Texas Dept of Family and Protective Services
Form 2935 January 2006 / Pg 1 of 2
ADMISSION INFORMATION
Operation Name:
Director’s Name:
Brighton Center CDC
Irma Bustos Director, Meredith McGhee Assistant Director & Martha Garza Assistant Director
Child’s Name
Date of Birth
Parent’s Name & Telephone Number to call 1st in case of an emergency:
Child’s Home Address
Child’s Home Telephone Number:
Date of Admission
Date of Withdrawal
Parent’s or Guardian’s Name
Address (if different from child’s address)
Mother’s Social Security Number:
Father’s Social Security Number:
List telephone numbers where Mother’s Telephone No. Father’s Telephone No. parents/guardian may be reached while child will be in care: Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached:
Guardian’s Telephone No.
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.
do not give consent for my child to be transported and supervised by the operation’s employees. for emergency care
CHECK ALL THAT APPLY: 1. TRANSPORTATION:
I hereby
give
2.
I hereby
give
WATER ACTIVITIES:
sprinkler play 3. MEALS MY CHILD WILL AT THE CENTER. 4.
EAT
Breakfast
do not give my consent for my child to participate in Water Activities: water table play Lunch
Snack
RECEIPT OF WRITTEN OPERATIONAL POLICIES: I acknowledge receipt of the facility’s operational policies including those for discipline and guidance.
5. MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES:
6. Race / Ethnic Category (Check One):
Preferred language (Check One):
Mondays
From:
To:
HISPANIC or LATINO
ENGLISH
Tuesdays
From:
To:
WHITE
SPANISH
Wednesdays
From:
To:
BLACK or AFRICAN AMERICAN
OTHER: Specify
Thursdays
From:
To:
NATIVE HAWAIIAN or PACIFIC ISLANDER
Fridays
From:
To:
ASIAN
_________________
AMERICAN INDIAN or ALASKA NATIVE _____________________________________________ Signature – Parent or Legal Guardian and Date
OTHER: Specify __________________ ____________________________________________ Signature – Parent or Legal Guardian and Date
EMERGENCY MEDICAL AUTHORIZATION: In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize Bright Beginnings staff to take my child to: Licensed Physician:
Hospital/Clinic:
Address:
Address:
Office Phone:
Phone:
I give consent for this facility to secure any and all necessary emergency medical care for my child. Parent/Legal Guardian Signature and Date: CONSENT FOR RELEASE OF INFORMATION: (Photo and News Release) I hereby authorize Brighton and Bright Beginnings Child Development Center to use pictures and information for: Check All That Apply:
Classroom use only _________________________________________________________________ Signature - Parent or Legal Guardian
Brighton Organization Marketing _________________ Date
HEALTH REQUIREMENTS:
I have attached a copy of my child’s shot record.
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. Name of Child:
IMMUNIZATIONS
Date of Birth: Date / dose 1
Date / dose 2
Date / dose 3
Date / dose 4
Date / booster
Hepatitis B DTP / DTaP / DT Hib POLIO IPV or OPV MMR Varicella (see below) Pneumococcal Conjugate Vaccine Hepatitis A TB TEST (if required)
Positive
Signature or stamp of a physician or public health personnel verifying immunization information above.
Negative
Date:
Health Care Professional’s Signature
Date
For additional information regarding immunizations contact the Department of State Health Services at http://www.dshs.state.tx.us/immunize/school_info.htm
________________________________________________________________ Signature - Parent or Legal Guardian
_________________ Date
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: 1. HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is physically able to take part in the day care program. ___________________________________________________________ Health Care Professional's Signature
_________________ Date
Name and address of health care professional: 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. 4. 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 profes sional’s signed statement and will submit it to the child-care operation. 5. Permission to administer Children’s Tylenol should my child reach a high temperature exceeding over 101 degrees, before arrival for pick-up. I have attached a permission form from my physician with the amount to give my child. 2. 3.
6. Copy of Health Insurance Card or Insurance Carrier information:
_________________________________________________________________ Signature - Parent or Legal Guardian
_________________ Date
I verify all information on this form to be true and correct. Signature – Parent or Legal Guardian
Date