Enrollment Form "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.Signature RevisionOperation Name*Select DaycareLittle Christian Academy, Inc.ABC Day CareBob's Day CareStream Bend DaycareShallow Brook DaycareFalling Leaf DaycareTwisting Pine DaycareElm Street DaycareFirst Ranked DaycareFirst Choice DaycareRolling Hills DaycareTall Pines DaycareApple Tree DaycareOrange Tree DaycareRound Rock DaycareWPMGTEST T6 FacilityNumber StatusReason InactiveSelect BelowFirst ChoiceSecond ChoiceThird ChoicePersonal InformationChild's Full Name First Last NicknameDate of Admission Photo of Child Drop files here or Select files Max. file size: 64 MB, Max. files: 1. Date of Birth AgeGradePreKindergartenFirstSecondThirdSex Male Female Child’s Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent or Guardian InformationAdd every parent or guardian responsible for this child. Legal Name Relationship to Child Phone Parent Email Actions Edit Delete There are no Parent or Guardians. Add Parent or Guardian Maximum number of parent or guardians reached. Parent Name First Last Parent Email Child Lives With Both Parents Mom Dad Guardian Are there any custody arrangements or court orders that affect who may pick up your child or make decisions about your child’s care?*If Yes, our staff will follow up with you about any required documentation. You do not need to upload court papers to submit this application. Yes No Consent InformationTransportationI give consent for my child to be transported and supervised by the operation's employees. Check all that apply. For emergency care On field trips To and from home To and from school 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. Field Trip CommentsWater ActivitiesI give consent for my child to participate in the following water activities. Check all that apply. Water table play Sprinkler play Wading pools Swimming pools Aquatic playgrounds Is your child a competent swimmer? Yes No Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming?If yes, your child is required to wear a life jacket while in or near a swimming pool.Note: A competent swimmer can enter and exit a pool safely on their own, tread water or float on their back for one minute, and swim 25 yards with no assistance. Yes No Receipt of Written Operational PoliciesI acknowledge receipt of the facility's operational policies, including those for the following. Discipline and guidance Suspension and expulsion Emergency plans Procedures for conducting health checks Safe sleep Procedures for parents to discuss concerns with the director Procedures for parents to participate in activities Promotion of indoor and outdoor physical activity including criteria for extreme weather conditions 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 Regulation (CCR), DFPS, Child Abuse Hotline and CCR website Select AllMealsI understand 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 Times in CareMy child is normally in care on the following days and times.Monday AM Hours : Minutes AM PM AM/PM Monday PM Hours : Minutes AM PM AM/PM Tues AM Hours : Minutes AM PM AM/PM Tuesday PM Hours : Minutes AM PM AM/PM Wednesday AM Hours : Minutes AM PM AM/PM Wednesday PM Hours : Minutes AM PM AM/PM Thursday AM Hours : Minutes AM PM AM/PM Thursday PM Hours : Minutes AM PM AM/PM Friday AM Hours : Minutes AM PM AM/PM Friday PM Hours : Minutes AM PM AM/PM Saturday AM Hours : Minutes AM PM AM/PM Saturday PM Hours : Minutes AM PM AM/PM Sunday AM Hours : Minutes AM PM AM/PM Sunday PM Hours : Minutes AM PM AM/PM Receipt of Parent’s RightsI acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility.Special Care NeedsCheck all that apply. Explain any selected Special Care needs below. Environmental allergies Limitations or restrictions on child’s activities Food intolerances Reasonable accommodations or modifications Existing illness Adaptive equipment Previous serious illness Symptoms or indications of complications Injuries and hospitalizations in past 12 months Continuous long-term medications Other Other Special Care NeedsExplain any needs selected above.Does your child have diagnosed food allergies? Yes No Food Allergy Emergency Plan Submitted Date Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit 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).School Age ChildrenDoes your child attend pre-kindergarten or school away from this child care operation?Select Yes when your child attends pre-kindergarten or school away from this child care operation. Yes No My child attends the following schoolSchool Area Code and Phone No.My child has permission to walk to or from school or home ride a bus be released to the care of their sibling younger than 18 years old Authorized pick up or drop off locations other than the child’s address.Child's required immunizations, vision and hearing screening are current and on file at their school. Yes Emergency Contact(s) Legal Name Relationship to Child Phone Actions Edit Delete There are no Emergency Contacts. Add Emergency Contact Maximum number of emergency contacts reached. Medical InfomationCommon Childhood Medical IssuesConstipationConvulsionsDiarrheaFainting SpellsFrequent ColdsFrequent Ear InfectionsFrequent Sore ThroatsLiceRingwormSkin RashSoilingStomach UpsetsUrinary ProblemWormsOtherCommon Childhood IllnessesAsthmaBronchitisChicken PoxDiabetesHeart DiseaseHepatitisImpetigoMeaslesMumpsGerman MeaslesPolioScarlet FeverTuberculosisWhooping CoughOtherOther Medical IssuesOther IllnessesList of Medications the Child Takes(One per line. Click the "plus sign" to add a line) Add RemoveVaccine HistoryChild's Physician NameEnter the physician the child may be taken to for emergency medical care.Physician PhonePhysician Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Care Facility NameEnter the emergency care facility the child may be taken to if emergency medical care is needed.Emergency Care Facility PhoneEmergency Care Facility Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Admission Health RequirementWhen the child does not attend pre-kindergarten or school away from the operation, select the admission-health option that applies. Signed professional statement attached Religious medical affidavit attached Parent statement; professional statement to follow Vaccine Schedule is Attached Yes Vaccines*Upload Documents Drop files here or Select files Max. file size: 64 MB. Vaccines Child's Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Chickenpox (Varicella) HistorySelect how chickenpox (varicella) history will be documented for this enrollment. No documented history used Parent statement on this form Qualified external statement attached Approximate Chickenpox DateEnter the approximate date your child had chickenpox when the parent-statement option is selected. Health Insurance DetailsAuthorized Pickup ListAuthorized Contact Legal Name Relationship to Child Actions Edit Delete There are no Authorized Contacts. Add Authorized Contact Maximum number of authorized contacts reached. Developmental and Care InformationDetails about the child’s routines, likes/dislikes, and any special needsLanguages spoken at home Select Below English Spanish Other Legal Documentation (if applicable)Custody arrangements or court orders concerning the child This information allows daycares to provide tailored care, ensure the child’s safety, and handle emergencies efficiently.Upload Files Row ID Document Type Notes File Actions Edit Delete There are no Files. Add File Maximum number of files reached. Misc CommentsAdmission Dates Admission Dates Parent Email Parent Email Discipline Form Discipline Form Emergency Plan Emergency Plan Vaccines Vaccines
