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 Gender *

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

Child's Gender

Information about the employee registering the child

Waivers & 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. *
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. *
For additional information regarding immunizations, contact the Department of State health Services.
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:

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. *

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