Texas Dept of Family and Protective Services Operation Name Childs Full Name Childs Home Address Date

of Admission Parents or Guardians Name

ADMISSION INFORMATION
Directors Name Childs Date of Birth

Form 2935 Aug 2010 / Pg 1 of 3

Childs Home Telephone No.

Date of Withdrawal Address (if different from childs address)

List telephone numbers below where parents/guardian may be reached while child will be in care: Mothers Telephone No. Fathers Telephone No. Guardians Telephone No. Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached:

Cell Phone No Relationship

I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name & telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

CHECK ALL THAT APPLY: 1. TRANSPORTATION: Walk home 2. 3. 4. FIELD TRIPS: Parents Comments: WATER ACTIVITIES:

I hereby

give

do not give

consent for my child to be transported and supervised by the operations employees: to and from home to and from school my consent for my child to participate in Field Trips: my consent for my child to participate in Water Activities: swimming pools water table play

for emergency care I hereby I hereby give give sprinkler play

on field trips

do not give do not give

splashing/wading pools

RECEIPT OF WRITTEN OPERATIONAL POLICIES: I acknowledge receipt of the facilitys operational policies including those for discipline and guidance. 5. I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE: None Breakfast AM Snack Lunch PM Snack Supper Evening Snack 6. MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES: Mondays from: to: Tuesdays from: to: Wednesdays from: to: Thursdays from: to: Fridays from: to: Saturdays from: to: Sundays from: to:

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to: Name of Physician: Address: Ph.#: Name of Emergency Medical Care Facility: I give consent for the facility to secure any and all necessary emergency medical care for my child. Signature - Parent or Legal Guardian List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of: Address: Ph.#:

Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. 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

Texas Dept of Family and Protective Services

ADMISSION INFORMATION

Form 2935 Aug 2010 / Pg 2 of 3

SCHOOL AGE CHILDREN: My child attends the following school: Name of School and Address CHECK ALL THAT APPLY: His / her immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. Vision and Hearing screening records are also on file. Name of sibling(s): My child has permission to: ride a bus, and/or walk to or from school or home, be released to the care of his/her sibling(s) under 18 years old. School Ph.#

IMMUNIZATION RECORD:

I have provided the childcare operation with a copy of my childs most current immunization record.

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. Please check only one option: HEALTH-CARE PROFESSIONALS STATEMENT: I have examined the above named child within the past year and find that he / she is 1. able to take part in the day care program. Health Care Professional's Signature A signed and dated copy of a health care professionals statement is attached. Date

2. 3.

Medical diagnosis 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. 4. My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professionals signed statement and will submit it to the child-care operation. Name and address of health care professional:

Signature - Parent or Legal Guardian VISION

Date

R 20/ ________

L 20/ ________

PASS

FAIL

SIGNATURE ____________________________________________ HEARING R L SIGNATURE ___________________________________________ 1000 Hz

DATE _____________________________________ 2000 Hz 4000 Hz

PASS

FAIL

DATE ______________________________________

Signature Parent or Legal Guardian

Date

Texas Dept of Family and Protective Services

ADMISSION INFORMATION
HEALTH REQUIREMENTS

Form 2935 Aug 2010 / Pg 3 of 3

Name of Child:

Date of Birth:

Age Vaccine
Hepatitis B Rotavirus Diphtheria, Tetanus, Pertussis Haemophilus influenzae type b Pneumococccal Inactivated Poliovirus Influenza Measles, Mumps, Rubella Varicella Hepatitis A Meningococcal TB TEST (if required)

Birth

1 mos

2 mos

4 mos

6 mos

12 mos

15 mos

18 mos

19-23 Mos

2-3 Yrs

4-6 Yrs

Positive

Negative

Date:

Signature or stamp of a physician or public health personnel verifying immunization information above. Signature Date

Varicella (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 (date) and does not need varicella vaccine.

Parents signature

Date

I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years. For additional information regarding immunizations contact the Department of State Health Services at

www.dshs.state.tx.us/immunize/public.shtm

Signature Parent or Legal Guardian

Date