Enrollment Form — Divine Kids

Section 1 — General Information

Operation's Name

Child's Full Name *

Child's Date of Birth *

Child Lives With: *

Both parents Mom Dad Guardian

Child's Home Street Address, City, State and ZIP Code *

Date of Admission *

Date of Withdrawal

Parent or Guardian 1

Name of Parent or Guardian 1 *

Address of Parent or Guardian 1, if different from child's

Email Address *

Employer *

Parent or Guardian 2

Name of Parent or Guardian 2

Address of Parent or Guardian 2, if different from child's

Email Address

Employer

Phone Numbers Where Parents or Guardian May Be Reached While Child Is in Care

Parent 1 Area Code and Phone No. *

Parent 2 Area Code and Phone No.

Guardian's Area Code and Phone No.

Custody Documents on File?

Yes No

In Case of an Emergency, When the Parent or Guardian Cannot Be Reached, Call:

Name of Emergency Contact *

Relationship *

Area Code and Phone No. *

Street Address, City, State and ZIP Code

Authorized Persons to Pick the Child

I authorize the program to release my child to leave the program 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.

Name

Area Code and Phone No.

Name

Area Code and Phone No.

Name

Area Code and Phone No.

Section 2 — Consent Information

1. Transportation

I 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 school

2. 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

3. Water Activities

I give consent for my child to participate in the following water activities. Check all that apply.

Is your child a competent swimmer? *

Yes No

If no, your child is required to wear a life jacket while in or near a swimming pool.

Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming? *

Yes No

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.

4. Receipt of Written Operational Policies

I acknowledge receipt of the facility's operational policies, including those for the following. Check all that apply.

5. Meals

I understand the following meals will be served to my child while in care. Check all that apply.

6. Days and Times in Care *

My child is normally in care on the following days and times.

Day of Week	A.M.	P.M.	Day of Week	A.M.	P.M.
Monday			Friday
Tuesday			Saturday
Wednesday			Sunday
Thursday

7. Receipt of Parent's Rights *

8. Child's Special Care Needs

Check all that apply.

Other:

Explain any needs selected above:

Does your child have diagnosed food allergies?

Yes No

The Food Allergy Emergency Plan found on the Important Forms page must be filled and submitted before the first day of the child attending the program.

9. School-Age Children

My child attends the following school

School 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:

Section 3A — 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

Area Code and Phone No.

Street Address, City, State and ZIP Code

Name of Emergency Care Facility

Area Code and Phone No.

Street Address, City, State and ZIP Code

Parent or Legal Guardian *

Date

Section 3B — Child's Medical Insurance Information

The Center does not carry liability insurance; therefore, the child's medical insurance is required for medical emergencies when parents or an alternative contact cannot be reached, and it is necessary for taking the child to a medical facility.

Medical Insurance Card Attached: *

Yes No — I will submit when dropping my child off for the first time

Insurance Company Name

Policy / Member ID Number

Policy Holder Name

Insurance Contact Phone

Attach Insurance Card

Parent or Legal Guardian *

Date

Section 4 — Requirements for Exclusion from Compliance

I have attached a signed and dated affidavit stating that I decline immunizations by reason of conscience, including religious belief, on the form described by Health and Safety Code Section 161.0041 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.

Attach Signed Affidavit (if applicable)

Section 5 — Vision Exam Results

Right Eye 20/

Left Eye 20/

Result

Pass Fail

Printed Name

Date

Section 6 — Hearing Exam Results

Ear	1000 Hz	2000 Hz	4000 Hz	Pass or Fail
Right				Pass Fail
Left				Pass Fail

Printed Name

Date

Section 7 — Admission Requirement

If your child does not attend pre-kindergarten or school away from the program, one of the following must be presented when your child is admitted to the program or within one week of admission.

A signed and dated copy of a health care professional's statement is attached, which states that the healthcare professional has examined the above named child within the past year and finds the child is able to take part in the program. 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. My child has been examined within the past year by a health care professional and is able to participate in the program. Within 12 months of admission, I will obtain a health care professional's signed statement and submit it to the program.

Attach Supporting Statement / Affidavit

Parent or Legal Guardian *

Date

Section 8 — Vaccine Information

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

Vaccine	Vaccine Schedule	Date Child Received Vaccine
Hepatitis B	Birth (first dose)
	1 – 2 months (second dose)
	6 – 18 months (third dose)
Rotavirus	2 months (first dose)
	4 months (second dose)
	6 months (third dose)
Diphtheria, Tetanus, Pertussis	2 months (first dose)
	4 months (second dose)
	6 months (third dose)
	15 – 18 months (fourth dose)
	4 – 6 years (fifth dose)
Haemophilus Influenza Type B	2 months (first dose)
	4 months (second dose)
	6 months (third dose)
	12 – 15 months (fourth dose)
Pneumococcal	2 months (first dose)
	4 months (second dose)
	6 months (third dose)
	12 – 15 months (fourth dose)
Inactivated Poliovirus	2 months (first dose)
	4 months (second dose)
	6 – 18 months (third dose)
	4 – 6 years (fourth dose)
Influenza	Yearly, starting at 6 months. Two doses given at least four weeks apart are recommended for children who are getting the vaccine for the first time and for some other children in this age group.
Measles, Mumps, Rubella	12 – 15 months (first dose)
Measles, Mumps, Rubella	4 – 6 years (second dose)
Varicella (Chickenpox)	12 – 15 months (first dose)
Varicella (Chickenpox)	4 – 6 years (second dose)
Hepatitis A	12 – 23 months (first dose)
Hepatitis A	The second dose should be given six to 18 months after the first dose.

Section 9 — Vaccination Records

Please attach a copy of vaccination records from your public health personnel's office.

Select one: *

I am attaching a copy of my child's vaccination records below. Records will be provided when my child is dropped off at the program for the first time.

Attach Vaccination Records (if attaching now)

Section 10 — Varicella for Chickenpox

Varicella, the vaccine for chickenpox, is not required if your child has had chickenpox disease. If your child has had chickenpox, complete the statement below.

My child had varicella disease, chickenpox, on or about [date] and does not need varicella vaccine.

Printed Name

Date

Section 11 — Additional Information About Immunizations

For more information about immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm.

Section 12 — Gang Free Zone

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

Photo & Media Consent

Please select one: *

I consent I do not consent

Section 14 — Signatures

Full Name (Electronic Signature) *

Date Signed *

Next page is payment information.

Child Enrollment Form

Section 1 — General Information

Parent or Guardian 1

Parent or Guardian 2

Phone Numbers Where Parents or Guardian May Be Reached While Child Is in Care

In Case of an Emergency, When the Parent or Guardian Cannot Be Reached, Call:

Authorized Persons to Pick the Child

Section 2 — Consent Information

1. Transportation

2. Field Trips *

3. Water Activities

4. Receipt of Written Operational Policies

5. Meals

6. Days and Times in Care *

7. Receipt of Parent's Rights *

8. Child's Special Care Needs

9. School-Age Children

Section 3A — Authorization For Emergency Medical Attention

Section 3B — Child's Medical Insurance Information

Section 4 — Requirements for Exclusion from Compliance

Section 5 — Vision Exam Results

Section 6 — Hearing Exam Results

Section 7 — Admission Requirement

Section 8 — Vaccine Information

Section 9 — Vaccination Records

Section 10 — Varicella for Chickenpox

Section 11 — Additional Information About Immunizations

Section 12 — Gang Free Zone

Photo & Media Consent

Section 14 — Signatures