Venus Daycare Enrollment Application

Venus Daycare Enrollment Application

Blue-and-gold bilingual English/Spanish enrollment application for Venus Daycare, 1 Patriot Parkway, Venus, TX 76084 • 469-363-7770 • VenusDaycare.net. Please complete the form and select the program that best fits your child.
Program / Programa
Child Information
Requested Start Date / Fecha de inicio solicitada

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Legal Name / Nombre legal del niño

First NameMiddle NameLast Name
Date of Birth / Fecha de nacimiento

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address / Domicilio

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Name / Nombre preferido
Languages Spoken at Home / Idiomas que se hablan en casa

Other
Prior Childcare Experience, Siblings Attending, and Comforting Information / Experiencia previa de cuidado infantil, hermanos inscritos e información para calmar o consolar al niño
Parent / Guardian 1
Full Name

First NameMiddle NameLast Name
Relationship to Child
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian 2
Full Name

First NameMiddle NameLast Name
Relationship to Child
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employer
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Schedule and Care Needs
Días necesitados / Days needed
Hora típica de llegada / Typical drop-off time

Hour Minutes

AM/PM Option
Hora de recogida / Pickup time

Hour Minutes

AM/PM Option
Tipo de cuidado / Care option
Health and Medical Information
¿Tiene alergias? / Does the child have allergies?
Describa las alergias / Describe allergies
¿Tiene condiciones médicas? / Does the child have medical conditions?
Describa las condiciones médicas / Describe medical conditions
Nombre del médico / Physician name

First NameMiddle NameLast Name
Teléfono del médico / Physician phone
Please enter a valid phone number.Format: (000) 000-0000.
Estado de inmunización / Immunization status
Suba registros de inmunización o salud / Upload immunization or health records

Cancelof
Medicamentos actuales / Current medications
Restricciones alimentarias / Dietary restrictions
Nombre del dentista / Dentist name

First NameMiddle NameLast Name
Teléfono del dentista / Dentist phone
Please enter a valid phone number.Format: (000) 000-0000.
Hospital preferido / Preferred hospital
Consideraciones de desarrollo, conducta, sensoriales, del habla o movilidad / Developmental, behavioral, sensory, speech, or mobility considerations
Infant Care Details
Feeding Type / Tipo de alimentación
Feeding Schedule / Horario de alimentación
Bottle Preparation Instructions / Instrucciones para preparar biberones
Nap Schedule / Horario de siestas
Soothing Methods / Métodos para calmar

Other / Otro
Diaper and Skin Care Preferences / Preferencias de cambio de pañal y cuidado de la piel
Foods Introduced / Alimentos introducidos
Foods Not Introduced / Alimentos no introducidos
Toddler / Preschool Details
Toileting Information / Información de baño
Nap / Quiet Time Preferences / Preferencias de siesta / tiempo tranquilo

Other
Favorite Activities, Interests, Books, Songs, and Comfort Items / Actividades, intereses, libros, canciones y objetos de consuelo favoritos
How does your child communicate needs? / ¿Cómo comunica su hijo/a sus necesidades?

Other
Goals you want supported at Venus Daycare / Objetivos que desea apoyar en Venus Daycare
Contacts and Pickup Authorization
Emergency Contact 1 Name

First NameMiddle NameLast Name
Emergency Contact 1 Relationship
Emergency Contact 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Name

First NameMiddle NameLast Name
Emergency Contact 2 Relationship
Emergency Contact 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pickup 1 Name

First NameMiddle NameLast Name
Authorized Pickup 1 Relationship
Authorized Pickup 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pickup 2 Name

First NameMiddle NameLast Name
Authorized Pickup 3 Name / Nombre del autorizado 3

First NameLast Name
Authorized Pickup 3 Relationship / Relación del autorizado 3
Select one relationship / Seleccione una relación
Authorized Pickup 3 Phone / Teléfono del autorizado 3
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pickup 2 Relationship
Billing, Payment, and Agreements
Billing Preference / Preferencia de facturación
Payment Preference / Preferencia de pago
Acknowledgments / Reconocimientos (late-pickup policy and tuition/payment agreement)
Parent Certification Statement / Declaración de certificación de los padres
Parent / Guardian Printed Name / Nombre impreso del padre/madre/tutor

First NameMiddle NameLast Name
Electronic Signature / Firma electrónica
Date / Fecha

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Billing Notes / Notas adicionales de facturación
Should be Empty:

Venus Daycare Enrollment Application

Child Information

Parent / Guardian 1

Parent / Guardian 2

Schedule and Care Needs

Health and Medical Information

Infant Care Details

Toddler / Preschool Details

Contacts and Pickup Authorization

Billing, Payment, and Agreements