Company ADMISSION INFORMATION Operation Name The Kid’s Corral Director’s Name Providence Village – Minette McGuire Savannah – Brenda Rodriguez Child’s Full Name * Child’s Date of Birth * Child’s Home Telephone No. * Child’s Home Address * Date of Admission Date of Withdrawal Parent’s or Guardian’s Name * Home Address (if different from child’s address ) Mother’s Place of Employment: Father’s Place of Employment: Mother's Drivers License Number Father's Drivers License Number: Mother's E-mail Address: Father's E-mail Address List telephone numbers below where parents/guardian may be reached while child will be in care: Mother’s Cell No. * Mother’s Work No. Father’s Cell No. * Father’s Work No. Guardian’s Telephone No Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached: 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. Parent/Person 1 Parent/Person 2 Parent/Person 3 CHECK ALL THAT APPLY: 1. TRANSPORTATION: I hereby, transportation give do not give consent for my child to be transported and supervised by the operation’s employees: transport services for emergency care to and from home to and from school 2. FIELD TRIPS This center doesn’t go on field trips 3. WATER ACTIVITIES This center doesn’t have water activities 3. RECEIPT OF WRITTEN OPERATIONAL POLICIES RECEIPT OF WRITTEN OPERATIONAL POLICIES I acknowledge receipt of the facility’s operational policies including those for discipline and guidance. 5. I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE: meals Breakfast Lunch PM Snack 6. MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES: Mondays Mondays From To: Tuesdays Tuesdays From: To: Wednesdays Wednesdays From: To: Thursdays Thursdays From: To: Fridays Fridays From: Fridays To: 7. PHOTO RELEASE: I hereby, photo release give do not give - consent to release photos of my children. 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: Name of Emergency Medical Care Facility: Address: Address: Phone: Phone: I give consent for the facility to secure any and all necessary emergency medical care for my child. Signature – Parent or Legal Guardian * 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) of (800)-514-0383 (TTY). School Age Children: My Child attends the following school Name of School and Address School Ph. # CHECK ALL THAT APPLY: immunization record 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. My child has permission to: ride a bus and/or walk to and from school, be released to the care of his/her sibling(s) under 18 years old. Attach Immunization File IMMUNIZATION RECORD: I have provided the childcare operation with a copy of my child’s 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 represented when your child is admitted to the child-care operation or within one week of admission. Please check only one option: HEALTH-CARE PROFESSIONAL’S STATEMENT HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is able to take part in the day care program. Health Care Professional’s Signature Date Admission requirements A signed and dated copy of a health care professional’s statement is attached. 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. 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 professional’s signed statement and will submit it to the child-care operation. Name and address of health care professional: VISION (Required for Children over 4 years old) R 20/ L 20/ Vision Pass/Fail * Pass Fail Hearing (Required for Children over 4 years old) 100 HZ 200 HZ 400 HZ 100 HZ Right 200 HZ Right 400 HZ Right 100 HZ Left 200 HZ Left 400 HZ Left Hearing pass/Fail Pass Fail Signature – Parent or Legal Guardian Date HEALTH REQUIREMENTS Name of Child: * Date of Birth: * Age & Vaccination vaccination details Hepatitis B Rotavirus Diphteria, Tetanus, Pertussis Haemophilus influenza type b Pneumococcal Inactivated Poliovirus Influenza Measles, Mumps, Rubella Varicella Hepatitis A Meningococcal TB Test (if required) * Positive Negative Signature or stamp of a physician or public health personnel verifying immunization information above. Date * Signature * Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, complete the statement. My child had varicella disease (chickenpox) on or about and does not need varicella vaccine. Parent’s signature * Date * excluding my child from the immunization 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 Submit form to * Providence Campus Savannah Campus
