Humble Daycare | Enrollment Form

Admission Form

D's Heart to Heart
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.
Operation's Name
Director's Name
Child's Full Name *
Child's Date of Birth *

Month Day Year
Date
Child Lives With *

Both parents Mom Dad Guardian
Child's Home Address *
Street address, City, State, Zip Code
Date of Admission *

Month Day Year
Date
Date of Withdrawal

Month Day Year
Date
Name of Parent or Guardian Completing Form *
Address of Parent of Guardian (if different from the child's)
Street address, City, State, Zip Code
List phone numbers below where parents or guardian may be reached while child is in care.
Parent 1 Phone No. *
Please enter a valid phone number.
Parent 2 Phone No.
Guardian's Phone No.
Custody Documents on file

Yes No
In case of an emergency, call *
Name of Emergency Contact *
Relationship *
Phone *
Address *
Street address, City, State, Zip Code
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 phone number for each Children will only be released to a parent or guardian or to a person designated by the parent or guardian after verification of ID.
Authorized person 1
Phone
Authorized person 2
Phone
Authorized person 3
Phone
Consent Information
Transportation
I give consent for my child to be transported and supervised by the operation's employees (Check all that apply) *

Emergency Care Field Trips To and From Home To and From School None
Field Trips *

I give consent for my child to participate in field trips. I do not give consent for my child to participate in field trips.
Comments
Water Activities
I give consent for my child to be transported and supervised by the operation's employees (Check all that apply).

Water table play Sprinkler play Splashing and wading pools Swimming pools Aquatic playgrounds
Is your child able to swim without assistance? *

Yes No
If no, what type of assistance is needed
Receipt of Written Operational Policies:
I acknowledge receipt of the facility's operational policies, including those for (Check all that apply). *

Discipline and guidance Suspension and expulsion Emergency plans Procedures for conducting health checks Safe sleep Procedures for parents to discuss concerns with the director Promotion of indoor and outdoor physical activity including criteria for extreme weather conditions Procedures for parents to participate in operation activities Procedures for release of children Illness and exclusion criteria Procedures for dispensing medications Immunization requirements for children Meals and food service practices Procedures to visit the center without securing prior approval Procedures for supporting inclusive services Procedures for parents to contact Child Care Licensing (CCL), DFPS, Child Abuse Hotline, and CCL website
Meals:
I understand that the following meals will be served to my child while in care (Check all that apply). *

None Breakfast Morning Snack Lunch Afternoon Snack Supper Evening Snack
Days and Time in Care:
My child is normally in care on the following days and times: *

A.M. P.M.

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Sundays
Child's Special Care Needs (check all that apply)

Environmental allergies Limitations or restrictions on child's activities Food intolerances Reasonable accommodations or modifications Existing illness Adaptive equipment (include instructions below) Previous serious illness Symptoms or indications of complications Injuries and hospitalizations (past 12 months) Medications prescribed for continuous long-term use Other
Explain any needs selected above
Does your child have diagnosed food allergies?

Yes No
Food Allergy Emergency Plan Submitted Date

Month Day Year
Date
Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit https:// www.ada.gov/resources/child-care-centers/. 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).
Signature- Parent or Legal Guardian *

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Date Signed *

Month Day Year
Date
School Age Children
My child attends the following school
School Area Code and Phone No.
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 or her sibling under 18 years old
Authorized pick up or drop off locations other than the child's address
Child's required immunizations, vision and hearing screening, and TB screening are current and on file at their school. *

Yes No
Authorization For Emergency Medical Attention
In the event I cannot be reached to arrange for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician
Address
Name of Emergency Care Facility
Name of Emergency Care Facility
Address
Phone No.
I give consent for the facility to secure any and all necessary emergency medical care for my child
Signature - Parent or Legal Guardian *

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Date Signed *

Month Day Year
Date
Requirements for Exclusion from Compliance
Select all that apply:

I have attached a signed and dated affidavit stating that I decline immunizations for reason of conscience, including religious belief, on the form described by Section 161.0041 Health and Safety Code submitted no later than the 90th day after the affidavit is notarized. I have attached a signed and dated affidavit stating that the vision or hearing screening conflicts with the tenets or practices of a church or religious denomination that I am an adherent or member of.
Vision Exam Results
Right Eye 20/
Left Eye 20/
Pass Fail
Signature

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Date Signed

Month Day Year
Date
Hearing Exam Results

1000 Hz 2000 Hz 4000 Hz

Right Ear

Left Ear
Right Ear

Pass Fail
Left Ear

Pass Fail
Signature

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Date

Month Day Year
Date
Additional 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. (Select only one option.)

Health Care Professional’s Statement: I have examined the above named child within the past year and find that he or she is able to take part in the day care program. 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 amember 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 12months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.
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_______ ] and does not need varicella vaccine.
Date Signed

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Date

Month Day Year
Date
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.

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

	Date Received
Hepatitis B (birth, first dose)
Hepatitis B (1-2 months, 2nd dose)
Hepatitis B (6-18 months 3rd dose)
Rotavirus (2 months, 1st dose)
Rotavirus (4 months, 2nd dose)
Rotavirus (6 months, 3rd dose)
Diphtheria, Tetanus, Pertussis (2 months, 1st dose)
Diphtheria, Tetanus, Pertussis (4 months, 2nd dose)
Diphtheria, Tetanus, Pertussis (6 months, 3rd dose)
Diphtheria, Tetanus, Pertussis (15-18 months, 4th dose)
Diphtheria, Tetanus, Pertussis (4-6 yrs, 5th dose)
Haemophilus Influenza Type B (2 months, 1st dose)
Haemophilus Influenza Type B (4 months, 2nd dose)
Haemophilus Influenza Type B (6 months, 3rd dose)
Haemophilus Influenza Type B (12-15 months, 4th dose)
Pneumococcal (2 months, 1st dose)
Pneumococcal (4 months, 2nd dose)
Pneumococcal (6 months, 3rd dose)
Pneumococcal (12-15 months, 4th dose)
Inactivated Poliovirus (2 months, 1st dose)
Inactivated Poliovirus (4 months, 2nd dose)
Inactivated Poliovirus (6-18 months, 3rd dose)
Inactivated Poliovirus (4-6 years, 4th dose)
Influenza (annually from 6 months)
Measles, Mumps, Rubella (12-15 months, 1st dose)
Measles, Mumps, Rubella (4-6 yrs old)
Varicella (12-15 months, 1st dose)
Varicella (4-6 yrs, 2nd dose)
Hepatitis A (12-23 months, 1st dose)
Hepatitis A (6-18 months after 1st dose)

TB Test (if required)

Positive Negative
Date of TB test

Month Day Year
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-practices-privacy#security
Child's Parent of Legal Guardian

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Date Signed

Month Day Year
Date
Should be Empty:

Admission Form

Consent Information

Authorization For Emergency Medical Attention

Requirements for Exclusion from Compliance

Vision Exam Results

Useful links

Contact

15026 Marine Rd, Humble, TX 77396

(281) 570-6895

Open 24 Hours Monday-Friday

dshearttoheart19@gmail.com

	A.M.	P.M.
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

	1000 Hz	2000 Hz	4000 Hz
Right Ear
Left Ear