Humble ISD Employee Childcare Admission Information

Assistant Superintendent: Luci Schulz
Director of Special Programs: Tempie Smith

For office use only: Date of Admission________________ Date of Withdrawal:_______________

Information about the child

Child's Name (First, Last) *

Child's Date of Birth (ex. 1/01/2010) *

Home Phone # *

Child's Home Address (Street Address) *

City *

Zip Code *

Child's Gender *

Male

Female

If you have more than one child to admit to the program, please add them here. If not, skip to the next section.

Child #2 Name (First, Last)

Child's Date of Birth (ex. 1/01/2010)

Home Phone #

Home Address (Street Address)

City

Zip Code

Child's Gender

Male

Female

Child #3 Name (First, Last)

Child's Date of Birth (ex. 1/01/2010)

Home Phone #

Home Address (Street Address)

City

Zip Code

Child's Gender

Male

Female

Information about the employee registering the child

Name (First, Last) *

Address (if different from child's address)

SSN (Billing Purposes) *

Work Telephone *

Work Location (School/Dept.) *

Position/Title *

Email address *

Cell Phone *

Home Telephone (If no home phone, please enter NONE) *

Spouse's Name (First, Last)

Spouse's Email Address

Spouse's Cell Phone

Waivers & Health Requirements

Please acknowledge that you have read this policy statement:

"I understand that HISD Employee Childcare does not provide transportation, field trips or water activities for the children enrolled in the Employee Childcare program."

Acknowledge you have read this policy by typing YES in the space provided below. *

HEALTH REQUIREMENTS
A current immunization record must be provided to the child care before the first day of care. The childcare requires updated immunization records in accordance with the Department of State Health Services schedule.

I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I understand I must provide an official notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for two years. *

I am excluding my child from immunization requirements. My notarized affidavit will be presented on or before the first day of care.

I am NOT excluding my child from immunization requirements. I will provide a copy of my child's immunization record on or before the first day of care.

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please check YES and enter the approximate date. *

My child has not had chickenpox

My child has had chickenpox My child has had chickenpox

For additional information regarding immunizations, contact the Department of State health Services.

ADMISSION REQUIREMENT
One of the following must be presented when your child is registered for the Employee Childcare program or within one week of admission. Please choose ONE option:
*

A signed and dated copy of a health care professional's statement is attached to this form or will be submitted on the first day of care.

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.

If you have a statement to attach to this form, you may upload it here.

The name of my child's health care professional is *

Street Address *

City *

Zip Code *

Phone Number *

Medical diagnosis and treatment do/do not 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. *

There IS a conflict, as stated above.

There IS NOT a conflict, as stated above.

The registration fee must be paid in full to reserve a place for your child at the Humble ISD Early Learning Center.

You may upload your signed and dated affidavit here.

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