Combined Enrollment Packet
Combined Enrollment Packet
Combined Enrollment Packet
be filled out completely in this enrollment packet. Signature is required where there is an X. Current up to date shot records must be turned in on the first day your child attends. Immunization records will be checked before your child can start. If your child is behind on any immunizations, they will not be allowed to stay; the immunizations will need to be updated for the child to begin attending. If you are having shot records faxed to our school, we will have to receive them in advance of your childs enrollment date. No child will be allowed to attend Oakdale without current immunization records in their file. Health statements are required to be signed by a doctor and turned in to Oakdale within 1 week of your childs first day of attendance. Picture I.D. is required to enroll your child at Oakdale. Accepted forms of I.D.: Texas Drivers License or State of Texas I.D. If your child is being enrolled in a 3 year old Kindergarten class, your child must be in uniform to stay. Please refer to Oakdale Private School Policies and Procedures. Thank you!
Child's Name: ______________________________________ Date of Birth: ______________________________________ Enrollment Date: ___________________________________ Withdrawal Date: ___________________________________ Days In Care: (Circle Days) Sun Mon Tue Wed Thur Fri Sat
___________________________________
Parent Signature
Date
Non-Discrimination Policy In accordance with federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication and Compliance, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call 202-260-1026, 866-632-9992 (toll free) or 202-401-0216 (TDD). USDA is an equal opportunity provider and employer.
CHECK IF NO INCOME
Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and case number for the person who receives benefits. If no one receives these benefits, skip to part 3.
NAME:_________________________________________________ CASE NUMBER: _________________________________
Part 3. (Applies only to parents/guardians with children enrolled in a day care home) If any member of your household receives benefits listed on the enclosed List of Eligible Federal/State Funded Programs (H1660), provide the name of the program and case number: NAME: ___________________________________ CASE NUMBER: ____________ Check here if no case number Part 4. Total Household Gross IncomeYou must tell us how much and how often
B. Gross income and how often it was received A. Name (List only household members with income)
(Example)
1. Earnings from work 2. Welfare, child support, before deductions alimony $200/weekly_____ $150/twice a month_
Jane Smith
$200/bi-monthly
$ $ $ $ $
/ / / / /
$ $ $ $ $
/ / / / /
$ $ $ $ $
/ / / / /
$ $ $ $ $
/ / / / /
Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign) An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the I do not have a Social Security Number box. (See Privacy Act Statement on the next page.) I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Sign here: _________________________________________ Date: ____________________________ Address: ___________________________________________ City:_______________________________________________ Phone Number: _______________________ State: ________________ Zip Code: ________________ Print name: ________________________________________
Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve the participant for free or reduced price meals. You must include the last four digits of the Social Security Number of the adult household member who signs the application. The Social Security Number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for the participant or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a Social Security Number. We will use your information to determine if the participant is eligible for free or reduced price meals, and for administration and enforcement of the Program. Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and em ployer.
July 2011
ENROLLMENT FORM
Facility Name: OAKDALE PRIVATE SCHOOL Child's Name: Child's Address: Date of Admission: Mother's Name: Father's Name: Drop Date: DL#: DL#: Attendance Hours: Mother's Cell #: Father's Cell #: Operation ID: 1222407 Director Name: Tammy Wildman Date of Birth: Child's Home Telephone No.: Child's Age: Mother's Employer: Father's Employer: Child Lives With: Mother's Wk #/Dept./Ext: Father's Wk #/Dept./Ext:
Circle Meals your child will be served daily: Breakfast AM Snack Lunch PM Snack Supper Evening Snack Name to call in Emergency (If parents cannot be reached):
Relationship to Child :
Telephone No:
I hereby authorize the facility to allow my child to leave the facility ONLY with the following persons. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID, and to anyone listed on this form. Name: Name: Telephone No: Telephone No:
List any special problems that your child may have; such as allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other information which staff should be aware of: (Please provide documentation from your child's doctor)
I give consent for this facility to secure any and all necessary emergency medical care for my child. Please check all that apply: TRANSPORTATION:
I hereby give / do not give
X__________________________________________________
Signature - Parent or Legal Guardian Date
WATER ACTIVITIES:
I hereby
FIELD TRIPS:
I hereby
SCHOOL AGE CHILDREN: My child attends the following school and his/her immunization records are on file at the school and all immunizations and the tuberculosis test are current. Vision and Hearing screening records are also on file. __________________________________________________________ Name of School and the Address ____________________________________________ School Telephone No.
