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Admission Information

Use this form to collect all required information about a child enrolling in day care.

Directions: The day care 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 day care provider before the child's first day of enrollment. The day care provider keeps the form on file at the child care facility.

General Information

Operation's Name:(Required)

Director's Name:(Required)

Child's Full Name:(Required)

Child's Date of Birth:(Required)

Child Lives With?(Required)

Both parents

Mom

Dad

Guardian

Child's Home Address:(Required)

Date of Admission:(Required)

Date of Withdrawal:(Required)

Name of Parent or Guardian Completing Form:(Required)

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

List phone numbers below where parents or guardian may be reached while child is in care.

Parent 1 Phone No.:(Required)

Parent 2 Phone No.:(Required)

Guardian's Phone No.:(Required)

Custody Documents on File?(Required)

Yes

In case of an emergency, call:

Name of Emergency Contact:(Required)

Relationship:(Required)

Area Code and Phone No.:(Required)

Address:(Required)

I authorize the child care operation to release my child to leave the child care operation 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:(Required)

Area Code and Phone No.:(Required)

Name:(Required)

Area Code and Phone No.:(Required)

Name:(Required)

Area Code and Phone No.:(Required)

Consent Information

1. Transportation:

I give consent for my child to be transported and supervised by the operation's employees (Check all that apply).(Required)

for emergency care

on field trips

to and from home

to and from school

2. Field Trips:(Required)

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:(Required)

3. Water Activities:

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

water table play

sprinkler play

splashing or wading pools

swimming pools

aquatic playgrounds

Is your child able to swim without assistance:(Required)

Yes

If no, what type of assistance is needed:(Required)

4. Receipt of Written Operational Policies:

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

5. Meals:

I understand that the following meals will be served to my child while in care (Check all that apply):(Required)

None

Breakfast

Morning snack

Lunch

Afternoon snack

Supper

Evening snack

6. Days and Times in Care:

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

Day of the Week

Monday (A.M.)(Required)

Monday (P.M.)(Required)

Tuesday (A.M.)(Required)

Tuesday (P.M.)(Required)

Wednesday (A.M.)(Required)

Wednesday (P.M.)(Required)

Thursday (A.M.)(Required)

Thursday (P.M.)(Required)

Friday (A.M.)(Required)

Friday (P.M.)(Required)

Saturday (A.M.)(Required)

Saturday (P.M.)(Required)

Sunday (A.M.)(Required)

Sunday (P.M.)(Required)

Child's Special Care Needs (check all that apply)(Required)

Other:(Required)

Explain any needs selected above:(Required)

Does your child have diagnosed food allergies?(Required)

Yes

Food Allergy Emergency Plan Submitted Date:(Required)

Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit https:// www.ada.gov/resources/child-care-centers/. If you believe that such an operation may be practicing discrimination in violation of Title Ill, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).

Signature - Parent or Legal Guardian(Required)

Date(Required)

School Age Children

My child attends the following school:(Required)

School Area Code and Phone No.:(Required)

My child has permission to (check all that apply):(Required)

walk to or from school or home

ride a bus

be released to the care of his or her sibling under 18 years old

Authorized pick up or drop off locations other than the child's address:(Required)

Child's required immunizations, vision and hearing screening, and TB screening are current and on file at their school.(Required)

Child's required immunizations, vision and hearing screening, and TB screening are current and on file at their school.

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(Required)

Address(Required)

Phone No.(Required)

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

Signature - Parent or Legal Guardian(Required)

Date Signed(Required)

Requirements for Exclusion from Compliance

Requirements for Exclusion from Compliance(Required)

I have attached a signed and dated affidavit stating that I decline 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.

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.

Vision Exam Results

Right Eye 20/(Required)

Left Eye 20/(Required)

Vision Exam Results(Required)

Pass

Fail

Signature(Required)

Date Signed(Required)

Hearing Exam Results

Ear

Right(Required)

1000 Hz

Right(Required)

2000 Hz

Right(Required)

4000 Hz

Pass or Fail(Required)

Pass

Fail

Right

Left(Required)

1000 Hz

Left(Required)

2000 Hz

Left(Required)

4000 Hz

Pass or Fail(Required)

Pass

Fail

Left

Signature(Required)

Date Signed(Required)

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. (Select only one option.)

