Summer Admission Form

Bear Valley Academy Summer Enrichment Admission Form

You will be required to sign this form in several places. Please sign your full name which serves as your electronic signature.
Summer Enrichment

Please select the program your child will attend and be in our center. Summer Enrichment hours are 9:00 am to 12:00 pm. Students 18 months through 7 years are eligible for two session options with both being held on Tuesday/Wednesday/Thursday.
Summer Session*
Student Status*

Current student (2019-2020)Sibling of current student
Student Information

Please use the child's full name (Ex. Madelyn, not Maddie)
Name*

First NameMiddle NameLast Name
Name used at home*
Language spoken at home*
Gender*

MaleFemale
Date of birth*

MonthDayYear
Date
Child lives with*

Both parentsDadMomGuardianOther
Custody documents on file at school*
Child's address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Legal Guardian

Parent/Legal Guardian listed here will be our first contact.
Name*

First NameLast Name
Relationship to child*
Primary phone number (where you can be reached while child is in care)*

Area CodePhone Number
Secondary phone number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is this person an authorized pick-up for the child?*

YesNo
Additional Parent/Legal Guardian

Parent/Legal Guardian listed here will be our second contact.
Name*

First NameLast Name
Relationship to child*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary phone number (where you can be reached while child is in care)*

Area CodePhone Number
Secondary phone number*

Area CodePhone Number
Email*
example@example.com
Is this person an authorized pick-up for the child?*

YesNo
Authorizations
I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons and the above parents/guardians marked as an authorized pick-up. Children will ONLY be released to a parent/guardian or person designated after verification of ID. In the event that a person "not listed" has to pick up my child, I understand that BVA must receive a phone call from one of the approved parents stating who that person will be. Do not leave any fields black. Each field must hae either the required information or N/A.

Authorized Pick-Up Persons

	Name	Phone Number	Relation to Child
Authorized Pick-up 1
Authorized Pick-up 2
Authorized Pick-up 3

Signature - Parent or Legal Guardian*

Clear
Transportation and Field Trips

We do not transport children except in the event of emergency.

We do not take children on field trips.
Water Activity Authorization- I give consent for my child to participate in the following water activities:*

Sprinkler playSplashing/wading poolsWater table playNone
Meals- I understand that the following meals, provided by the parent, will be served to my child while in care. NO PEANUTS PLEASE. Bear Valley Academy is a peanut-free campus.*

AM Snack
Photograph Authorization- We request permission for photos of your child to be used in publications and advertisements about Bear Valley Academy. This includes, but is not limited to, Bear Valley Academy Facebook page and website. Please indicate if you authorize the use of photographs.*

YesNo
Skin Product Authorization- Indicate if you authorize application of sunscreen, insect repellent, diaper ointment, or other skin products to your child. List products you will supply for use. *Please note that we recommend applying sun screen or insect repellent at home and may require additional release to apply at school.*

YesNo
Skin Product Names*
N/A if none
Emergency Medical Information
I give consent for the child care operation to secure any and all necessary emergency medical care for my child. In the event I cannot be reached to make arrangement for emergency medical care, I authorize the person in charge to take my child to the physician or emergency medical care facility listed below.

I authorize the individuals listed below to be called and make medical decisions for my child if the parents or legal guardians cannot be reached. I have notified said individuals about this responsibility.

