combined enrollment packet

7/27/2019 Combined Enrollment Packet

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Requirements for enrollment at Oakdale Private School

(Please allow 20-30 minutes upon enrollment)

All spaces must be filled out completely in this enrollmentpacket. Signature is required where there is an X.

Current up to date shot records must be turned in on the

first day your child attends. Immunization records will be

checked before your child can start. If your child is behind

on any immunizations, they will not be allowed to stay; the

immunizations will need to be updated for the child to

begin attending. If you are having shot records faxed to ourschool, we will have to receive them in advance of your

childs enrollment date. No child will be allowed to attend

Oakdale without current immunization records in their file.

Health statements are required to be signed by a doctor and

turned in to Oakdale within 1 week of your childs first day

of attendance.

Picture I.D. is required to enroll your child at Oakdale.

Accepted forms of I.D.: Texas Drivers License or State of

Texas I.D.

If your child is being enrolled in a 3 year old

Kindergarten class, your child must be in uniform to stay.

Please refer to Oakdale Private School Policies and

Procedures.

Thank you!


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Child's Name: ______________________________________

Date of Birth: ______________________________________

Enrollment Date: ___________________________________

Withdrawal Date: ___________________________________

Days In Care: (Circle Days)

Sun Mon Tue Wed Thur Fri Sat

Hours In Care:

Start Time: ________AM/PM End Time: _________AM/PM

Other: _______________________________________________________

Meals/Snacks Served to Child While In Care: (Circle Meals)

Breakfast AM Snack Lunch PM Snack Supper Eve Snack

___________________________________ ________________________Parent Signature Date

Non-Discrimination Policy

Child Care Enrollment Form(This form must be renewed every year-annually)

In accordance with federal law and U.S. Department of Agriculture policy, this institution is prohibited from

discriminating on the basis of race, color, national origin, sex, age, or disability.

To file a complaint of discrimination, write USDA, Director, Office of Adjudication and Compliance, 1400

Independence Avenue, SW, Washington, D.C. 20250-9410 or call 202-260-1026, 866-632-9992 (toll free) or

202-401-0216 (TDD). USDA is an equal opportunity provider and employer.


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CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

July 2011 CACFP Meal Benefit Income EligibilityChild Care Form

Page 1

Part 1. All Household Members

Name of Enrolled Child(ren):

Names of all household members

(First, Middle Initial, Last)

CHECK IF A FOSTER CHILD (THELEGAL RESPONSIBILITY OF AWELFARE AGENCY OR COURT)* IF ALL CHILDREN LISTED BELOWARE FOSTER CHILDREN, SKIP TO

PART 5 TO SIGN THIS FORM. CHECK

IF NO INCOME

Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and case numberthe person who receives benefits. If no one receives these benefits, skip to part 3.

NAME:_________________________________________________ CASE NUMBER: _________________________________

Part 3. (Applies only to parents/guardians with children enrolled in a day care home) If any member of your househo

receives benefits listed on the enclosed List of Eligible Federal/State Funded Programs (H1660), provide the name of theprogram and case number: NAME: ___________________________________ CASE NUMBER: ____________Check here if no case number

Part 4. Total Household Gross IncomeYou must tell us how much and how often

A. Name(List only household members withincome)

B. Gross income and how often it was received

1. Earnings from workbefore deductions

2. Welfare, child support,alimony

3. Pensions, retirement,Social Security, SSI, VAbenefits

4. All Other Incom

(Example)

Jane Smith $200/weekly_____ $150/twice a month_ $100/monthly_____ $200/bi-monthly

$ / $ / $ / $ /

$ / $ / $ / $ /

$ / $ / $ / $ /

$ / $ / $ / $ /

$ / $ / $ / $ /

Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)

An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the lafour digits of his or her Social Security Number or mark the I do not have a Social Security Number box. (SeePrivacy Act Statement on the next page.)

I certify that all information on this form is true and that all income is reported. I understand that the center or day care homwill get Federal funds based on the information I give. I understand that CACFP officials may verify the information. Iunderstand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may

be prosecuted.

Sign here: _________________________________________ Print name: ________________________________________

Date: ____________________________

Address: ___________________________________________ Phone Number: _______________________

City:_______________________________________________ State: ________________ Zip Code: ________________

Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __ I do not have a Social Security Number


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CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

July 2011 CACFP Meal Benefit Income EligibilityChild Care Form

Page 2

Part 6. Participants ethnic and racial identities (optional)

Mark one ethnic identity: Mark one or more racial identities:

Hispanic or Latino

Not Hispanic or Latino

Asian American Indian or Alaska Native

White Native Hawaiian or Other Pacific Islander

Black or African AmericanPart 7. Sharing Information With Other Programs: OPTIONAL

The above information may be disclosed for the purpose of enrolling children in the Childrens Health Insurance Program(CHIP). Parents/guardians are not required to consent to such disclosure and electing not to allow disclosure will notadversely affect a childs eligibility.

I do elect to allow my household information to be disclosed.

I do not elect to allow my household information to be disclosed.

Dont fill out this part. This is for official use only.Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12

Total Income: ____________ Per:Week, Every 2 Weeks, Twice A Month,Month, Year Household size: _________Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___ Tier I_____ Tier II____

Reason: _____________________________________________________________________________________________________

Determining Officials Signature: _______________________________________________________________ Date: ______________

Confirming Officials Signature: ________________________________________________________________ Date: ______________

Follow-up Officials Signature: _________________________________________________________________ Date:______________

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application.You do not have to give the information, but if you do not, we cannot approve the participant for free or reduced pricemeals. You must include the last four digits of the Social Security Number of the adult household member who signs theapplication. The Social Security Number is not required when you apply on behalf of a foster child or you list a

Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program orFood Distribution Program on Indian Reservations (FDPIR) case number for the participant or other (FDPIR) identifieror when you indicate that the adult household member signing the application does not have a Social Security Number.We will use your information to determine if the participant is eligible for free or reduced price meals, and foradministration and enforcement of the Program.

Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordancewith Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basisof race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office ofAdjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice).Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Serviceat (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.


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Operation ID:

1222407

Child's Name: Date of Birth:

Child's Address: Child's Home Telephone No.:

Date of Admission: Drop Date: Attendance Hours: Child's Age: Child Lives With:

Mother's Name: DL#: Mother's Cell #: Mother's Employer: Mother's Wk #/Dept./Ext:

Father's Name: DL#: Father's Cell #: Father's Employer: Father's Wk #/Dept./Ext:

Circle Meals your child will be served daily: Circle days your child will attending:

Breakfast AM Snack Lunch PM Snack Supper Evening Snack Su M Tu W Th F Sa

Name to call in Emergency (If parents cannot be reached): Relationship to Child : Telephone No:

Name: Telephone No:

Name: Telephone No:

Name of Siblings:

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

Name of Physician: Address: Phone No.:

X__________________________________________________Signature - Parent or Legal Guardian Date

Please check all that apply:

TRANSPORTATION: I hereby give / do not give my consent for my child to be transported and supervised by facility's staff:

WATER ACTIVITIES: I hereby give / do not give my consent for my child to participate in water activities:

FIELD TRIPS: I hereby give / do not give my consent for my child to participate in field trips

__________________________________________________________

Name of School and the Address School Telephone No.

ENROLLMENT FORMFacility Name:

OAKDALE PRIVATE SCHOOL

Director Name:

Tammy Wildman

Name of Emergency Medical Care Facility:

Houston Northwest Medical Center

Address:

710 F.M. 1960 West Houston, Tx 77090

Phone No.:

281-440-1000

____________________________________________________________________

____________________________________________________________________

In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in

charge to take my child to:

I give consent for this facility to secure any and all necessary emergency

medical care for my child.

By signing this form, I acknowledge receipt of the facility's operational policies

including those for discipline and guidance. X__________________________________________________Signature - Parent or Legal Guardian Date

I hereby authorize the facility to allow my child to leave the facility ONLY with the following persons. Children will only be released to a parent or a

person designated by the parent/guardian after verification of ID, and to anyone listed on this form.

List any special problems that your child may have; such as allergies, existing illness, previous serious illness, injuries during the past 12 months, any

medication prescribed for long-term continuous use, and any other information which staff should be aware of: (Please provide documentation from

your child's doctor)

SCHOOL AGE CHILDREN: My child attends the following school and his/her immunization records are on file at the school and all

immunizations and the tuberculosis test are current. Vision and Hearing screening records are also on file.

____________________________________________

Please alert the front desk at any time to request to speak with the center director with any concerns about the center policies. Parents are allowed to visit and

observe their child at any time without securing approval. If parents would like to participate in operational activities please request to see the director. If you

would like to review the minimum standards or the most recent licensing inspection report, please notify the front desk to speak with the director. For further

assistance you may call local TDPRS office at: 713-940-5102 or www.tdprs.state.tx.us Abuse Hotline: 1-800-252-5400


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Name of Child: Date of Birth:

IMMUNIZATION Date / Dose 1 Date / Dose 2 Date / Dose 3 Date / Dose 4 Date / Booster

Hepatitis B (Hep B)

Rotavirus (RV)

Diphtheria, tetanus,

pertussis (DTaP)

Haemophilus influenza

type b (Hib)

Pneumococcal (PCV)

nactivated poliovirus

(IPV)

nfluenza

Measles, mumps, rubella

(MMR)

Varicella (VAR)

Hepatitis A (Hep A)

Meningococcal (MCV4)

TB Test (if required) Date:

Please check only one option:

Name and address of health care professional:

VISION ___PASS ___FAIL

HEARING 1000 Hz 2000 Hz 4000 Hz

R

L

___________________________________________________________________________

Signature

___________________________________

Date

X__________________________________________________________________________Signature - Parent or Legal Guardian

___________________________________

Date

___ PASS ___ FAIL

4. ___ 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.

X__________________________________________________________________________Signature - Parent or Legal Guardian ___________________________________DateR 20/ _______________ L 20/ ________________

___________________________________________________________________________

Health Care Professional's Signature

___________________________________

Date

2. ___ A signed and dated copy of a health care professional's statement is attached.

3. ___ 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.

___ I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official notarized affidavit form

developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.

For additional information regarding immunizations contact the Department of State Health Services at

www.dshs.state.tx.us/immunize/public.shtm

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.

1. ___ HEALTH-CARE PROFESSIONAL'S STATEMENT: I have examined the above named child within the past year and find that he / she is able

o take part in the day care program.

HEALTH REQUIREMENTS

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the

statement: My child had varicella disease (chickenpox) on or about (date) ________________ and does not need varicella vaccine.

________________________________________________________

Parent's Signature

______________________________________________________

Date

___ Negative___ Positive

__________________________________________________________________________________________________________

Signature or Stamp of Physician or Public Health Personnel verifying immunization information above

__________________________________________________

Date


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I have received and read this establishment's nondiscrimination policystatement and complaint procedures.

X___________________________________________________Signature

________________________

Date

Oakdale Private School

17100 Butte Creek Rd. Houston, Texas 77090

Tel. 281-444-4547

Fax 281-444-6139

NONDISCRIMINATION STATEMENT

This child care vender is in compliance with TITLE VI of the CIVIL

RIGHTS ACT of 1964 (Public Law 88-352); the AGE DISCRIMINATION

ACT of 1975 (Public Law 94-135), and the REHABILITATION ACT of

1973 (Public Law 93-112). This is an Equal Opportunity Program. No

person, in the United States shall, on the grounds of race, color,

national origin, age, sex, disability, political beliefs or religion, beexcluded from participation in, be denied the benefits of, or be otherwise

subjected to discrimination. If you believe you have been discriminated

against because of race, color, or religion, you may lodge a complaint

with this Day Care Center's Owner/Director, Tammy R. Wildman, or with

the Neighborhood Centers, Inc., and/or write immediately to the Civil

Rights Department, Texas Department of Human Services, P.O. Box

14030, Austin, Texas 78714-9030, Telephone 512-450-3630.


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Child's Name: _____________________________ Age: _______I give Oakdale Private School permission to administer First Aid to my child:

* In case of emergency, the school staff promptly contacts the parent(s).

Parent's Name: ___________________________________________________

Address: ________________________________________________________City State Zip

Home Telephone #: _______________________________________________

Work Telephone #: ___________________________ Dept./Ext.: ____________

Family Physician's Name: ___________________________________________

Office Telephone #: _______________________________________________

Name: _____________________________ Telephone #: _________________

Address: ___________________________ Relationship to Child: ___________

X___________________________________________________Signature of Parent or Guardian

_______________

Date

EMERGENCY INFORMATION

Street

IN CASE OF EMERGENCY WHEN NEITHER PARENT CAN BE REACHED, PLEASE CONTACT:

Oakdale Private School

17100 Butte Creek Rd Houston, Texas 77090

Tel. 281-444-4547

Fax 281-444-6139

FIRST AID PERMISSION AND EMERGENCY INFORMATION

* If neither parent, nor the emergency phone number can be reached, and

in case of a surgical emergency, I hereby give permission to the physician

selected by Oakdale Private School's Director to hospitalize and secure

proper treatment for my child as named above.


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DATE

TIME

CALLED

PERSON

CONTACTED REASON RESPONSE

STAF

INITIA

CONTACT LOG

combined enrollment packet

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