Crowley United Methodist Preschool

Crowley United Methodist Preschool

509 West Peach Street

Crowley, TX 76036

(817) 297-1485

Date of Admission ______

Date of Withdrawal ______

2017-2018 Enrollment Information

Child’s Name ______Date of Birth ______

Child’s Address ______City ______Zip ______

Parent/Guardian Name ______Relationship to Child ______

Cell Phone ______Business Phone ______

Parent/Guardian Name ______Relationship to Child ______Cell Phone ______Business Phone ______

Email Address (1): ______Email Address (2):______

Parent/Guardian Address (if different from child) ______City ______State ______Zip ______

Please list anyone else to whom the facility is authorized to release your child:

Name ______Phone # ______Relationship ______

Please list two (2) emergency contacts:

Name ______Phone # ______Relationship ______

Address______

Name ______Phone # ______Relationship ______

Address______

***List any special circumstances and/or history that your child may have (such as allergies, existing illness, previous serious illness and injuries, any hospitalizations during the past 12 months, any medications prescribed for long-term continuous use, any physical, mental or emotional needs) and any other information staff should know about your child:

______

If no medical history, medications or allergies, please check: NONE ______

Please write “YES” you give consent or “NO” you do not give consent for each of the following:

Water Activities: Sprinkler Play ______Splashing/Wading Pools ______

Inflatable Bounce House and/or Slide ______

Authorization for Emergency Medical Attention and Emergency Evacuation:

In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the facility Director or person in charge to take my child to:

Name of Physician ______Address ______Phone ______

Name of Hospital ______Address ______Phone ______

I give consent for this facility to secure any and all necessary emergency medical care for my child. I authorize the staff of Crowley United Methodist Preschool and the church to transport my child to another location if a situation occurs that makes it in the best interest of the children to evacuate the building.

Signature______Date ______

Rev 1/20/2017

Crowley United Methodist Preschool

Medical Information

2017-2018 School Year

Child’s Name ______Date of Birth ______

Admission Requirement—Texas Child Care Licensing requires the following information to be submitted each year to complete your child’s file.

* Current Immunization Record (copy and attach to this form)

* Health Care Professional’s Statement: One of the following must be presented within two weeks of the starting date.

1. ______ I have examined the child listed above within the past year and find that he/she is physically able

to take part in a Daycare/Preschool program.

Health Care Professional’s Signature ______Date ______

2. ______A signed and dated copy of a health care professional’s statement is attached.

3. ______To claim an exclusion for reasons of conscience, including a religious belief, a

signed and dated affidavit from the Texas Department of State Health Services is attached.

All children four years of age or older attending preschool must have their vision and hearing screened by a health care professional.

* Vision Screening:

Vision: Right 20/______Left 20/______PASS ______or FAIL ______

Health Care Professional’s Signature ______Date ______

* Hearing Screening:

Hearing: Left: PASS ______or FAIL ______

Right: PASS ______or FAIL ______

Health Care Professional’s Signature ______Date ______

Rev 1/20/2017