Form 2935 PDF Details

The Texas Department of Family and Protective Services Form 2935, commonly referred to as the Admission Information Form, is a comprehensive document designed to collect crucial details about children as they are admitted into daycare operations. This form, updated in August 2010, spans across three pages, capturing a wide array of information that includes the child's full name, date of birth, home address, and the dates of admission and withdrawal. It also asks for detailed contact information for the parents or guardians, including addresses and telephone numbers where they can be reached during the day, and designates who is authorized to pick up the child from the daycare. Additionally, the form delves into various consents and acknowledgments from parents or guardians concerning transportation, field trips, water activities, the receipt of the daycare's operational policies, meal provisions, and the child's routine care schedule. Emphasizing health and safety, it includes an authorization for emergency medical attention, specifying contact details for a preferred physician and emergency medical care facility. This section is crucial for ensuring swift action during emergencies if the parent or guardian cannot be reached. Furthermore, the document outlines requirements for submitting immunization records and health care professional's statements to confirm the child's fitness for daycare participation. It even accommodates religious or conscience-based exemptions to standard immunization requirements, reflecting a thoughtful approach to inclusivity and respect for diverse beliefs. The Form 2935 is an essential tool in fostering a safe, well-organized, and responsive care environment for children, demonstrating the Texas Department of Family and Protective Services' commitment to their wellbeing and safety.

QuestionAnswer
Form NameForm 2935
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other nameswform 2935, how to form 2935, texas daycare form 2935, form 2935 admission information

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Texas Dept of Family and Protective Services

ADMISSION INFORMATION

Form 2935 Aug 2010 / Pg 1 of 3

Operation Name

 

 

Director’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Full Name

 

 

Child’s Date of Birth

Child’s Home Telephone No.

 

 

 

 

 

 

 

 

 

 

 

Child’s Home Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Admission

Date of Withdrawal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent’s or Guardian’s Name

 

 

Address (if different from child’s address)

 

 

 

 

 

 

 

 

 

 

 

 

List telephone numbers below where parents/guardian may be reached while child will be in care:

 

 

 

 

 

Mother’s Telephone No.

 

Father’s Telephone No.

 

Guardian’s Telephone No.

 

 

Cell Phone No

 

 

 

 

 

 

 

 

Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached:

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name & telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

CHECK ALL THAT APPLY:

1. TRANSPORTATION: Walk home

I hereby

give

do not give

− consent for my child to be transported and supervised by the

 

 

 

 

operation’s employees:

 

for emergency care

on field trips

to and from home

to and from school

2.

FIELD TRIPS:

I hereby

give

do not give

− my consent for my child to participate in Field Trips:

 

Parent’s Comments:

 

 

 

 

 

 

3.

WATER ACTIVITIES:

I hereby

give

do not give

− my consent for my child to participate in Water Activities:

 

 

 

sprinkler play

splashing/wading pools

swimming pools

water table play

4.

RECEIPT OF WRITTEN OPERATIONAL POLICIES:

 

 

 

 

 

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

 

 

5. I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE:

 

 

 

None

Breakfast

AM Snack

Lunch

PM Snack

Supper

Evening Snack

 

 

6. MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES:

 

 

 

 

Mondays

from:

 

to:

 

 

 

 

 

Tuesdays

from:

 

to:

 

 

 

 

 

Wednesdays

from:

 

to:

 

 

 

 

 

Thursdays

from:

 

to:

 

 

 

 

 

Fridays

from:

 

to:

 

 

 

 

 

Saturdays

from:

 

to:

 

 

 

 

 

Sundays

from:

 

to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:

In the event 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:

Address:

Ph.#:

Name of Emergency Medical Care Facility:

Address:

Ph.#:

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

Signature - Parent or Legal Guardian

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of:

Child daycare operations are public accommodations 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 at (800) 514-0301 (voice) or (800)-514-0383 (TTY).

Signature – Parent or Legal Guardian

Date

Texas Dept of Family and Protective Services

ADMISSION INFORMATION

Form 2935 Aug 2010 / Pg 2 of 3

SCHOOL AGE CHILDREN:

My child attends the following school:

Name of School and Address

CHECK ALL THAT APPLY:

His / her immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. Vision and Hearing screening records are also on file.