Admission Requirement(Required)

Health Care Professional's Statement: I have examined the above named child within the past year and find that he or she is able to take part in the day care program.

A signed and dated copy of a health care professional's statement is attached.

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 day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.

Signature - Health Care Professional

Date Signed

Signature - Parent or Legal Guardian(Required)

Date Signed(Required)

Infant Sleep Exception/Health Care Professional Recommendation

When a health care professional determines that it is medically necessary for an infant to sleep in an alternative position (other than sleeping on the infant's back), sleep in a restrictive device (such as a bouncer seat or swing), or needs to be swaddled to sleep, use this form to ensure that a licensed child care center, licensed child care home, or registered child care home that cares for the infant meets the minimum standards required by Texas Human Resources Code §42.042(e)(8)(A) and (B). The standards for these operations require the operation to:

follow the directions of an infant's health care professional to provide specialized medical assistance to the infant (746.3815 and 747.3615); and
maintain, while active, this form and any other directions from the health care professional that the parent provides to the operation [See §746.603(a)(10) or §747.603(a)(9)]. Keep the exception form in the infant's classroom, so that a caregiver may refer to the health care professional's instructions.

Directions: This exception will not be effective until all sections and signatures are complete. Once completed, the exception is acceptable for use by the child care operation.

Infant's Information

Infant's Name(Required)

Date of Birth(Required)

Infant's Age(Required)

Parent/Guardian's Name(Required)

Address(Required)

Home Phone(Required)

Work Phone(Required)

Fax(Required)

Email(Required)

The infant's health care professional must complete the following section.

Health Care Professional Information

Name of Infant's Health Care Professional(Required)

Name of Practice(Required)

Address(Required)

Fax number(Required)

Work Phone(Required)

Home Phone(Required)

Email(Required)

The Texas child care minimum standards (§§746.2426, 746.2427 and 746.2428 for child care centers or 8§747.2326, 747.2327 and 747.2328 for licensed or registered child care homes) require child care operations to place all infants on their backs to sleep in a crib and to ensure that infants do not sleep in restrictive devices and are not laid down to sleep swaddled. But, based on the advice of the infant's health care professional, when medically necessary, the center may be authorized to use an alternative sleep position, restrictive device, or swaddle for the infant due to medical reasons.

The above named infant has the following medical condition that necessitates an alternative sleep position, allow for sleep in a restrictive device, or requires swaddling for sleeping:(Required)

Health Care Professional Information

Please describe the appropriate sleep position/restrictive device/swaddling technique to be used for the above named infant and include the effective dates for the exception:(Required)

Effective Dates of Exception(Required)

From

Effective Dates of Exception(Required)

Health Care Professional's Signature(Required)

Date(Required)

Waiver of Liability

I affirm and acknowledge that the below named child care operation has provided me with the operation's safe sleep policy.
I further authorize the child care operation and its caregivers to place my infant in an alternative sleep position, restrictive device, or swaddling at the recommendation of my infant's health care professional, as described above.
I, as the parent or guardian of the above mentioned infant, release and hold harmless the below named child care operation, its officers, directors, caregivers, and employees from any and all liability whatsoever associated with harm to my infant due to Sudden Infant Death Syndrome (SIDS).

Parent or Guardian's Signature(Required)

Date Signed(Required)

An authorized official with the child care operation must complete the following section.

Child Care Operation Information and Signature

Name of Child Care Operation(Required)

Operation Number(Required)

Operation Representative's Signature

Date Signed

Privacy Statement

HHSC values your privacy. For more information, read our privacy policy online at: https://hhs.texas.gov/policies-practices- privacy#security.

Operational Discipline and Guidance Policy

This form provides the required information per 26 Texas Administrative Code (TAC) minimum standards §744.501(7), §746.501(a)(7), and §747.501(5).

Directions: Parents will review this policy upon enrolling their child. Employees, household members, and volunteers will review this policy at orientation. A copy of the policy is provided in the operational policies.

