Admissions Form

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.

General Information

Child's Date of Birth(Required)
Child Lives With(Required)
Child's Home Address(Required)
Date of Admission(Required)
Date of Withdrawal(Required)
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(Required)
Parent 1 Telephone No.
Parent 2 Telephone No.
Guardian's Telephone No.
 
Custody Documents on File

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

1. Transportation (Check All that Apply)
I give consent for my child to be transported and supervised by the operation's employees:
2. Field Trips
3. Water Activities (Check All that Apply)
I give consent for my child to participate in the following water activities:
4. Receipt of Written Operational Policies (Check All that Apply)
I acknowledge receipt of the facility's operational policies, including those for:
5. Meals (Check All that Apply)
I understand that the following meals will be served to my child while in care:
6. Days and Times in Care

My child is normally in care on the following days and times:
Monday
A.M.
P.M.
 
Tuesday
A.M.
P.M.
 
Wednesday
A.M.
P.M.
 
Thursday
A.M.
P.M.
 
Friday
A.M.
P.M.
 
Saturday
A.M.
P.M.
 
Sunday
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 charge to take my child to:

Address(Required)
Address(Required)
(Parent/Guardian Signature)

Child's Additional Information Section

Does your child have diagnosed food allergies?
Plan Submitted on

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).

Date

School Age Children

My child has permission to (check all that apply):
Immunizations, vision and hearing screening, and TB screening

Admission Requirement

Steps for this section:
Accepted file types: jpg, jpeg, png, pdf, doc, docx, heic, Max. file size: 300 MB.

Requirements for Exclusion

Requirements for Exclusion #1
Requirements for Exclusion #2
Accepted file types: jpg, jpeg, png, pdf, doc, docx, heic, Max. file size: 300 MB.

Vision Exam Results

Pass or Fail:
Date Signed

Hearing Exam Results

Ear: Left
1000 Hz
2000 Hz
4000 Hz
 
Pass or Fail:
Ear: Right
1000 Hz
2000 Hz
4000 Hz
 
Pass or Fail:
Date Signed

Vaccine Information

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

Hepatitis B
Birth (first dose)
1–2 months (second dose)
6–18 months (third dose)
 
Rotavirus
2 months (first dose)
4 months (second dose)
6 months (third dose)
 
Diphtheria, Tetanus, Pertussis
2 months (first dose)
4 months (second dose)
6 months (third dose)
15–18 months (fourth dose)
4–6 years (fifth dose)
 
Haemophilus Influenza Type B
2 months (first dose)
4 months (second dose)
6 months (third dose)
12–15 months (fourth dose)
 
Pneumococcal
2 months (first dose)
4 months (second dose)
6 months (third dose)
12–15 months (fourth dose)
 
Inactivated Poliovirus
2 months (first dose)
4 months (second dose)
6–18 months (third dose)
4–6 years (fourth dose)
 
Influenza
#1
#2
#3
#4
#5
#6
 
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.
Measles, Mumps, Rubella
12–15 months (first dose)
4–6 years (second dose)
 
Varicella
12–15 months (first dose)
4–6 years (second dose)
 
Hepatitis A
12–23 months (first dose)
The second dose should be given 6 to 18 months after the first dose.
 

Physician or Public Health Personnel Verification

Steps for this section:
Accepted file types: jpg, jpeg, png, pdf, doc, docx, heic, Max. file size: 300 MB.

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

TB Test (If Required)

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.

Privacy Statement

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

Signatures

Date SIgned(Required)
Center Designee:


 Date Signed: