Woodcrest Mother's Day Out and Preschool Enrollment Application

Phone number *

Your occupation *

Address *

Does the child live with you? *

Other parent/guardian's first name

If applicable

Other parent/guardian's last name

If applicable

Date of Admission *

What date is your child planning to begin attending the program?

Child's full name *

Child's date of birth *

Child's gender *

Emergency contact name *

Someone who is not listed above. This number will be called in the event the parents or guardians are unable to be reached.

Emergency contact telephone number *

Emergency contact's relationship to child *

Persons who can pick up child. *

Children will ONLY be released to parents or persons listed herein after verification of ID. Please list Full Name and Phone Number for each person. (You do not need to list parents' names again.)

My child will normally be in care at Woodcrest on the following days: (Check all that apply) *

Woodcrest is closed Fridays, Saturdays, and Sundays.

Mondays

Tuesdays

Wednesdays

Thursdays

I acknowledge receipt of the facility's operational policies including those for discipline and guidance. *

I am aware that Woodcrest will be serving a morning snack to my child. I will provide their lunch. *

I give permission for my child to attend field trips as long as I receive written notice prior to the trip. *

I give permission for my child to be transported by employees of Woodcrest in case of an emergency. *

I give permission for my child to participate in water activities, including sprinkler play, water table play, and splashing/wading pools. *

Authorization for Emergency Medical Attention

If I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

Name of Physician: *

Physician's address: *

Physician's telephone number *

Name of Hospital: *

Hospital address: *

Hospital telephone number: *

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

Digital Signature (PRINT FULL NAME) *

By filling out this field, I agree to the terms and conditions regarding emergency response for my child as outlined in the facility's operational policies.

Health Admission Requirement *

One of the following must be presented when your child is admitted; please check only one:

1. A signed and dated copy of a health care professional's statement is attached or on file.

2. A signed and dated affidavit is attched stating that medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization which I adhere to or am a member of.

3. My child has been examined within the past year by a health care professional. I will submit a health care professional's signed statement prior to my child attending class.

Name and address of Heath Care Professional: *

Digital Signature (PRINT FULL NAME) *

By filling out this field, I agree to the terms and conditions regarding health admission for my child as outlined in the facility's operational policies.

Immunization Record *

One (only one) of the following must be presented before your child can attend child care:
(Immunization record can be excluded 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 two years.)

I will provide the child care operation with a copy of my child's most current immunization record.

I am excluding my child from the immunization requirements for the reasons listed above.

For additional information regarding immunizations contact the Department of State Health Services at: www.dshs.state.tx.us/immunize/public.shtm

Child daycare operations are public accomodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line t (800) 514-0301 (voice) or (800) 514-0383 (TTY).

Digital Signature (PRINT FULL NAME) *

By filling out this field, I agree that all information above is accurate and truthful.

Today's date *

Woodcrest Mother's Day Out Media Release

Parent’s Name *

Child’s Name *

Today's date *

I give permission for still photos, action video, digital images and/ or audio recordings of my child to be made by Woodcrest MDO for the following forms of media:

(check all that apply)

Photographs used in brochures, newspaper ads, etc for publicity

Photographs or videos on MDO or church website or social media pages (including Facebook, Instagram, X/Twitter, and any others operated by Woodcrest Methodist MDO)

Photographs used to create slide show at the end of the year

Photographs for scrapbooks or other parent/family purposes only

Additional contact methods

In addition to reaching me by telephone, I also give Woodcrest teachers and staff permission to contact me by:

Email

Text message

Social media

Digital Signature (PRINT FULL NAME) *

By filling out this field, I agree that all information above is accurate and truthful.

Today's date *