Discipline and Guidance Policy

Discipline must be:

Individualized and consistent for each child;
Appropriate to the child's level of understanding; and
Directed toward teaching the child acceptable behavior and self-control.

A caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control, and self-direction, which include at least the following:

Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;
Reminding a child of behavior expectations daily by using clear, positive statements;
Redirecting behavior using positive statements; and
Using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more than one minute per vear of the child's age.

There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited:

Corporal punishment or threats of corporal punishment;
Punishment associated with food, naps, or toilet training;
Pinching, shaking, or biting a child;
Hitting a child with a hand or instrument;
Putting anything in or on a child's mouth;
Humiliating, ridiculing, rejecting, or yelling at a child;
Subjecting a child to harsh, abusive, or profane language;
Placing a child in a locked or dark room, bathroom, or closet with the door closed or open; and
Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age.

Additional Discipline and Guidance Measures

(Only Applies to Before or After School Program (BAP)/School Age Program (SAP) that Operates under 26 TAC Chapter 744)

A program must take the following steps if it uses disciplinary measures for teaching a skill, talent, ability, expertise, or proficiency:

Ensure that the measures are considered commonly accepted teaching or training techniques;
Describe the training and disciplinary measures in writing to parents and employees and include the following information:
1. The disciplinary measures that may be used, such as physical exercise or sparring used in martial arts programs;
2. What behaviors would warrant the use of these measures; and
3. The maximum amount of time the measures would be imposed;
Inform parents that they have the right to ask for additional information; and
Ensure that the disciplinary measures used are not considered abuse, neglect, or exploitation as specified in Texas Family Code §261.001 and TAC Chapter 745, Subchapter K, Division 5, of this title (relating to Abuse and Neglect).

Signature

This policy is effective on the following date:(Required)

Signed by:(Required)

Role:(Required)

Parent

Caregiver/Employee

Household Member (CH. 747 only)

Minimum Standards Related to Discipline

Tite 26, Chapter 746 Subchapter L: hitp://texreg. C?tac_view=5&ti=26&pt=1&ch=746&sch=L&r|=Y
Title 26, Chapter 747 Subchapter L: http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=26&pt=1&ch=747&sch=L&rl=Y
Title 26, Chapter 744 Subchapter G: http://texreg.sos.state.tx.us/public/readtacSext.ViewTAC?tac_view=5&ti=26&pt=1&ch=744&sch=G&r|=Y

Childcare Agreement

Date Enrolled(Required)

I(Required)

agree to make payments to Alphabet Zone every week in the amount of(Required)

This amount includes care for the following children:(Required)

Hours of care, Breakfast, Lunch and Snack, Care, Preschool for ages 3-5. and school transportation for school age children (does not include summer school. Summer school service is extra). My eligible hours of care are from(Required)

untill(Required)

PM.

Rates are based on a 10 hour day. Contact Director if over 10 hours is needed to adjust pymt and avoid late plu fees. Alphabet Zone cut off time for entrance into the center is 9:00 am unless Doctor or Dentist note is supplied. As agreed upon by myself and Alphabet Zone my late fees will begin at(Required)

My late fees are $2.00 per minutes for each child after this time due upon pickup. I agree to make payments every Friday Morning or every other Friday in advance of service. Payments after Friday will incur a late fee of $35 plus $10 daily on Monday until all my fees are paid in full. Alphabet Zone will be closed 9 Holidays per year (listed below) and I am aware that Holidays are subject to change and that my full fee is due unless I use 1 of my 8 vacation weeks. I am aware that Supply fees are due yearly and will be billed on the anniversary of my enrollment even if waived upon enrollment. I understand that if my child attends the facility for 1 day or 5 days that my fee still remains the same amount. Each family/child will be eligible for 6 weeks of vacation fees which are 1/2 of the weekly fee. Also due in advance. Vacation weeks must be applied for in advance. If no advance notice is given, full fee will be billed. Methods of payment are cards thu invoicing and auto draft, which will be charged on Thursday mornings automatically. Payments that do not clear when run will incur a automatic $35 returned item fee. The payment will be ran again each morning until processed or until alternate arrangements are made.

