General Information Operation’s Name Director's Name Child’s Full Name * Child’s Date of Birth * Child Lives With * Both parents Dad Mom Guardian Child’s Home Address * Date of Admission * Date of Withdrawal Name of Parent or Guardian Completing Form * Address of Parent or Guardian (if different from the child's) * List telephone numbers below where parents/guardian may be reached while child is in care. Parent 1 Telephone No. * Parent 2 Telephone No. Parent Email ID * Guardian's Telephone No. Custody Documents on File * Yes No Give the name, address, and phone number of the responsible individual to call in case of an emergency if parents/guardian cannot be reached: * Phone Number * Address * Relationship *
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. Name and Phone Number * Name and Phone Number Name and Phone Number Consent Information Check All That Apply: 1.TRANSPORTATION *
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 for emergency care * Yes No on field trips * Yes No to and from home * Yes No to and from school * Yes No child is school * Yes No a school aged student * Yes No 3.WATER ACTIVITIES *
I give consent for my child to participate in the following water activities:
water table play * Yes No sprinkler play * Yes No splashing/wading pools * Yes No swimming pools * Yes No aquatic playgrounds * Yes No 4.RECEIPT OF WRITTEN OPERATIONAL POLICIES *
I acknowledge receipt of the facility’s operational policies, including those for:
5. MEALS *
I understand that the following meals will be served to my child while in care:
Breakfast * Yes No Lunch * Yes No Afternoon snack * Yes No Supper * Yes No 6. DAYS AND TIMES IN CARE *
My child is normally in care on the following days and times:
AM / PM 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
Authorization For Emergency Medical Attention | Name of Physician * Address * Phone Number * Name of Emergency Care Facility * Address * Phone Number * 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: Does your child have diagnosed food allergies? *
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:
Name of School School Phone Number My child has permission to (check all that apply) Authorized pick up/drop off locations other than the child’s address 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 * Name and Address of Health Care Professional * Comments / Message Requirements for Exclusion Requirements for Exclusion Date Signed Hearing Exam Results Ear Right Frequency 1000 Hz 2000 Hz 4000 Hz Pass or Fail Pass Fail Ear Left Frequency 1000 Hz 2000 Hz 4000 Hz Pass or Fail Pass Fail Date Signed Vaccine Information
The following vaccines require multiple doses over time. Please provide the date your child received each dose.
Vaccine Hepatitis B Vaccine Schedule Birth (first dose) 1–2 months (second dose) 6–18 months (third dose) Dates Child Received Vaccine Vaccine Rotavirus Vaccine Schedule 2 months (first dose) 4 months (second dose) 6 months (third dose) Dates Child Received Vaccine Vaccine Diphtheria, Tetanus, Pertussis Vaccine Schedule 2 months (first dose) 4 months (second dose) 6 months (third dose) 15–18 months (fourth dose) 4–6 years (fifth dose) Dates Child Received Vaccine Vaccine Haemophilus Influenza Type B Vaccine Schedule 2 months (first dose) 4 months (second dose) 6 months (third dose) 12–15 months (fourth dose) Dates Child Received Vaccine Vaccine Pneumococcal Vaccine Schedule 2 months (first dose) 4 months (second dose) 6 months (third dose) 12–15 months (fourth dose) Dates Child Received Vaccine Vaccine Inactivated Poliovirus Vaccine Schedule 2 months (first dose) 4 months (second dose) 6 months (third dose) 4–6 years (fourth dose) Dates Child Received Vaccine Vaccine Influenza Vaccine Schedule Yearly, starting at 6 months. Two doses given at least four weeks apart are recommended for children who are getting the vaccine for the first time and for some other children in this age group. Dates Child Received Vaccine Vaccine Measles, Mumps, Rubella Vaccine Schedule 12–15 months (first dose) 4–6 years (second dose) Dates Child Received Vaccine Vaccine Varicella Vaccine Schedule 12–15 months (first dose) 4–6 years (second dose) Dates Child Received Vaccine Vaccine Hepatitis A Vaccine Schedule 12–23 months (first dose) The second dose should be given 6 to 18 months after the first dose. Dates Child Received Vaccine Physician or Public Health Personnel Verification
Signature or stamp of a physician or public health personnel verifying immunization information above:
Date SIgned Varicella (Chickenpox) 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. Date SIgned Additional Information Regarding Immunizations
For additional information regarding immunizations, visit the Texas Department of State Health Services website at
TB Test (If Required) Positive Negative Positive Negative Date 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.
Signatures Date SIgned