Name of sibling(s):

My child has permission to:

ride a bus, and/or

School Ph.#

walk to or from school or home,

be released to the care of his/her sibling(s) under 18 years old.

IMMUNIZATION RECORD:

I have provided the childcare operation with a copy of my child’s most current immunization record.

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.

Please check only one option:

1. HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is able to take part in the day care program.

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.

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.

Name and address of health care professional:

 

 

Signature - Parent or Legal Guardian

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VISION

R 20/ ________

 

 

L 20/ ________

PASS

FAIL

 

 

 

 

 

 

 

 

SIGNATURE ____________________________________________

 

DATE _____________________________________

 

 

 

 

 

 

 

 

 

 

 

HEARING

1000 Hz

 

2000 Hz

4000 Hz

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

PASS

FAIL

 

L

 

 

 

 

 

 

 

 

SIGNATURE ___________________________________________

 

DATE ______________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature – Parent or Legal Guardian

Date

Texas Dept of Family and Protective Services

ADMISSION INFORMATION

Form 2935 Oct 2008 / Pg 3 of 3

HEALTH REQUIREMENTS

Name of Child:

Date of Birth:

Age ►

Vaccine ▼

Birth

1 mos

 

 

2 mos 4 mos 6 mos 12 mos 15 mos 18 mos

19-23

Mos

2-3 Yrs 4-6 Yrs

Hepatitis B

Rotavirus

Diphtheria, Tetanus, Pertussis

Haemophilus influenzae type b

Pneumococccal

Inactivated Poliovirus

Influenza

Measles, Mumps,

Rubella

Varicella

Hepatitis A

Meningococcal

TB TEST (if required)

Positive

Negative

Date:

Signature or stamp of a physician or public health personnel verifying immunization information above.

 

Signature

Date

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

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

Signature – Parent or Legal Guardian

Date

How to Edit Form 2935 Online for Free

dfps admission form can be completed online with ease. Simply open FormsPal PDF tool to finish the job fast. In order to make our tool better and simpler to utilize, we continuously design new features, with our users' feedback in mind. It merely requires a couple of basic steps:

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This document requires specific information to be typed in, hence be sure to take some time to type in exactly what is asked:

1. To begin with, while filling out the dfps admission form, start out with the section that includes the subsequent blank fields:

2935 form writing process described (portion 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Name, Name, Phone Number, Phone Number, Check All That Apply, Consent Information, for emergency care, on field trips, to and from home, to and from school, Field Trips, I give consent for my child to, and Comments with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part # 2 of filling in 2935 form

Regarding Check All That Apply and on field trips, be certain that you double-check them in this current part. Those two are thought to be the most important ones in the form.

3. Completing Water Activities I give consent, water table play, sprinkler play, swimming pools, aquatic playgrounds, Receipt of Written Operational, Discipline and guidance, Suspension and expulsion, Emergency plans, Procedures for conducting health, Safe sleep, Procedures for release of children, Illness and exclusion criteria, Procedures for dispensing, and Immunization requirements for is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Guidelines on how to prepare 2935 form portion 3

4. To move ahead, this part involves filling in a handful of blanks. These include Day of the Week, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, Authorization For Emergency, In the event I cannot be reached, Phone Number, Address, Name of Emergency Care Facility, Address, and Phone Number, which you'll find fundamental to continuing with this form.

The way to prepare 2935 form step 4

5. To conclude your form, the final part has a few additional blank fields. Filling out List any special needs that your, Does your child have diagnosed, Yes, Plan Submitted on, Child day care operations are, Signature Parent or Legal Guardian, Date Signed, My child attends the following, School Phone Number, School Age Children, My child has permission to check, walk to or from school or home, ride a bus, be released to the care of hisher, and Authorized pick updrop off will wrap up everything and you're going to be done in no time!

Child day care operations are, Authorized pick updrop off, and School Phone Number inside 2935 form

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