Admission Information

Purpose: Use this form to collect all the required information about a child enrolling in daycare.

Directions: The daycare 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 daycare provider before the child’s first day of enrollment. The daycare provider keeps the form on file at the childcare facility.

Required fields are indicated with a “*“.

Note: To upload any file or reports or records you have to be first enrolled your child in the Emerson Academy. After that, one unique admission ID will get generated and emailed. You have to use that ID to upload files or to fill up the rest of the forms.

General information

Operation’s Name: Emerson Academy

Director’s Name: Sarah Johnson and Crystal Oliver

Child’s basic information:

Child’s First Name: *

Child’s Middle Name:

Child’s Last Name:*

Child’s Date of Birth:(Please enter a date in mm/dd/yyyy format only)*

Child’s Home Address:*

Child Lives With:

Date of Admission:(Please enter a date in mm/dd/yyyy format only)

Date of Withdrawal:(Please enter a date in mm/dd/yyyy format only)

Parent or Guardian’s details:

Name of Parent or Guardian Completing Form:

Address of Parent or Guardian (if different from the child’s):

Email address:*

List telephone numbers below where parents/guardian may be reached while child is in care.

Parent 1 Telephone Number:*

Parent 2 Telephone Number:*

Guardian’s Telephone Number:

Custody Documents on File:

YesNo

The name, address, and phone number of the responsible individual to call in case of an emergency if parents/guardian cannot be reached to filled in the Emergency Contact form ,(opens in a new window).

Children will only be released to a parent or guardian or a person designated by the parent/guardian after verification of ID. Please list name and telephone number for each in the Child Release policy form (opens in a new window).

Consent information

Check all that apply:

Transportation:

I give consent for my child to be transported and supervised by the operation’s employees:

for emergency care

on field trips

to and from home

to and from school

Field trips:

I give consent for my child to be transported and supervised by the operation’s employees:

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 participate in the following water activities:

water table play

sprinkler play

splashing/wading pools

swimming pools

aquatic playgrounds

Receipt of written operational policies:

I acknowledge receipt of the facility’s operational policies, including those for:

Discipline and guidance

Procedures for release of children

Suspension and expulsion

Illness and exclusion criteria

Emergency plans

Procedures for dispensing medications

Procedures for conducting health checks

Immunization requirements for children

Safe sleep

Meals and food service practices

Procedures for parents to discuss concerns with the director

Procedures to visit the center without securing prior approval

Procedures for parents to participate in operation activities

Procedures for parents to contact Child Care Licensing, DFPS, Child Abuse Hotline, and DFPS website

Meals:

I understand that the following meals will be served to my child while in care:

None

Breakfast

Morning snack

Lunch

Afternoon snack

Supper

Evening snack

Days and times in care:

My child is normally in care on the following days and times:
Day of the Week	AM	PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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:

Name of Physician:

Physician Address:

Physician Phone Number:

Name of Emergency Care Facility:

Emergency care facility Address:

Emergency care facility Phone Number:

I give consent for the facility to secure any and all necessary emergency medical care for my child.

Medical statement and reports

List of documents which are necessary for the admission in the day care facility for various programs.

Healthcare professional’s signed and dated statement if your child does not attend pre-kindergarten or school away from the childcare operation.
Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which you adhere to or if you are a member of, then please upload signed and a dated affidavit stating the same.
Any special needs that your child may have such as environmental allergies, food intolerances, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of.
The action plan for such occurrences provided by the respective person.
Immunization details, hearing and vision screening reports.
If you are declining 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. Please upload the signed and dated scanned copy of affidavit stating the same.
If you adhere to practices of a church or religious denomination or if you are a member of in which the vision or hearing screening conflicts with the tenets or practices, then please upload a signed and dated affidavit stating the same.

All these listed documents can be uploaded on the Health statement file upload page ,(opens in a new window)

For additional information regarding immunizations, visit the website Texas Department of State Health Services opens in a new window.

Under the Texas Penal Code, any area within 1,000 feet of a childcare centre is a gang-free zone, where criminal offences related to organized criminal activity are subject to harsher penalties.

DFPS values your privacy. For more information, read our Privacy and Security Policy ,(opens in a new window). online.

Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practising discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).