Alphabet Zone Holidays: Christmas eve, Christmas Day, Thanksgiving Day, The day after Thanksgiving, Presidents Day, Memorial Day, Independence Day, Columbus Day, Labor Day and New Years Eve/Day. If the holiday falls on the weekend we will be closed the Friday before or the Monday after the holiday. You will be notified in advance.

Please read this fee agreement carefully and ask the director about anything that you don't understand. By signing this agreement, I acknowledge that I fully understand and agree with the terms as described within, I also understand That this is a binding agreement between myself and Alphabet Zone. I have received a copy for my records.

Parent Signature(Required)

Date(Required)

Director Signature

Date

TRANSPORTATION AUTHORIZATION

I(Required)

(PARENTS NAME) GIVE PERMISSION FOR MY CHILD

(CHILD'S NAME)(Required)

TO BE TRANSPORTED BY ALPHABET ZONE CHILDCARE CENTER.

CHECK ALL THAT APPLY:(Required)

SCHOOL

FIELD TRIPS

TO AND FROM HOME

I UNDERSTAND THAT STAR KIDS WILL ENFORCE SEAT BELT USAGE AT ALL TIMES. I UNDERSTAND THAT MY CHILD WILL BE IN A CAR SEAT OR BOOSTER SEAT (ACCORDING TO THE LAW AND AGE REQUIREMENTS) WHILE IN THE CAR AT ALL TIMES. I ALSO UNDERSTAND MY CHILD WILL NOT BE LEFT ALONE IN THE CAR FOR ANY REASON. ALPHABET ZONE EARLY STEAM CENTER CARRIES AUTO INSURANCE AS REQUIRED BY LAW. PARENTS WILL BE REQUIRED TO SUPPLY REQUIRED RESTRAINT SYSTEM FOR THEIR CHILD IF TRANSPORTATION IS REQUESTED.

ALPHABET ZONE CHILDCARE CENTER HAS MY PERMISSION TO ADMINISTER ANY AND ALL FIRST AID AND EMERGENCY PROCEDURES THAT MY CHILD MAY NEED WHILE BEING TRANS-PORTED BY THE CENTER. I UNDERSTAND THAT MY CHILD WILL BE TRANSPORTED TO THE NEAREST EMERGENCY CENTER FOR TREATMENT.

PARENTS SIGNATURE(Required)

Date(Required)

PERMISSION TO PHOTOGRAPH

I(Required)

Give Alphabet Zone Childcare Ctr. permission to photograph

my child(ren)(Required)

my child(ren)

TYPE OF USE

STILL PHOTOGRAPHS:(Required)

Yes

Display on Alphabet Zone Bulletin Boards(Required)

Yes

Display on Alphabet Zone Website(Required)

Yes

Display on Alphabet Zone Facebook Page(Required)

Yes

Display on Alphabet Zone Monthly Newsletter(Required)

Yes

Display on Art Projects(Required)

Yes

Display on Advertisement Material(Required)

Yes

VIDEOS:

For Teaching, Arts N Crafts, Albums, and/or Advertising.(Required)

Yes

**| understand that these photos and/or videos WILL NOT be sold, distributed or shared with any other individual or business**

I understand that it is my responsibility to update this form in the event that I no longer wish to authorize one or more of the above uses. I agree that this form will remain in effect during the term of my childs enrollment.

Signature(Required)

Date(Required)

Infant Instructions

Effective:(Required)

Thru(Required)

Can be extended by completing dates at bottom of this page

Infant Name:(Required)

DOB:(Required)

Known Allergies/Sensitivities:(Required)

Parent Name:(Required)

Emergency Ph#:(Required)

Please plainly write out the instructions on how to feed your infant:(Required)

Please plainly write out the instructions for diapering your infant:(Required)

Please plainly write out any additional instructions for your infant or any instructions your infant teacher may need to follow concerning your infant.(Required)

Signature(Required)

Date(Required)

All info above remains the same as of(Required)

All info above remains the same as of

Instructions effective(Required)

until(Required)

