* = Required Information
List telephone numbers below where parents/guardian may be reached while child will be in care:
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 pa rent or a person designated by the parent/guardian after veri fication of ID.
CHECK ALL THAT APPLY:
1.   TRANSPORTATION
I hereby  give  do not give - consent for my child to be transported and supervisedby the operation's employees
for emergency care
on field trips
to and from home
to and from school
2.   FIELD TRIPS
I hereby  give  do not give - my consent for my child to participate in Field Trips
3.   WATER ACTIVITIES
I hereby  give  do not give - my consent for my child to participate in Water Activities.
sprinkler play
splashing/wading pools
swimming pools
water table play
4.   RECEIPT OF WRITTEN OPERATIONAL POLICIES
I acknowledged 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
 None
 Breakfast
 Am Snack
 Lunch
 PM Snack
 Supper
 Evening Snack
6. MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES
 Mondays
 Tuesdays
 Wednesdays
 Thursdays
 Fridays
 Saturdays
 Sundays
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:
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Child daycare operations are public accommodations under the Amer icans 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) or (800)-514-0383 (TTY).
SCHOOL AGE CHILDREN
  My child attends the following school:
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 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 able to take part in the day care program.
2.   A signed and dated copy of a health care professional's statement is attached.
3.   Medical diagnosis and treatment conflict with the tenets and practices of a recognized relig ious 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 prog ram. Within 12 months of admission, I will obtain a health care professional’s signed statement and will submit it to the child-care operation.
VISION
PASS FAIL
HEARING
1000 Hz
2000 Hz
4000 Hz
PASS FAIL
HEALTH REQUIREMENTS
Age →
Vaccine ↓
Birth 1 mos 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 19-23 Mos 2-3 Yrs 4-6 Yrs
Hepatitis B
Rotavirus
Diphtheria, Tetanus, Pertussis
Haemophilus influenzae type b
Pneumococccal
Inactivated Poliovirus
Influenza
Measles, Mumps, Rubella
Varicella
Hepatitis A
Meningococcal
Positive Negative
Signature or stamp of a physician or public health personnel verifying immunization information above.
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.
  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
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