1annualenrollmentform fillable

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