Requirements for enrollment at Oakdale Private School (Please allow 20-30 minutes upon enrollment) All spaces must

be filled out completely in this enrollment packet. 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 our school, 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!

Child Care Enrollment Form

(This form must be renewed every year-annually)

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 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.

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

Part 1. All Household Members Name of Enrolled Child(ren):
CHECK IF A FOSTER CHILD (THE LEGAL RESPONSIBILITY OF A WELFARE AGENCY OR COURT) * IF ALL CHILDREN LISTED BELOW ARE FOSTER CHILDREN, SKIP TO PART 5 TO SIGN THIS FORM.

Names of all household members (First, Middle Initial, Last)

CHECK IF NO INCOME

Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and case number for the 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 household receives benefits listed on the enclosed List of Eligible Federal/State Funded Programs (H1660), provide the name of the program 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
B. Gross income and how often it was received A. Name (List only household members with income)
(Example)

1. Earnings from work 2. Welfare, child support, before deductions alimony $200/weekly_____ $150/twice a month_

3. Pensions, retirement, Social Security, SSI, VA benefits $100/monthly_____

4. All Other Income

Jane Smith

$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 last four digits of his or her Social Security Number or mark the I do not have a Social Security Number box. (See Privacy 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 home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Sign here: _________________________________________ Date: ____________________________ Address: ___________________________________________ City:_______________________________________________ Phone Number: _______________________ State: ________________ Zip Code: ________________ Print name: ________________________________________

Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __

July 2011

I do not have a Social Security Number

CACFP Meal Benefit Income Eligibility Child Care Form Page 1

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)

Part 6. Participants ethnic and racial identities (optional) Mark one ethnic identity: Mark one or more racial identities: Hispanic or Latino Asian American Indian or Alaska Native Not Hispanic or Latino White Native Hawaiian or Other Pacific Islander Black or African American Part 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 not adversely 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 price meals. You must include the last four digits of the Social Security Number of the adult household member who signs the application. 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 or Food Distribution Program on Indian Reservations (FDPIR) case number for the participant or other (FDPIR) identifier or 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 for administration and enforcement of the Program. Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. 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, 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 Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and em ployer.

July 2011

CACFP Meal Benefit Income Eligibility Child Care Form Page 2

ENROLLMENT FORM
Facility Name: OAKDALE PRIVATE SCHOOL Child's Name: Child's Address: Date of Admission: Mother's Name: Father's Name: Drop Date: DL#: DL#: Attendance Hours: Mother's Cell #: Father's Cell #: Operation ID: 1222407 Director Name: Tammy Wildman Date of Birth: Child's Home Telephone No.: Child's Age: Mother's Employer: Father's Employer: Child Lives With: Mother's Wk #/Dept./Ext: Father's Wk #/Dept./Ext:

Circle Meals your child will be served daily: Breakfast AM Snack Lunch PM Snack Supper Evening Snack Name to call in Emergency (If parents cannot be reached):

Circle days your child will attending: Su M Tu W Th F Sa

Relationship to Child :

Telephone No:

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. Name: Name: Telephone No: Telephone No:

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)

____________________________________________________________________ ____________________________________________________________________ Name of Siblings: ____________________________________________________________________

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION: 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: Name of Physician: Name of Emergency Medical Care Facility: Houston Northwest Medical Center Address: Address: 710 F.M. 1960 West Houston, Tx 77090 Phone No.: Phone No.: 281-440-1000

I give consent for this facility to secure any and all necessary emergency medical care for my child. Please check all that apply: TRANSPORTATION:
I hereby give / do not give

X__________________________________________________
Signature - Parent or Legal Guardian Date

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

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. __________________________________________________________ Name of School and the Address ____________________________________________ School Telephone No.

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 By signing this form, I acknowledge receipt of the facility's operational policies including those for discipline and guidance.

__________________________________________________ Signature - Parent or Legal Guardian Date

HEALTH REQUIREMENTS
Name of Child: IMMUNIZATION Hepatitis B (Hep B) Rotavirus (RV) Diphtheria, tetanus, pertussis (DTaP) Haemophilus influenza type b (Hib) Pneumococcal (PCV) Inactivated poliovirus (IPV) Influenza Measles, mumps, rubella (MMR) Varicella (VAR) Hepatitis A (Hep A) Meningococcal (MCV4) TB Test (if required) ___ Positive ___ Negative Date: Date / Dose 1 Date / Dose 2 Date / Dose 3 Date of Birth: Date / Dose 4 Date / Booster

__________________________________________________________________________________________________________ __________________________________________________ Signature or Stamp of Physician or Public Health Personnel verifying immunization information above 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 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 2. ___ A signed and dated copy of a health care professional's statement is attached. ___________________________________ Date

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:

X__________________________________________________________________________
Signature - Parent or Legal Guardian VISION R 20/ _______________ ___________________________________________________________________________ Signature HEARING R L 1000 Hz 2000 Hz 4000 Hz

___________________________________ Date ___PASS ___FAIL

L 20/ ________________

___________________________________ Date

___ PASS ___ FAIL

X__________________________________________________________________________
Signature - Parent or Legal Guardian

___________________________________ 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, be excluded 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. I have received and read this establishment's nondiscrimination policy statement and complaint procedures.

X___________________________________________________
Signature

________________________ Date

Oakdale Private School 17100 Butte Creek Rd Houston, Texas 77090 Tel. 281-444-4547 Fax 281-444-6139 FIRST AID PERMISSION AND EMERGENCY INFORMATION 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). * 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.

X___________________________________________________
Signature of Parent or Guardian

_______________ Date

EMERGENCY INFORMATION Parent's Name: ___________________________________________________ Address: ________________________________________________________

Street City State Zip

Home Telephone #: _______________________________________________ Work Telephone #: ___________________________ Dept./Ext.: ____________ Family Physician's Name: ___________________________________________ Office Telephone #: _______________________________________________
IN CASE OF EMERGENCY WHEN NEITHER PARENT CAN BE REACHED, PLEASE CONTACT:

Name: _____________________________ Address: ___________________________

Telephone #: _________________ Relationship to Child: ___________

CONTACT LOG
DATE TIME PERSON CALLED CONTACTED REASON RESPONSE STAFF INITIALS