ABC WEE School Admission Form
2023/204
Operations Name
Director's Name
Date of Admission
-
Month
-
Day
Year
Date
Child's Full Name
*
First Name
Middle Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Childs Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Parent or Guardian Completing the Form
*
First Name
Last Name
Child lives with:
*
Both parents
Mom
Dad
Guardian
Custody Documents on File
Yes
No
Parent/Guardian Address (if different than child's)
List telephone numbers below where parents/guardians may be reached while child is in care.
If there is not an existing phone number, please enter all zeros
Parent/ Guardian Name
*
First Name
Last Name
Parent/ Guardian Cell Phone No.
*
-
Area Code
Phone Number
Parent/ Guardian Work Phone No.
*
-
Area Code
Phone Number
Parent/ Guardian Email Address
*
example@example.com
Parent 2/ Guardian Name
*
First Name
Last Name
Parent 2/ Guardian Cell Phone No.
*
-
Area Code
Phone Number
Parent 2/ Guardian Work Phone No.
*
-
Area Code
Phone Number
Parent 2/ Guardian Email Address
*
example@example.com
Give the name, address and phone number of the responsible individual to call in case of emergency if parents/guardian cannot be reached.
Name of Emergency Contact Person
*
First Name
Last Name
Phone Number for Emergency Contact Person
*
-
Area Code
Phone Number
Address of Emergency Contact Person
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Child
*
Authorized Persons
*
First Name
Last Name
Phone Number
1.
2.
3.
Consent Information; Check all that apply:
I give my consent for my child to participate in the following water activities
*
water table play
sprinkler play
splashing/wading pools
I give my consent for the child care providers to apply the following creams/ointments to my child as needed
*
Diaper Cream
Sunscreen
Bug Spray
Parent Provided Diaper Cream, Sunscreen, and/or Bug Spray
None of the Above
I give my consent for my child to be photographed for use in the school only (We will not use photos for social media)
*
Do
Do Not
I understand that the following meals will be served to my child while in care
*
Morning snack
Parent provided lunch
Afternoon snack
My child is normally in care on the following days and times
*
Monday
Tuesday
Wednesday
Thursday
Friday
A.M.
P.M.
Authorization For Emergency Medical Attention; In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in the charge to take my child to:
Physician and Emergency Facility Information
*
Name
Address
Phone Number
Physician
Emergency Care Facility
I give consent for the facility to secure any and all necessary medical care for my child
*
Do
Do Not
I give consent for my child to be transported and supervised by the operation's employees for emergency care.
*
Do
Do Not
Signature - Parent or Legal Guardian
*
Date Signed
*
Child's Additional Information Section
Child's Special Care Needs (check all that apply)
*
Environmental allergies
Food intolerances
Existing illness
Previous serious illness
Injuries and hospitalizations (past 12 months)
Limitations or restrictions on child's activities
Reasonable accommodations or modifications
Adaptive equipment (include instructions below)
Symptoms or indications of complications
Medications prescribed for continuous long-term use
None of the Above
Other
Explain any needs selected above:
*
N/A if Non Applicable
Does your child have Physician diagnosed food allergies?
*
Yes
No
Please list your child's Medically Diagnosed Allergies
Date of Submitted Allergy Plan
-
Month
-
Day
Year
Date Picker Icon
Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit https://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
*
Date Signed
*
Admission Requirement; If your child does not attend pre-kindergarten or school away from the child care operation, one of the following must be presented when your child is admitted to the child care operation or within ONE WEEK of admission.
Check only one option:
*
A signed and dated copy of a health care professional's statement is attached
Medical diagnoses and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.
My child has been examined in the past year by a medical health care professional and is able to participate in the day care program.
Signature - Parent or Legal Guardian
*
Date Signed
*
Requirements for Exclusion from Compliance
Please choose one:
*
I have provided the child care operation with a copy of my child's most recent immunization record.
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 Section 161.0041 Health and Safety Code submitted no later than the 90th day 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. Within 12 months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.
Signature
*
Date Signed
*
Varecella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement: My child had varicella disease (chickenpox) on or about (add date below) and does not need varicella vaccine.
Date of chickenpox
Signature
*
Date Signed
Additional Information Regarding Immunizations; For additional information regarding immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm.
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 punishment.
Privacy Statement; HHSC values your privacy. For more information, read our privacy policy online at https://hhs.texas.gov/policies-practices-privacy#security.
Child's Parent or Legal Guardian Signature
*
Date Signed
*
Center Designee Signature
Date Signed
For Office Use Only
Headmaster/ Reg and Supply Fee
Email/ Remind
Submit
Should be Empty: