Admissions Packet | Kids R Love Learning Center

Child & family information

From the Information & Transportation Form and Form 2935 admission information. Operation: KIDS R LOVE LEARNING CENTER - 1748151 · Director: VICTORIA TRUJILLO

Child's full name *

Child's date of birth

Home address

City

State

ZIP

Who does the child live with?

Parent / Guardian 1 name *

Best phone to reach you *

Parent email (for your confirmation)

Date of admission

Parent 1 phone

Parent 1 work number

Parent / Guardian 2 name

Parent 2 phone

Parent 2 work number

Guardian's phone (if different)

Guardian name (if any)

Parent 1 address, if different from child's

Parent 2 address, if different from child's

Custody documents on file? Yes No

Name of school attending

School phone

School hours

Room number

Teacher's name

Emergency contacts & who may pick up your child

In case of an emergency, when the parent or guardian cannot be reached, we will call these contacts. Children will only be released to a parent or guardian or to a person designated by the parent or guardian after verification of ID.

Emergency contact 1

Relationship

Contact 1 phone

Contact 1 work number

Emergency contact 2

Relationship

Contact 2 phone

Contact 2 work number

May release my child to — name 1

Phone

May release my child to — name 2

Phone

May release my child to — name 3

Phone

Primary doctor's name

Doctor's contact number

Doctor's address

Preferred hospital / emergency care facility

Facility address

Facility phone

List any known allergies

List current medication(s)

Comments and any other significant information

Consent information (Form 2935)

1. Transportation — I give consent for my child to be transported and supervised by the operation's employees for: Emergency care 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

Field trip comments

3. Water activities — I give consent for my child to participate in: 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. *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.

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

I acknowledge receipt of the facility's operational policies listed above.

5. Meals — I understand that the following meals will be served to my child while in care: None Breakfast Morning snack Lunch Afternoon snack Supper Evening snack

6. Days and times in care — my child is normally in care on:

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.

Explain any needs selected above

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).

Does your child have diagnosed food allergies? Yes No

Food Allergy Emergency Plan submitted (date)

9. School-age children — my child has permission to: Walk to or from school or home Ride a bus Be released to the care of their sibling younger than 18 years old

My child's required immunizations, vision and hearing screening, and TB screening are current and on file at their school.

Immunization record (Form 2935)

Provide the date your child received each dose. Leave blank any that don't apply yet — the office can update the record with you. For additional information about immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm.

Hepatitis B
Birth (1st)
1–2 months (2nd)
6–18 months (3rd)

Rotavirus
2 months (1st)
4 months (2nd)
6 months (3rd)

Diphtheria, Tetanus, Pertussis (DTaP)
2 months (1st)
4 months (2nd)
6 months (3rd)
15–18 months (4th)
4–6 years (5th)

Haemophilus Influenza Type B (Hib)
2 months (1st)
4 months (2nd)
6 months (3rd)
12–15 months (4th)

Pneumococcal
2 months (1st)
4 months (2nd)
6 months (3rd)
12–15 months (4th)

Inactivated Poliovirus (IPV)
2 months (1st)
4 months (2nd)
6–18 months (3rd)
4–6 years (4th)

Influenza — most recent dose (yearly, starting at 6 months)

Measles, Mumps, Rubella (MMR)
12–15 months (1st)
4–6 years (2nd)

Varicella (chickenpox)
12–15 months (1st)
4–6 years (2nd)

Hepatitis A
12–23 months (1st)
2nd (6–18 months after 1st)

Varicella is not required if your child has had chickenpox — my child had varicella disease (chickenpox) on or about:

TB test, if required Positive Negative

TB test date

Admission requirement — if your child does not attend pre-kindergarten or school away from the center, one of the following must be presented at admission or within one week (select one): A signed and dated copy of a health care professional's statement is attached (I have examined the child within the past year and find they are able to take part in the day care program) 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

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 screening results (if already done)

Hearing screening results (if already done)

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

Child assessment (Form 7293)

These questions help us provide the best, most appropriate care for your child. This information is confidential and will not be shared without your written permission.

1. Health

Does your child have any allergies? Yes No

If so, what allergies?

How should we respond if he/she has an allergic reaction?

Does your child have an existing illness? Yes No

Previous serious illness, injury, or hospitalization in the past 12 months? Yes No

Is your child taking any medication? Yes No

Is the medication prescribed for continuous use? Yes No

If so, how is the medication administered, and will it need to be administered while he/she is in care?

Are there any side effects we should be alerted to? Yes No

If yes, which side effects?

2. Toileting

Does your child need assistance with toileting? Yes No

How can we best help?

What are your ideas about toilet training?

How can we best help?

3. Behavior

Does your child have any special fears? How does your child communicate his/her needs?

Are there special words your child uses that might not be readily recognized?

How do you tell your child to stop a behavior you don't approve of, or that might be dangerous?

When your child gets upset, what helps him/her calm down?

What is a good way to distract your child during a temper tantrum?

Are there routines that are particularly helpful at naptime?

What position is most comfortable for your child when napping?

4. Eating preferences

What are your child's favorite foods?

Does your child use utensils, eat with fingers, feed self?

Does your child choke easily while eating? Yes No

5. Activities

What activities do you like to do with your child?

What activities does your child like to do when playing with other children?

What does your child like to do when playing alone?

6. Family history

Tell us about your family (child's parents, siblings, grandparents, and other extended family)

Additional comments

Medication authorization (only if your child takes medication)

Name of medication

Reason for medication

Dose

Time / frequency

Date to start

Date to stop

Route Oral Inhaled Topical Other

Expiration date

Additional instructions / comments

Known side effects

Prescribing health care provider (prescription medication)

Provider phone number

For controlled substances — amount of medication received

I, the parent or legal guardian, authorize Kids R Love Learning Center Personnel to administer the medication named above to my child in the manner as stated. I release any liability in relation to the administration of this medication. I also acknowledge that I, the parent/guardian, have given the first dose of this medication without any allergic or unexpected reactions.

Infant care instructions (6 weeks – 12 months · under-3 packet)

In order to serve your infant in a more individual manner, we ask that you provide this additional information. If your child is 12 months–2 years, fill in whatever applies.

Type of formula (be specific)

Warmed? Yes No

How often is the bottle to be given?

How many ounces of formula should be prepared?

Is your infant on any solids and/or table foods?

Known allergies — food

Known allergies — skin

Known allergies — other

Skin care ointment

Special soap

Does your baby use a pacifier? Yes No

Favored sleeping position On Back On Stomach On Side

Other helpful information — include a feeding and sleeping schedule along with anything of special interest

Infant Safe Sleep policy (Form J-800-2550)

This form provides the required information per minimum standards §746.501(9) and §747.501(6) for the safe sleep policy. Parents will review this policy upon enrolling their infant at Kids R Love Learning Center, 1107 Roberts Cut Off Rd, River Oaks, TX 76114, and a copy of the policy is provided in the parent handbook. Parents can review information on safe sleep and reducing the risk of Sudden Infant Death Syndrome / Sudden Unexpected Infant Death Syndrome (SIDS/SUIDS) at: http://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

All staff, substitute staff, and volunteers at Kids R Love Learning Center will follow these safe sleep recommendations of the American Academy of Pediatrics (AAP) and the Consumer Product Safety Commission (CPSC) for infants to reduce the risk of SIDS/SUIDS:

Always put infants to sleep on their backs unless you provide an Infant Sleep Exception form 2710 signed by the infant's health care professional [§746.2427 and §747.2327].
Place infants on a firm mattress, with a tight fitting sheet, in a crib that meets the CPSC federal requirements for full size cribs and for non-full size cribs [§746.2409 and §747.2309].
For infants who are younger than 12 months of age, cribs should be bare except for a tight fitting sheet and a mattress cover or protector. Items that should not be placed in a crib include: soft or loose bedding, such as blankets, quilts, or comforters; pillows; stuffed toys/animals; soft objects; bumper pads; liners; or sleep positioning devices [§746.2415 and §747.2315]. Also, infants must not have their heads, faces, or cribs covered at any time by items such as blankets, linens, or clothing [§746.2429 and §747.2329].
Do not use sleep positioning devices, such as wedges or infant positioners. The AAP has found no evidence that these devices are safe. Their use may increase the risk of suffocation [§746.2415 and §747.2315].
Ensure that sleeping areas are ventilated and at a temperature that is comfortable for a lightly clothed adult [§746.3407(10) and §747.3203(10)].
If an infant needs extra warmth, use sleep clothing (such as sleepers or footed pajamas) as an alternative to blankets [§746.2415 and §747.2315].
Place only one infant in a crib to sleep [§746.2405 and §747.2305].
Infants may use a pacifier during sleep. But the pacifier must not be attached to a stuffed animal or the infant's clothing by a string, cord, or other attaching mechanism that might be a suffocation or strangulation risk [§746.2415 and §747.2315].
If the infant falls asleep in a restrictive device other than a crib (such as a bouncy chair or swing, or arrives to care asleep in a car seat), move the infant to a crib immediately, unless you provide an Infant Sleep Exception form 2710 signed by the infant's health care professional [§746.2426 and §747.2326].
Our child care program is smoke-free. Smoking is not allowed in Texas child care operations (this includes e-cigarettes and any type of vaporizers) [§746.3703(d) and §747.3503(d)].
Actively observe sleeping infants by sight and sound [§746.2403 and §747.2303].
If an infant is able to roll back and forth from front to back, place the infant on the infant's back for sleep and allow the infant to assume a preferred sleep position [§746.2427 and §747.2327].
Awake infants will have supervised "tummy time" several times daily. This will help them strengthen their muscles and develop normally [§746.2427 and §747.2327].
Do not swaddle an infant for sleep or rest unless you provide an Infant Sleep Exception form 2710 signed by the infant's health care professional [§746.2428 and §747.2328].

Privacy Statement: DFPS values your privacy. For more information, read our privacy policy at: http://www.dfps.state.tx.us/policies/privacy.asp

I have reviewed the Operational Policy on Infant Safe Sleep above.

Tuition agreement

Your weekly tuition, as quoted by our office ($ per week)

Dear Parents/ Guardian,

Thank you for choosing Kids R Love as your childcare center. We hope to provide you with quality service meeting both the needs of you and your child's. There is a one time registration fee of $80 due when you pick up paperwork to secure your child's place until they are ready to start. Your weekly tuition is $ _____________ a week. Tuition is due every Monday for the current week of childcare. If you are paying tuition on or after Wednesday of the current week, payment is considered late. Please add a $20.00 late fee to your weekly childcare tuition.

Please also be advised if your child is out all week due to illness/ vacation or for personal reasons, your weekly tuition cost will be ½ off your regular tuition. (Example: Weekly Tuition = $150.00 – ½ Tuition due would be $75.00). Please call to make your payment over the phone if you can not make it into the daycare to avoid late charge.)

The childcare center hours of operation are Monday through Friday from 6:30am to 6:00pm. Please arrive no later than 6:00pm for child pick-up or have an alternative authorized person for child pick-up. If you arrive after 6:00pm, there will be an extended late pick-up fee of $15 for the first 1-15 minutes and $1.00 per minute/per child for following minutes. Please be prepared to pay cash to the staff who stayed late with your child/children.

*** NO REFUNDS ARE GIVEN AFTER PAYMENT HAS BEEN RECEIVED. ***

Please sign and date below, acknowledging you have fully read and understand the above mentioned. Thank you, Kids R Love Learning Center — LOCATION: KIDS R LOVE LEARNING CENTER, 1107 ROBERTS CUT OFF RD., RIVER OAKS, TX 76114 · HOURS: 6:30AM - 6:00PM

I have read and fully understand the Tuition Agreement above. *

Photo release

I, the parent of a child/children at KIDS R LOVE LEARNING CENTER (hereinafter known as the "Daycare"), agree to the following:

I understand that my child(ren) whose name(s) are listed below may be photographed at the Daycare during normal daycare hours, field trips, or activities. I understand that these photographs may be used in promoting child care services, either in print or on the Internet.

With my signature below I grant permission for my child(ren) to be photographed, or their images recorded for print or electronic use in promoting the Daycare's services. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child's enrollment. I understand that there will be no payment for me or my child's participation in this release.

The child(ren) covered by this release

Your choice * I grant permission as described above I do NOT grant permission

Discipline & guidance policy (Form 1099)

This form provides the required information per 26 Texas Administrative Code (TAC) minimum standards §744.501(7), §746.501(a)(7), and §747.501(5). Parents will review this policy upon enrolling their child.

Discipline must be: 1) Individualized and consistent for each child; 2) Appropriate to the child's level of understanding; and 3) Directed toward teaching the child acceptable behavior and self-control.

A caregiver may only use positive methods of discipline and guidance that encourage self-esteem, self-control, and self-direction, which include at least the following: 1) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior; 2) Reminding a child of behavior expectations daily by using clear, positive statements; 3) Redirecting behavior using positive statements; and 4) Using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more than one minute per year of the child's age.

There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited: 1) Corporal punishment or threats of corporal punishment; 2) Punishment associated with food, naps, or toilet training; 3) Pinching, shaking, or biting a child; 4) Hitting a child with a hand or instrument; 5) Putting anything in or on a child's mouth; 6) Humiliating, ridiculing, rejecting, or yelling at a child; 7) Subjecting a child to harsh, abusive, or profane language; 8) Placing a child in a locked or dark room, bathroom, or closet with the door closed or open; and 9) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age.

I have reviewed the Operational Discipline and Guidance Policy.

