.org
Dear Parents,

We are delighted that you are interested in your child attending Retta Christian Learning Center. All classes have many fun activities and learning experiences for your child. The state requires that we have certain information, one being a signed document, page 2 of the admission form, from the doctor stating that the child is healthy and may attend day care. We also need a copy of the shot record to attach to page 3 of the admission form showing the child is current on all shots.
As a reminder of some of the very important items in the handbook, I have listed them below:
- peanut free facility—peanut products are not allowed in the center as we have children with peanut allergies (ex. peanut butter sandwich, peanut butter cookies, trial mix containing peanuts) but you may use other nut substitutes--almond butter, Nutella, WOW Butter or sunflower butter. Label the bag telling us which substitute you are using.
- closed toe and heel shoes—required as it reduces the number of accidents from falling and there are less ant bites as we have the opportunity to get them off shoes before they reach skin. Your child will not be able to play on the outside play structures if they do not have closed shoes. Crocks, mules and sandals are not allowed
- nap—a blanket and pillow and a soft stuffed animal are allowed for napping. These must be small as they must fit in your child's cubby. The state requires that no belongings may protrude from the cubby and touch other children's belongings.
- no toys from home—teacher will notify parents if they are having a "show and share" day and that is only time something should be brought
- food preparations—send food that can be put on a plate and eaten. Limit food needs to be warm, warm it at home and put in a soup thermos.
The fee schedule is available. You will continue to earn the two week vacation each year to be taken in at least a week interval. We still have the referral system for you to get free tuition. The form for referrals is in the packet and has the explanation. We are delighted you and your child are a part of our family at Retta Christian Learning Center. If you have questions or concerns, please feel free to talk with any member of management.
"Every Child Learns'
Thank you,

Suzette Deer -- Director
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 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:*
Child's Full Name:*
Child's Date of Birth:*

MonthDayYear
Date
Both parentsMomDadGuardian
Child's Home Address:*
Date of Admission:*

MonthDayYear
Date
Date of Withdrawal:

MonthDayYear
Date
Name of Parent or Guardian 1:*
Parent 1 Phone No.:*
Format: (000) 000-0000.
Address of Parent or Guardian 1:*
Name of Parent or Guardian 2:*
Parent 2 Phone No.:*
Format: (000) 000-0000.
Address of Parent or Guardian 2:*
YesNo
I authorize the child care operation to release my child to leave the child care operation only with the following persons.

They are also the Emergency Contacts in the event the parents cannot be reached. Please list name, phone number, and address 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 of Emergency Contact 1:*
Relationship:*
Phone No.:*
Format: (000) 000-0000.
Address:*
Name of Emergency Contact 2:*
Relationship:*
Phone No.:*
Format: (000) 000-0000.
Address:*
Name of Emergency Contact 3:*
Relationship:*
Phone No.:*
Format: (000) 000-0000.
Address:*
Consent Information
for emergency careon field tripsto and from hometo and from school
I give consent for my child to participate in field trips.I do not give consent for my child to participate in field trips.
water table playsprinkler playsplashing or wading poolsswimming poolsaquatic playgrounds
YesNo
YesNo
YesNo
Discipline and guidanceProcedures for release of childrenSuspension and expulsionIllness and exclusion criteriaEmergency plansProcedures for dispensing medicationsProcedures for conducting health checksImmunization requirements for childrenSafe sleepMeals and food service practicesProcedures for parents to discuss concerns with the directorProcedures to visit the center without securing prior approvalPromotion of indoor and outdoor physical activity including criteria for extreme weather conditionsProcedures for supporting inclusive servicesProcedures for parents to participate in operation activitiesProcedures for parents to contact Child Care Regulation (CCR), DFPS, Child Abuse Hotline, and CCR website
BreakfastMorning snackParents provide personal lunchAfternoon snack

6. Days and Times in Care: My child is normally in care on the following days and times:*

Rows	A.M.	P.M.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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.
Signature - Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date
Environmental allergiesLimitations or restrictions on child's activitiesFood intolerancesReasonable accommodations or modificationsExisting illnessAdaptive equipment, include instructions belowPrevious serious illnessSymptoms or indications of complicationsInjuries and hospitalizations in the past 12 monthsMedications prescribed for continuous long-term useNoneOther (list info in box below)
YesNo
Food Allergy Emergency Plan Submitted 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).
Signature - Parent or Legal Guardian*

Clear
Date Signed*

MonthDayYear
Date
9. School Age Children
My child attends the following school:
School Area Code and Phone No.:
walk to or from school or homeride a busbe 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:
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*
Area Code and Phone No.*
Name of Emergency Care Facility*
Address*
Area Code and Phone No.*
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature Parent or Legal Guardian*

