This form must be filled out and returned before your child’s first day of enrollment. It will be kept in the students file at the program home. The non refundable registration fee of $100 must be paid with the completed registration form. A material fee of $100 must be paid each semester, the first with enrollment in August, and the second will be with January tuition.

Fees must be paid to Venmo account @aplaceforwonder

PARENTS/GUARDIANS WHO MAY BE REACHED WHILE CHILD IS IN CARE

*If there are custody documents, please provide with enrollment paperwork

EMERGENCY CONTACT (other than parent/guardian listed above)

AUTHORIZED PERSONS TO PICKUP CHILD

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

In the event I cannot be reached to arrange for emergency medical care, I authorize the persons in charge to take my child to:

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

ADMISSION REQUIREMENT

A signed and dated copy of a health care professional’s statement that the child is able to participate in the program.

Each child must have completed health and immunization forms, and vision/hearing spinal screening and results provided for their records. These must be completed on a yearly basis.

These records must be submitted within 30 days of admission

REQUIREMENTS FOR EXCLUSION FROM COMPLIANCE

I have attached a signed and dated affidavit stating I decline immunizations for reasons of conscience, including religious beliefs, on the form described by Section 161.0041 Health and Safety Code submitted no later than the 90th day after the affidavit is notarized.

A copy of your child’s immunization records with dates and signatures or your affidavit for declining immunizations must be submitted before your child starts the program. For additional information regarding immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm

CHILD’S SPECIAL CARE NEEDS (Check all that apply)