Please alert the front desk at any time to request to speak with the center director with any concerns about the center policies. Parents are allowed to visit and observe their child at any time without securing approval. If parents would like to participate in operational activities please request to see the director. If you would like to review the minimum standards or the most recent licensing inspection report, please notify the front desk to speak with the director. For further assistance you may call local TDPRS office at: 713-940-5102 or www.tdprs.state.tx.us Abuse Hotline: 1-800-252-5400 By signing this form, I acknowledge receipt of the facility's operational policies including those for discipline and guidance.
HEALTH REQUIREMENTS
Name of Child: IMMUNIZATION Hepatitis B (Hep B) Rotavirus (RV) Diphtheria, tetanus, pertussis (DTaP) Haemophilus influenza type b (Hib) Pneumococcal (PCV) Inactivated poliovirus (IPV) Influenza Measles, mumps, rubella (MMR) Varicella (VAR) Hepatitis A (Hep A) Meningococcal (MCV4) TB Test (if required) ___ Positive ___ Negative Date: Date / Dose 1 Date / Dose 2 Date / Dose 3 Date of Birth: Date / Dose 4 Date / Booster
__________________________________________________________________________________________________________ __________________________________________________ Signature or Stamp of Physician or Public Health Personnel verifying immunization information above 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 (date) ________________ and does not need varicella vaccine. ________________________________________________________ Parent's Signature ______________________________________________________ Date
___ 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: 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. ___________________________________________________________________________ Health Care Professional's Signature 2. ___ A signed and dated copy of a health care professional's statement is attached. ___________________________________ Date
3. ___ 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. 4. ___ 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. Name and address of health care professional:
X__________________________________________________________________________
Signature - Parent or Legal Guardian VISION R 20/ _______________ ___________________________________________________________________________ Signature HEARING R L 1000 Hz 2000 Hz 4000 Hz
L 20/ ________________
___________________________________ Date
X__________________________________________________________________________
Signature - Parent or Legal Guardian
___________________________________ Date
Oakdale Private School 17100 Butte Creek Rd. Houston, Texas 77090 Tel. 281-444-4547 Fax 281-444-6139 NONDISCRIMINATION STATEMENT
This child care vender is in compliance with TITLE VI of the CIVIL RIGHTS ACT of 1964 (Public Law 88-352); the AGE DISCRIMINATION ACT of 1975 (Public Law 94-135), and the REHABILITATION ACT of 1973 (Public Law 93-112). This is an Equal Opportunity Program. No person, in the United States shall, on the grounds of race, color, national origin, age, sex, disability, political beliefs or religion, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination. If you believe you have been discriminated against because of race, color, or religion, you may lodge a complaint with this Day Care Center's Owner/Director, Tammy R. Wildman, or with the Neighborhood Centers, Inc., and/or write immediately to the Civil Rights Department, Texas Department of Human Services, P.O. Box 14030, Austin, Texas 78714-9030, Telephone 512-450-3630. I have received and read this establishment's nondiscrimination policy statement and complaint procedures.
X___________________________________________________
Signature
________________________ Date
Oakdale Private School 17100 Butte Creek Rd Houston, Texas 77090 Tel. 281-444-4547 Fax 281-444-6139 FIRST AID PERMISSION AND EMERGENCY INFORMATION Child's Name: _____________________________ Age: _______
I give Oakdale Private School permission to administer First Aid to my child: * In case of emergency, the school staff promptly contacts the parent(s). * If neither parent, nor the emergency phone number can be reached, and in case of a surgical emergency, I hereby give permission to the physician selected by Oakdale Private School's Director to hospitalize and secure proper treatment for my child as named above.
X___________________________________________________
Signature of Parent or Guardian
_______________ Date
Home Telephone #: _______________________________________________ Work Telephone #: ___________________________ Dept./Ext.: ____________ Family Physician's Name: ___________________________________________ Office Telephone #: _______________________________________________
IN CASE OF EMERGENCY WHEN NEITHER PARENT CAN BE REACHED, PLEASE CONTACT:
CONTACT LOG
DATE TIME PERSON CALLED CONTACTED REASON RESPONSE STAFF INITIALS