Admission Form

Admission Information

Use this form to collect all required information about a child enrolling in day care.
Directions: The day care provider gives this form to the child’s parent or guardian. The parent or guardian completes the form in
its entirety 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. Must submit one admission form per child.

General Information

List telephone numbers below where parents/guardian may be reached while child is in care.
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 telephone number for each. Children will only be released to a parent or guardian or to a person designated by the parent/guardian after verification of ID.

Consent Information

Check All That Apply:
I give consent for my child to be transported and supervised by the operation’s employees:
Our center will provide transportation to and/or from school
I give consent for my child to participate in the following water activities:
I acknowledge receipt of the facility’s operational policies, including those for:
I understand that the following meals will be served to my child while in care:
My child is normally in care on the following days and times:

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
Signature – Parent or Legal Guardian

Child's Additional Information Section

List any special needs that your child may have, such as environmental allergies, food intolerances, 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:
Child day care 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).  

School Age Children

My child attends the following school: 

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.  
Click or drag files to this area to upload. You can upload up to 5 files.

Requirements for Exclusion

Hearing Exam Results

Vaccine Information

The following vaccines require multiple doses over time. Please provide the date your child received each dose.

Physician or Public Health Personnel Verification

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

Varicella (Chickenpox)

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 penalties.

Privacy Statement

HHSC values your privacy. For more information, read our privacy policy online at: https://hhs.texas.gov/policies-practicesprivacy# security

Signatures

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contact us

Postal Address

Kids in Kare
17645 Kieth Harrow Blvd.
Houston, TX 77084

Phone & E-mail

Phone: (832)427-4438
Fax: (281)8597792
info@kidsinkare.com

Business Hours

Monday – Friday
5:30 am – 7:00 pm
Weekend Closed

Our Services

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