K-n-K Development Center - Inspirational Church

We Provide Quality Service
– Infant, Toddler, and After School Care!

HOURS OF OPERATION:

Monday – Friday
6:30 am to 6:00 pm

PHONE:

(210) 648-5430

After School Pickup Available!

THE STUDENTS WILL BE TAUGHT THE FOLLOWING:

Alphabets
Numbers
Basic math
Science
Language
Reading and writing
Maps
Sign language
And a little Spanish
Activities to reinforce their learning

Our MOTTO

I dreamt I stood in a studio
And watched two sculptors there.
The clay they used was a young child’s mind,
One was a teacher and caregiver –
the tools she used
Were books, toys, music, and art.
The Other, a parent,
worked with guiding hand,
And a gentle loving heart
Day after day, the teacher toiled with touch
That was skillful and sure,
While the parent labored by his side
And polished and smoothed it over.
And When, at last, their task was done,
They were proud of what they had wrought,
For the things they had molded into the child,
Could neither be sold nor brought
And each agreed they would have failed
If each had worked alone,
For behind the teacher stood the child care center,
And behind the parent, a loving home.

Application

Child's Full Name:

First Name

Last Name

Child's Date of Birth:

Child Lives With:

Both Parents Mom Dad Guardian

Child's Home Address:

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Date of Admission:

Date of Withdrawal:

Name of Parent or Guardian Completing Form:

Address of Parent or Guardian (if different from the child's):

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

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

Parent 1 Telephone Number:

Parent 2 Telephone Number:

Guardian's Telephone Number:

Custody Documents on File:

Yes No

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

Relationship:

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

Name 1:

Phone 1:

Name 2:

Phone 2:

Name 3:

Phone 3:

Consent Information

Check All That Apply: 1. Transportation: I 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 - Information:

I give consent for my child to participate in field trips. I do not give consent for my child to participate in field trips

3. Water Activities: I give consent for my child to be transported and supervised by the operation's employees

5. Meals (Summer Food Program June - August) I understand that the following meals will be served to my child while in care:

6. Days and Times in Care Monday AM/PM times:

Tuesday AM/PM times:

Wednesday AM/PM times:

Thursday AM/PM times:

Friday AM/PM times:

Saturday AM/PM times:

Sunday AM/PM times:

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:

Physician's Address:

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Name of Emergency Care Facility:

Address:

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone:

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

Child's Additional Information Section

List any special needs that your child may have, such as environmental allergies, food intolerances, 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 caregivers should be aware of::

Does your child have diagnosed food allergies?

Yes No

Plan Submitted on:

Child day care 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 Signed:

My child attends the following school:

School Phone Number:

My child has permission to (check all that apply):

walk to or from school or home ride a bus be released to the care of his/her sibling under 18 years old

Authorized pick up/drop off locations other than the child’s address:

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

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

Yes No

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. 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 or she is able to take part in the day care program. 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 submit it to the child care operation.

Selection #1 requires the First and Last name - Health Care Professional

Date

Address of Health Care Professional:

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Signature — Parent or Legal Guardian:

Date Completed:

Requirements:

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 Exam Results

Right Eye 20/ Left Eye 20/

Pass Fail

Name:

Date Signed

Right Ear: 1000 Hz 2000 Hz 4000 Hz

Left Ear: 1000 Hz 2000 Hz 4000 Hz(1)

Pass or Fail:

Pass Fail

Hearing Exam Results Name:

Hearing Exam Results Date:

Vaccine Information

The following vaccines require multiple doses over time. Please provide the date your child received each dose.

Hepatitis B Birth (first dose)

Hepatitis B 1–2 months (second dose)

Hepatitis B 6–18 months (third dose)

Rotavirus Birth 2 months (first dose)

Rotavirus 4 months (second dose)

Rotavirus 6 months (third dose)

Diphtheria, Tetanus, Pertussis 2 months (first dose)

Diphtheria, Tetanus, Pertussis 4 months (second dose)

Diphtheria, Tetanus, Pertussis 6 months (third dose)

Diphtheria, Tetanus, Pertussis 15–18 months (fourth dose)

Diphtheria, Tetanus, Pertussis 4–6 years (fifth dose)

Haemophilus Influenza Type B 2 months (first dose)

Haemophilus Influenza Type B 4 months (second dose)

Haemophilus Influenza Type B 6 months (third dose)

Haemophilus Influenza Type B 12–15 months (fourth dose)

Pneumococcal 2 months (first dose)

Pneumococcal 4 months (second dose)

Inactivated Poliovirus 2 months (first dose)

Inactivated Poliovirus 4 months (second dose)

Inactivated Poliovirus 6–18 months (third dose)

Inactivated Poliovirus 4–6 years (fourth dose)

Influenza - Yearly, starting at 6 months. Two doses given at least four weeks apart are recommended for children who are getting the vaccine for the first time and for some other children in this age group.

Measles, Mumps, Rubella 12–15 months (first dose)

Measles, Mumps, Rubella 4–6 years (second dose)

Varicella 12–15 months (first dose)

Varicella 4–6 years (second dose)

Hepatitis A 12–23 months (first dose)

Hepatitis A The second dose should be given 6 to 18 months after the first dose.

Varicella (Chickenpox)

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

Signature:

Date Signed

Additional Information Regarding Immunizations

For additional information regarding immunizations, visit the Texas Department of State Health Services website at www.dshs.state.tx.us/immunize/public.shtm.

TB Test (If Required)

TB Test:

Positive Negative

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

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. HHSC values your privacy. For more information, read our privacy policy online at: https://hhs.texas.gov/policies-practicesprivacy#security

Child's Parent or Legal Guardian:

Date Signed.

Center Designee:

Date Signed_Center Designee:

We Provide Quality Service – Infant, Toddler, and After School Care!

HOURS OF OPERATION:

PHONE:

THE STUDENTS WILL BE TAUGHT THE FOLLOWING:

Our MOTTO

Application

Consent Information

Authorization For Emergency Medical Attention

Child's Additional Information Section

Admission Requirement

Vision Exam Results

Vaccine Information

Varicella (Chickenpox)

Additional Information Regarding Immunizations

TB Test (If Required)

Gang Free Zone

Privacy Statement

We Provide Quality Service
– Infant, Toddler, and After School Care!