Registration

First Name *

Last Name *

Date of Birth *

Place of Birth(City & State) *

Parent's Names *

Address *

City *

Zip *0 / 5

Home Phone *0 / 10

Mother's Work Phone0 / 10

Father's Work Phone *

Mobile Phone *

Email *

With Whom Does the Child Live *

Both ParentsMotherFatherOther

If other please specify Relationship

Name *

Phone *

Address *

Guarantor (Person Responsible For Registration And Fees) *

Mother's Employer *

Father's Employer

List who else is authorized to pick your child from the Academy - (will have to show their picture ID, so please provide their Driver License number). include spouse if authorized t0 pick when the child does not live with both parents.

Name Phone No. & Relationship *

PLEASE PROVIDE IMMUNIZATION RECORDS. IF THE CHILD IS 4 YEARS OR OLDER WE ALSO REQUIRE HEARING AND VISION TEST RESULT REPORTS.

Transportation: I hereby give or do not give consent for my child to be transported by facility's staff on field trips or to the library or other nearby extra-curricular activities or to and from school *

GiveDo Not GiveField TripsExtra Curricular ActivitiesFrom School

Water Activities: I hereby give or do not give my consent for my child to participate in water sports provided by the facility: *

GiveDo Not GiveSplashing or Wading poolsSwimming Pools

School Age Children: My child attends the following school and his/her immunization records are on file at that school and immunization and TB test are current. *

Please consider my child for admission. I understand there is an annual registration fee. Please read the Fee Schedule, Terms, and Conditions.
I have read and agree to the Fee Schedule & T/C’s

Date *

Driver License No *

Emergency Authorization

First Name *

Child's Last Name *

Parent's Names *

Street Address *

Guardians Name (If Different From Parents)

Home Phone Number0 / 10

Mother's Work Number0 / 10

Mobile Phone

Father's Work Number

Mobile Phone

If a parent (guardian) cannot be reached in case of emergency, the Academy permission to contracted the following persons in the order listed:

Name

Phone

Street Address

Name

Phone

Street Address

Emergency contacts must be reliable persons, who could make themselves available immediately and who have transportation during your child’s attendance hours. They must be people whom your child knows well, and who can and are ready to pick your child from school and provide care.
In case the services of a physician are required before either a parent (guardian) or one of the emergency contacts can be reached, the following doctor may give my child any treatment necessary. I (the parent or guardian) assume responsibility for payment of such professional service.

Doctor *

Phone *

Street Address *

Is Your Child Allergic To Any Medication

Please Specify

Is Your Child Allergic To Any Medication

Immunization Record

Name of Child

Date of Birth

TB TEST (if required)

PositiveNegative

Date

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 ___________ 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

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:

HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is to take part in the day care programA signed and dated copy of a health care professional’s statement is at attachedMedical 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 day care program. 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

L 20/

R 20/

PassFail

HEARING:

1000HZ (R)

1000HZ (L)

2000HZ (R)

2000HZ (L)

4000HZ (R)

4000HZ (L)

Name and Address of health care professional

Name

Address

PassFail

Registration

With Whom Does the Child Live *

Transportation: I hereby give or do not give consent for my child to be transported by facility's staff on field trips or to the library or other nearby extra-curricular activities or to and from school *

Water Activities: I hereby give or do not give my consent for my child to participate in water sports provided by the facility: *

Emergency Authorization

Immunization Record

TB TEST (if required)

Schedule a Tour