Enrollment Form

General Information

Operation's Name *

Director's Name *

Student name *

Student date of birth * +

School Year & Semester *

Student Lives With *

Both Parents

Mom

Dad

Guardia

Student's Home Address

Street address *

Apartment, suite, or unit #

City *

State *

Zip code *

Phone number *

Email Address *

Home of record

Is the student's home of record a parent, guardian, or any other domicile owned or otherwise provided by someone other than the student? *

Yes

No

Parent/guardian name *

Street address *

Apartment, suite, or unit #

City *

State *

Zip code *

Phone number *

Email Address *

Emergency contacts

Name *

Phone number *

Relationship *

Name *

Phone number *

Relationship *

Name *

Phone number *

Relationship *

Custody Documents on file? *

Yes

No

If Yes, Upload here

I authorize the child care operation to release my child to leave the child care opereation ONLY with the following persons.

Please list the name and phone number for each . Children will only be released to a parent or guardian or to a person designed by the parent/guardian after verification of ID.

Name *

Phone number *

Name *

Phone number *

Name *

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: *

For Emergency Care

On Field Trips

To and From Home

To and From School

2. Field Trips *

I give consent for my child to participate in the field trips.

I do not give consent for my child to participate in the field trips.

3. Water Activities

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

I understand that the following meals will be served to my child while in care: *

6. Days and Times in Care

My Child is in Care on the following days *

Authorization For Emergency Medical Attention

In the event I cannot be reached to make arragements fo emergency medical care, I authorize the person incharge to take my child to:

Name of Physician *

Phone number *

Address *

Name of Emergency Care Facility *

Address *

Phone number *

Child's Additional Information Section

Child day care operations are public accommodations under thte 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 at (800) 541-03301 (voice) or (800) 514-0383 (TTY).

Does your child diagnosed with food allergies? *

Yes

No

Plan Submitted On Plan Submitted On

School Age Children

List any special needs 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. *

My child attends the following school *

School Phone Number *

My child has permission to (check all that apply) *

walk to or from school or home

ride a bus

be released to the care of his/her sibling under 18 years old

Authorized pick up/drop off locations other than the child's address *

My child has permission to (check all that apply)

Child's required immunizations, vision and hearing screening, and TB screening are current and on file at their school.

Water Table Play	Sprinkler Play	Splashing/Wading Pools	Swimming Pools
Aquatic Playgrounds

Discipline and guidance	Suspension and expulsion
Emergency Plans	Procedures for conducting health checks
Safe sleep	Procedures for parents to discuss concerns with the director
Procedure for parents to participate in operation activities	Procedures for release of children
Illness and exclusion criteria	Procedure for dispensing medications
Immunization requirements for children	Meals and food service practice
Procedures to visit the center without securing prior approval	Procedures for parents to contact Child Care Licensing (CCL), DFPS, Child Abuse Hotline, and CCL website

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.

Enrollment Form

Home of record

Emergency contacts

Consent Information

Authorization For Emergency Medical Attention

Child's Additional Information Section

School Age Children

Admission Requirement