Admission Information — Form 2935

Form 2935 
January 2025
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:
Director's Name:
Child's Full Name:
Child's Date of Birth:
Child Lives With:
Both parents
Mom
Dad
Guardian
Child's Home Address:
Date of Admission:
Date of Withdrawal:
Name of Parent or Guardian 1:
Address of Parent or Guardian 1 if different from the child's:
Name of Parent or Guardian 2:
Address of Parent or Guardian 2 if different from the child's:
List phone numbers below where parents or guardian may be reached while child is in care.
Parent 1 Area Code and Phone No.:
Parent 2 Area Code and Phone No.:
Guardian's Area Code and Phone No.:
Custody Documents on File:
Yes
No
In case of an emergency, when the parent or guardian cannot be reached, call:
Name of Emergency Contact:
Relationship:
Area Code and Phone No.:
Address:
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:
Area Code and Phone No.:
Name:
Area Code and Phone No.:
Name:
Area Code and Phone No.:
Consent Information
1. Transportation:
I give consent for my child to be transported and supervised by the operation's employees. Check all that apply.
for emergency care
on field trips
to and from home
to and from school
2. Field Trips:
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:

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3. Water Activities:
I give consent for my child to participate in the following water activities. Check all that apply.
water table play
sprinkler play
splashing or wading pools
swimming pools
aquatic playgrounds
Is your child able to swim without assistance?
Yes
No
If no, your child is required to wear a life jacket while in or near a 
swimming pool.
Does your child have any physical, health, behavioral or other 
condition that would put them at risk while swimming?  
Yes
No
If yes, your child is required to wear a life jacket while in or near a 
swimming pool.
Do you want your child to wear a life jacket while in or near a 
swimming pool?  
Yes
No
*A competent swimmer can enter and exit a pool safely on their own, tread water or float on their back for one minute, and swim 25 yards 
with no assistance.
4. Receipt of Written Operational Policies:
I acknowledge receipt of the facility's operational policies, including those for the following. Check all that apply.
Discipline and guidance
Procedures for release of children
Suspension and expulsion
Illness and exclusion criteria
Emergency plans
Procedures for dispensing medications
Procedures for conducting health checks
Immunization requirements for children
Safe sleep
Meals and food service practices
Procedures for parents to discuss concerns with the director
Procedures to visit the center without securing prior approval
Promotion of indoor and outdoor physical activity including 
criteria for extreme weather conditions
Procedures for supporting inclusive services
Procedures for parents to participate in operation activities
Procedures for parents to contact Child Care Regulation (CCR), DFPS,
Child Abuse Hotline, and CCR website
5. Meals:
I understand that the following meals will be served to my child while in care. Check all that apply:
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
A.M.
P.M.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
7. Receipt of Parent’s Rights:
I acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility.
Signature — Parent or Legal Guardian
Date Signed

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8. Child's Special Care Needs, check all that apply
Environmental allergies
Limitations or restrictions on child's activities
Food intolerances
Reasonable accommodations or modifications
Existing illness
Adaptive equipment, include instructions below
Previous serious illness
Symptoms or indications of complications
Injuries and hospitalizations in the past 12 months
Medications prescribed for continuous long-term use
Other:
Explain any needs selected above:
Does your child have diagnosed food allergies?
Yes
No
Food Allergy Emergency Plan Submitted Date:
Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit 
www.ada.gov/resources/child-care-centers/. If you believe that such an operation may be practicing discrimination in violation of Title III, you 
may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).
Signature — Parent or Legal Guardian
Date Signed
9. School Age Children
My child attends the following school:
School Area Code and Phone No.:
My child has permission to: 
Check all that apply.
walk to or from school or home
ride a bus
be released to the care of their sibling younger than 18 years old
Authorized pick up or drop off locations other than the child’s address:
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
Address
Area Code and Phone No.
Name of Emergency Care Facility
Address
Area Code and Phone No.
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature — Parent or Legal Guardian
Date Signed

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Requirements for Exclusion from Compliance
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/
Left Eye 20/
Pass
Fail
Signature
Date Signed
Hearing Exam Results
Ear
1000 Hz
2000 Hz
4000 Hz
Pass or Fail  
Right
 Pass
 Fail
Left
 Pass
 Fail
Signature
Date Signed
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.
Health Care Professional’s Statement: I have examined the above named child within the past year and find they are 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.
Name of Health Care Professional, if selected
Address of Health Care Professional, if selected
Signature — Health Care Professional
Date Signed
Signature — Parent or Legal Guardian
Date Signed

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Vaccine Information
The following vaccines require multiple doses over time. Provide the date your child received each dose.
Vaccine
Vaccine Schedule
Dates Child Received Vaccine
Hepatitis B
Birth (first dose)
1–2 months (second dose)
6–18 months (third dose)
Rotavirus
2 months (first dose)
4 months (second dose)
6 months (third dose)
Diphtheria, Tetanus, Pertussis
2 months (first dose)
4 months (second dose)
6 months (third dose)
15–18 months (fourth dose)
4–6 years (fifth dose)
Haemophilus Influenza Type B
2 months (first dose)
4 months (second dose)
6 months (third dose)
12–15 months (fourth dose)
Pneumococcal
2 months (first dose)
4 months (second dose)
6 months (third dose)
12–15 months (fourth dose)
Inactivated Poliovirus
2 months (first dose)
4 months (second dose)
6–18 months (third dose)
4–6 years (fourth dose)
Influenza
Yearly, starting at 6 months. Two doses given at least 
four weeks apart are recommended for children who are 
getting the vaccine for the first time and for some other 
children in this age group.
Measles, Mumps, Rubella
12–15 months (first dose)
4–6 years (second dose)
Varicella
12–15 months (first dose)
4–6 years (second dose)
Hepatitis A
12–23 months (first dose)
The second dose should be given six to 18 months after 
the first dose.

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Varicella for Chickenpox
Varicella, the vaccine for chickenpox, is not required if your child has had chickenpox disease. If your child has had chickenpox, complete the
statement: My child had varicella disease, chickenpox, on or about [date] and does not need varicella vaccine.
Signature
Date Signed
Additional Information About Immunizations
For additional information about immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/
immunize/public.shtm.
TB Test if required
Positive
Negative
Date:
Gang Free Zone
Under the Texas Penal Code, any area within 1,000 feet of a child care center is a gang-free zone, where criminal offenses related to 
organized criminal activity are subject to harsher penalties.
Privacy Statement
HHSC values your privacy. For more information, read our privacy policy online at https://hhs.texas.gov/policies-practices-privacy#security
Signatures
Child's Parent or Legal Guardian
Date Signed
Center Designee
Date Signed
Physician or Public Health Personnel Verification
Signature or stamp of a physician or public health personnel verifying immunization information above:
Signature
Date Signed