Do not leave any fields blank. Each field must be COMPLETE with the required information. For example - Address: 555 Brown Lane, Colleyville, TX 76034

Emergency Contact Information*

	Name	Phone Number	Address
Physician
Emergency Medical Care Facility
Contact 1 (other than parent/guardian)
Contact 2 (other than parent/guardian)

I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature - Parent or Legal Guardian*

Clear
Medical Information

Complete as appropriate. If none, enter N/A.
Environmental allergies:*
Food intolerances:*
Existing Illness:*
Previous Serious Illness:*
Medication prescribed for long-term continuous use:*
Injuries and hospitalizations during the last 12 months:*
Any other special needs information which caregivers should be aware of:*
Childcare operations are public accomodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in the violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).
My child has a diagnosed food allergies:*

YesNo
I am submitting a Food Allergy & Anaphylaxis Emergency Care Plan signed by my child's health care professional.*

YesN/A
Signature - Parent or Legal Guardian*

Clear
Health-Care Professional's Statement*

I provided a signed Health-Care Professional's Statement to the center.I have a attached a signed and dated affidavit stating that I decline immunizations for reasons 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.My child has been examined within the past year by a health-care professional and is able to participate in the program. Within 12 months of admission, I will obtain a health-care professional's signed statement and will submit it to the center.
I selected that my child has been examined within the past year by a health-care professional. The name and address of said health-care professional is as follows: (If you did not select this option type N/A)*
Most recent physical examination date:*

MonthDayYear
Date
Varicella History- If your child had varicella disease (chickenpox) and does not need the varicella vaccine check yes, provide the approximate date. Otherwise, check no.*

YesNo
Signature - Parent of Legal Guardian*

Clear
Human Papillomavirus (HPV)*
Meningococcal (MCV)*
For additional information regarding immunizations, contact the Department of State Health Services at www.dshs.state.tx.us/immunize/public.shtm
Vision & Hearing*

My child will be younger than 4 years old on the first day of the current school year and does not require a copy of their vision/hearing screening to be on file.My child will be 4 years or older on the first day of the current school year and is required to have a copy of their vision/hearing screening on file which I have provided.I have attached a signed and dated affidavit stating that the vision or hearing screening conflicts with the practices of a church or religious denomination that I am an adherent member of.
Signature - Parent or Legal Guardian*

Clear
Policies Acknowledgment
Bear Valley Academy's school policies can be found in the Parent Handbook on our website or in our school office. Please review our operational policies.
I acknowledge written receipt and understand the center's operational policies, including those for:*

Discipline and guidanceSuspension and expulsionEmergency plansProcedures for conducting health checksSafe sleepProcedures for parents to discuss concerns with the directorProcedures for parents to participate in operation activitiesProcedures for release of childrenIllness and exclusion criteriaProcedures for dispensing medicationImmunization requirements for childrenMeals and food service practicesProcedures for visiting the center without securing prior approvalProcedures for parents to contact Child Care Licensing, DFPS, Child Abuse Hotline & DFPS website
Parent or Legal Guardian Agreement
Bear Valley Academy reserves the right to place children in any classroom and to refuse the requests that are not in the best interests of the child, class, or program.

I understand that the supply fee is non-refundable. Tuition is due by June 1st. Parents are responsible for tuition regardless of absences.

I acknowledge that a staff member has provided me with a copy of Bear Valley Academy's Parent Handbook and discussed the contents with me. I agree to abide by the rules, policies, standards, and procedures of Bear Valley Academy including payment of all tuition and fees owed.

I understand that the following documents, as applicable, MUST be on file with the school before June 1st. I acknowledge that failure to turn in all required documents could result in my child's inability to attend the program.
- Completed Admission Form (this form)
- Most current copy of the child's immunization records
- Signed copy of the Health Care Professional's Statement or exemption
- Signed copy of my child's hearing/vision screening or exemption (if the child is 4 or older before June 1st)
- Food Allergy & Anaphylaxis Emergency Care Plan (if needed)
- Authorization for Dispensing Medication Form (if needed)
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 pentalties.

DFPS values your privacy. For more information, read their Privacy and Security Policy online at www.dfps.state.tx.us/policies/privacy.asp
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Bear Valley Academy Summer Enrichment Admission Form

Summer Enrichment

Student Information

Parent/Legal Guardian

Additional Parent/Legal Guardian

Authorizations

Emergency Medical Information

Medical Information

Policies Acknowledgment

Parent or Legal Guardian Agreement