Clear
Date Signed*

MonthDayYear
Date

Vaccine Requirements

Please provide an updated and validated shot record or exemption form for your child.
Health Statement Requirements

Please provide a health statement from your child's doctor stating they have been seen for a wellness checkup in the last 12 months and are well enough to attend childcare.
Vision Exam Results

Please provide validated vision and hearing results if your child is not in public school and is 4 years or older.
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
Signature - Parent or Legal Guardian*

Clear
Date Signed*

MonthDayYear
Date
Child's Parent or Legal Guardian*

Clear
Date Signed*

MonthDayYear
Date
Center Designee Signature _____________________________
Center Designee Date Signed ________________________
Operational Discipline and Guidance Policy

This form provides the required information per 26 Texas Administrative Code (TAC) minimum standards §744.501(7), §746.501(a)(7), and §747.501(5).
Directions: Parents will review this policy upon enrolling their child. Employees, household members, and volunteers will review this policy at orientation. A copy of the policy is provided in the operational policies.
Discipline and Guidance Policy
Discipline must be:
1) Individualized and consistent for each child;
2) Appropriate to the child's level of understanding; and
3) Directed toward teaching the child acceptable behavior and self-control.
A caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control, and self-direction, which include at least the following:
1) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;
2) Reminding a child of behavior expectations daily by using clear, positive statements;
3) Redirecting behavior using positive statements; and
4) Using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more than one minute per year of the child's age.
There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited:
1) Corporal punishment or threats of corporal punishment;
2) Punishment associated with food, naps, or toilet training;
3) Pinching, shaking, or biting a child;
4) Hitting a child with a hand or instrument;
5) Putting anything in or on a child's mouth;
6) Humiliating, ridiculing, rejecting, or yelling at a child;
7) Subjecting a child to harsh, abusive, or profane language;
8) Placing a child in a locked or dark room, bathroom, or closet with the door closed or open; and
9) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age.
Additional Discipline and Guidance Measures(Only Applies to Before or After School Program (BAP)/School Age Program (SAP) that Operates under 26 TAC Chapter 744)
A program must take the following steps if it uses disciplinary measures for teaching a skill, talent, ability, expertise, or proficiency:
• Ensure that the measures are considered commonly accepted teaching or training techniques;
• Describe the training and disciplinary measures in writing to parents and employees and include the following information:
(A) The disciplinary measures that may be used, such as physical exercise or sparring used in martial arts programs;
(B) What behaviors would warrant the use of these measures; and
(C) The maximum amount of time the measures would be imposed;
• Inform parents that they have the right to ask for additional information; and
• Ensure that the disciplinary measures used are not considered abuse, neglect, or exploitation as specified in Texas Family Code §261.001 and TAC Chapter 745, Subchapter K, Division 5, of this title (relating to Abuse and Neglect).
Signature
This policy is effective on the following date:*

MonthDayYear
Date
Signed by:*

Clear
ParentCaregiver/EmployeeHousehold Member (CH. 747 only)
Minimum Standards Related to Discipline

• Title 26, Chapter 746 Subchapter L: http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=26&pt=1&ch=746&sch=L&rl=Y• Title 26, Chapter 747 Subchapter L: http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=26&pt=1&ch=747&sch=L&rl=Y• Title 26, Chapter 744 Subchapter G: http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=26&pt=1&ch=744&sch=G&rl=Y

Getting To Know You
Child's Name*
Date*
1. Who are the members of your child's family?*
2. If there are siblings, what are their names and ages?*
3. What discipline methods do you use at home? What works best?*
4. Do you have pets? If so, what kind and what are their names?*
5. What are your favorite family activities?*
6. What church does your family attend?*
7. What are your current goals for the development of your child?*
8. What is your favorite thing about your child?*
Should be Empty:

Retta Christian Learning Center

Admission Information

I authorize the child care operation to release my child to leave the child care operation only with the following persons.

Consent Information

7. Receipt of Parent's Rights:

9. School Age Children

Authorization For Emergency Medical Attention

Vaccine Requirements

Health Statement Requirements

Vision Exam Results

Gang Free Zone

Privacy Statement

Center Designee Signature _____________________________

Center Designee Date Signed ________________________

Operational Discipline and Guidance Policy

Discipline and Guidance Policy

Additional Discipline and Guidance Measures(Only Applies to Before or After School Program (BAP)/School Age Program (SAP) that Operates under 26 TAC Chapter 744)

Signature

Minimum Standards Related to Discipline

Getting To Know You