ADMISSION INFORMATION

Admission Information

Form 2935
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
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child lives with:
Child's Home Street Address, City, State and ZIP Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Admission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Withdrawal

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Parent or Guardian 1

First NameLast Name
Address of Parent or Guardian 1, if different from the child's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent or Guardian 2

First NameLast Name
Address of Parent or Guardian 2, if different from the child's

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 Area Code and Phone No.
Format: (000) 000-0000.
Parent 2 Area Code and Phone No.
Format: (000) 000-0000.
Guardian's Area Code and Phone No.
Format: (000) 000-0000.
Custody documents on file?
In case of an emergency, when the parent or guardian cannot be reached, call:
Name of Emergency Contact

First NameLast Name
Relationship
Area Code and Phone No.
Format: (000) 000-0000.
Street Address, City, State and ZIP Code

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.
Authorized Release Person 1 - Name

First NameLast Name
Authorized Release Person 1 - Area Code and Phone No.
Format: (000) 000-0000.
Authorized Release Person 2 - Name

First NameLast Name
Authorized Release Person 2 - Area Code and Phone No.
Format: (000) 000-0000.
Authorized Release Person 3 - Name

First NameLast Name
Authorized Release Person 3 - Area Code and Phone No.
Format: (000) 000-0000.

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

First NameLast Name
Area Code and Phone No. (Physician)
Format: (000) 000-0000.
Street Address, City, State and ZIP Code (Physician)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Emergency Care Facility
Area Code and Phone No. (Facility)
Format: (000) 000-0000.
Street Address, City, State and ZIP Code (Facility)

Street Address

Street Address Line 2

CityState / 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 (Section 3)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Section 4 – Requirements for Exclusion from Compliance
Exclusion Requirements
Section 5 – Vision Exam Results

Doctor completes this section.
Section 6 – Hearing Exam Results

Doctor completes this section.
Section 7 – Admission Requirement

Doctor completes this section.
Section 8 – Vaccine Information

Doctor completes this section.
Section 9 – Physician or Public Health Personnel Verification

Doctor completes this section.
Section 10 – Varicella for Chickenpox

Doctor completes this section.

Section 11 – Additional Information About Immunizations
For more information about immunizations, visit the Texas Department of State Health Services website at https://www.dshs.texas.gov/immunizations/public.
Section 12 – 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.
Section 13 – Privacy Statement
HHSC values your privacy. For more information, read our privacy policy online at https://hhs.texas.gov/policies-practices-privacy#security.
Section 14 – Signatures
Child's Parent or Legal Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Center Designee Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Operational Discipline and Guidance Policy

Form 1099
This form provides the required information per 26 Texas Administrative Code (TAC) minimum standards Sections 744.501(7), 746.501(a)(7), and 747.501(5).

Directions: Parents will review this policy when 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.
Section 1 – 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 on 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) grabbing or pulling a child;
4) putting anything in or on a child's mouth;
5) humiliating, ridiculing, rejecting or yelling at a child;
6) subjecting a child to harsh, abusive or profane language;
7) placing a child in a locked or dark room, bathroom or closet;
8) placing a child in a restrictive device for time out;
9) withholding active play or keeping a child inside as a consequence for behavior, unless the child is exhibiting behavior during active play that requires a brief supervised separation or time out that is consistent with 746.2803(4)(D); and
10) requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age.
Section 2 – Additional Discipline and Guidance Measures
Only applies to Before or After School Program (BAP) or 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:
• make sure 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 more information; and
• make sure that the disciplinary measures used are not considered abuse, neglect or exploitation as specified in Texas Family Code Section 261.001.
Section 3 – Effective Date, Signature and Role
This policy is effective on the following date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signed by
Role:
Section 4 – Minimum Standards Related to Discipline
- Title 26, Chapter 744 Subchapter G
- Title 26, Chapter 746 Subchapter L
- Title 26, Chapter 747 Subchapter L

Parent's Rights
This form provides the required information per Chapter 42 of the Human Resource Code (HRC) Section 42.04271.
Parents will review these rights upon enrolling their child.
Rights of Parent or Guardian
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.
Signature of Parent or Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Resources
Facility Information and Online Compliance History: childcare.hhs.texas.gov/Public/childcaresearch
Child Care Regulation Contact Information: www.hhs.texas.gov/providers/child-care-regulation

Grace Place Learning Center
3460 Roy Richard Dr.
Schertz, TX 78154
(210) 658-0846
Parent/Guardian Permission for Photographs and Social Media
At Grace Place Learning Center, we enjoy sharing special moments, classroom activities, and achievements with our families and community. We request your permission to use photographs and/or videos of your child for promotional and communication purposes.
I, ___________________________________ (Parent/Guardian Name), give permission for Grace Place Learning Center to photograph and/or record my child:

Parent/Guardian First NameParent/Guardian Last Name
Child's Name:

First NameLast Name
These photographs and/or videos may be used on:
- Grace Place Learning Center Facebook page
- Grace Place Learning Center Instagram account
- Grace Place Learning Center website
- Printed materials, newsletters, flyers, and advertisements
- Other center-related publications and communications
I understand that:
- Photos and videos may be viewed by the public when posted on social media or the internet.
- I may revoke this permission at any time by providing written notice to the center. Revocation will apply to future use and cannot remove materials already published.
Please select one:
Parent/Guardian Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name:

First NameLast Name
Relationship to Child:
Thank you for helping us celebrate and share the wonderful experiences at Grace Place Learning Center!
Should be Empty:

Rows	AM	PM
Monday
Tuesday
Wednesday
Thursday
Friday

ADMISSION INFORMATION

Sessions Offered, Tuition, and Other Fees

REGISTRATION CHECKLIST

Admission Information

Section 1 – General Information

Section 2 – Consent Information

1. Transportation

2. Field Trips

3. Water Activities

4. Receipt of Written Operational Policies

5. Meals

6. Days and Times In Care

7. Receipt of Parent's Rights

8. Child's Special Care Needs

9. School-Age Children

Section 3 – Authorization For Emergency Medical Attention

Section 4 – Requirements for Exclusion from Compliance

Section 5 – Vision Exam Results

Section 6 – Hearing Exam Results

Section 7 – Admission Requirement

Section 8 – Vaccine Information

Section 9 – Physician or Public Health Personnel Verification

Section 10 – Varicella for Chickenpox

Section 11 – Additional Information About Immunizations

Section 12 – Gang Free Zone

Section 13 – Privacy Statement

Section 14 – Signatures

Operational Discipline and Guidance Policy

Section 1 – Discipline and Guidance Policy

Section 2 – Additional Discipline and Guidance Measures

Section 3 – Effective Date, Signature and Role

Section 4 – Minimum Standards Related to Discipline

Parent's Rights

Rights of Parent or Guardian

Resources

Parent/Guardian Permission for Photographs and Social Media