Parent Signature/Date(Required)

All info above remains the same as of(Required)

All info above remains the same as of

Instructions effective(Required)

until(Required)

Parent Signature/Date(Required)

Pre-Enrollment Questionaire

Parent's Name:(Required)

Child's Name:(Required)

Child's DOB(Required)

Thanks for taking the time to complete our Questionaire. This will better enable us to determine if your child will benefit from our program. It will also help us to determine if we are equipt for your childs specific needs. Your responses will not be the sole determining factor in the enrollement of your child, but it will enable us to discuss issues and concerns prior to enrollment, avoiding misunderstandings in the future.

1. Has your child attend Daycare in the past 6 months:(Required)

2. Is your child completely potty trained?(Required)

3. If response to #2 is no, has potty training started?|(Required)

4. If the response to #3 is no, please emplain(Required)

5. Is your child currently in school?(Required)

6. Does your child have any medical issues that we may need to be aware of?(Required)

7. If response to #6 was yes please explain.(Required)

8. Is your child on any ongoing medications for the issue listed above?(Required)

9. Has your child ever been diagnosed with ADD, ADHD or any related diagnosis?(Required)

10. If the response to #9 was yes, what was his/her diagnosis?(Required)

11. Is your child on any medications for the diagnosis listed above?

12. Which medications does your child take and will the center need to administer them?(Required)

Mediations:

13. If your child is in school, are they on any specific plans at his/her school.(Required)

14. If your child is enrolled, would you be willing to share his/her plan so that we can better assist your child with his/her needs?(Required)

15. Is there anything that you feel we should know in order to better care your child?(Required)

WELCOME LETTER

Welcome to ALPHABET ZONE CHILDCARE CENTER, the innovations in early childcare and education for your child. We offer a structured program for children ages 2 thru 12. Our primary goal is to implement a program based on the Philosophy that "Children construct their own learning". We believe that every child should move along at his/her own pace and should be allowed to go as far as he/she is capable of soaring. Our program is hands on and enriched with technology and culture. Our staff are experienced and well trained to meet your child's needs. We look forward to watching your child grow and making new life long friends. Our summer program is full of activities to keep your child's interest and help your child to learn and experience new and exciting things.

ALPHABET ZONE CHILDCARE CTR would like to thank you for giving us the opportunity to provide quality childcare to your family. We would like to assure you that your child is in very capable hands with our trained, experienced staff and that we will do all that we can to accommodate your childcare needs. If at any time you feel that a one on one conference is needed please feel free to give us a call or email us at ALPHAZONENC@GMAIL.COM Our staff is here to offer assistance in any way and consults with me if and when an issue is not able to be resolved, however it is our goal to resolve all issues to the satisfaction of our parents, children and staff.

Once again thanks for your confidence in our facility and we look forward to working with you, your child and family for many years to come.

Your current Center Director is TIFFANY ALEXANDER and your current Center Manager is JOYCE SMITH. These individuals will be able to assist you with any needs or concerns you or your child may be experiencing.

Enr Pkt Nc

Admission Information

General Information

List phone numbers below where parents or guardian may be reached while child is in care.

In case of an emergency, call:

Consent Information

1. Transportation:

3. Water Activities:

4. Receipt of Written Operational Policies:

5. Meals:

6. Days and Times in Care:

School Age Children

Authorization For Emergency Medical Attention

Requirements for Exclusion from Compliance

Vision Exam Results

Hearing Exam Results

Admission Requirement

Infant Sleep Exception/Health Care Professional Recommendation

Infant's Information

Health Care Professional Information

Health Care Professional Information

Waiver of Liability

Child Care Operation Information and Signature

Privacy Statement

Operational Discipline and Guidance Policy

Discipline and Guidance Policy

Additional Discipline and Guidance Measures

Signature

Minimum Standards Related to Discipline

Childcare Agreement

TRANSPORTATION AUTHORIZATION

PERMISSION TO PHOTOGRAPH

Infant Instructions

Pre-Enrollment Questionaire

WELCOME LETTER

Alphabet Zone Kingwood

Alphabet Zone New Caney