Parent orientation

Welcome! Selecting child care is important to families. This is your orientation checklist. We will be sharing information with you about our center and we are also providing you with a copy of the center's policies and procedures. If an area is not covered or if you do not receive a copy of the policies and procedures, please be sure to let us know. The orientation covers:

A tour of the facility
An introduction to the teaching staff
A parent visit with the classroom teacher
An overview of the parent handbook
The policy for arrival and late arrival
An opportunity for an extended visit in the classroom by both parent and child for a period of time to allow both to be comfortable
An explanation of Texas Rising Star quality certification
A statement encouraging parents to inform the facility of any elements related to their CCMS enrollment that the program may be able to help with
An overview of family support resources and activities in the community
Information on child development and developmental milestones
A statement informing parents of the significance of consistent arrival times, including the points that children should arrive before the education portion of the program begins, to limit disruption, and that consistent routines prepare children for the transition to kindergarten
A statement to parents regarding limiting technology use on-site (e.g. encouraging them to refrain from cell phone use), so communication between parents, teachers, and children is not distracted by electronic devices while at the center
A statement to parents reflecting the role and influence of families

My signature below indicates that I have received a copy of the center's policies and procedures and an orientation was conducted with me which covered all areas outlined in this orientation plan.

Bus transportation info & etiquette (school-age)

Safety is our first and foremost concern at our centers, and while in transport to-and-from our centers. Kids R Love will provide transportation to-and-from the following designated schools: Joy Jame Elementary, AV Cato Elementary, Castleberry Elementary.

Departure times from the Kids R Love center and the elementary schools will be published for review. These times will be set by the Director and will be strictly followed by Staff. Children will have a (5) minute window after school has been released, to be at their designated pick-up locations at each school. If your child does not arrive at the designated pick-up location within the (5) minute window, the staff/ driver will notify the center by "cell phone" before leaving the school, and prepare to proceed to the next scheduled destination.

It is very important that YOU (as the parent), contact the center by 1:30 PM to report any changes in the status of your child's school pick-up or release of your child from the center for the current day.

BUS TRANSPORTATION ETIQUETTE: Always meet at designated areas on time for pick-ups · Always buckle-up (it's the law) · Keep all personal belongings together · Voices are to be kept low (Talk to the person nearest to you) · No throwing of any objects · Remain seated at all times.

I have reviewed the Bus Transportation Info & Etiquette.

Some items your child will need

Infant Room: Bottles with nipple covers · Diapers · 3 Boxes of Kleenex · Baby Food · Wipes · Extra Clothes

12 Months to 2 Years: Diapers or Pull-ups · Extra Clothes / under garments · Wipes · 3 Boxes of Kleenex

Some items your child will need

3 & 4 Year Old PRE-K Program will receive an additional supply list, please see the front office.

5 to 12 Years Old, please bring: Paint · Shaving Cream — 2 cans · Pipe Cleaners — 1 pk · Tissue — 1 pk · Germ X — 2 bottles · Glue Sticks — 1 pk · Journal / Spiral · Scissors — 1 pk · Crayons — 2 pk · Markers — 1 (10 ct) · Pencils — 2 pk · Construction Paper — 1 pk · Manilla Paper — 1 pk · Folder

Or a one time fee of $30

Emergency medical authorization & signature

In order to meet legal requirements, I hereby give my full and complete consent to KIDS R LOVE LEARNING CENTER to act on my behalf for any and all necessary emergency medical care/attentions for my child(ren) while in their legitimate care.

In the event I cannot be reached to arrange for emergency medical care, I authorize the person in charge to take my child to the physician and emergency care facility named in this packet, and I give consent for the facility to secure any and all necessary emergency medical care for my child.

Your relationship to the child

Date *

Type your full name — this is your electronic signature *

I attest that the information in this packet is true and complete, and that my typed name above is my electronic signature for every form in this packet — the Information & Transportation Form, Form 2935, the Child Assessment (Form 7293), the Discipline & Guidance Policy, the Medication Authorization (if completed), the Tuition Agreement, the Photo Release, the Parent Orientation, and the Infant Safe Sleep policy (for infants) — with the same effect as signing the paper forms. *

Yes — Kids R Love Learning Center may text me about my enrollment inquiry and enrollment, including tour scheduling and appointment reminders. Message frequency varies. Message and data rates may apply; reply STOP to opt out, HELP for help.

Optional — texting is never required to enroll. Privacy Policy · Terms & Conditions

Sends straight to our office — no printing, no email app. Questions? Call (817) 626-8604.

Complete your enrollment packet online

Before you start

Child & family information

Emergency contacts & who may pick up your child

Consent information (Form 2935)

Immunization record (Form 2935)

Child assessment (Form 7293)

Medication authorization (only if your child takes medication)

Infant care instructions (6 weeks – 12 months · under-3 packet)

Infant Safe Sleep policy (Form J-800-2550)

Tuition agreement

Photo release

Discipline & guidance policy (Form 1099)

Parent orientation

Bus transportation info & etiquette (school-age)

Some items your child will need

Some items your child will need

Emergency medical authorization & signature