FBC FIRST STEPS PRESCHOOL AND MOTHER'S DAY OUT REGISTRATION

Child's Full Name *

Gender *

Male

Female

Child's Date of Birth * +

Child's Street Address *

City *

State *

Zip Code *

I am registering my child for the fall/spring: (please select one) *

MDO Options (please select one): *

MDO - Tuesday only

MDO - Thursday only

MDO - Both Tuesday & Thursday

Do you need Extended Preschool (12:00 p.m.- 2:30 p.m.) *

Tuesday only

Thursday only

Both Tuesday & Thursday

None

Are you also registering for Summer Fun Days? *

Yes

No

Summer Fun Days

Tuesday Only

Thursday Only

Both Days

Mother's Name *

Mother's Cell Number *

Mother's Email Address *

Mother's Street Address *

City *

State *

Zip Code *

Father's Name

Father's Cell Number

Father's Email Address

Street Address

City

State

Zip Code

Please give the names of a person to call in case of emergency if parents can not be reached

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relation to Child *

Emergency Contact Street Address *

City *

State *

Zip Code *

Are you currently a member of a church? If so, where?

MEDICAL INFORMATION

Name of licensed physician *

Phone Number *

Hospital Preference *

Other Hospital: Name, Address, Phone Number *

Physician Address (Street, City, State, Zip) *

List any special problems your child may have such as ALLERGIES, existing or previous illnesses, injuries or hospitalizations, or any medications prescribed for long-term continuous use and any other information which caregivers should be aware of. Please type NONE if not applicable. *

Does you child have a DIAGNOSED FOOD ALLERGY? *

Yes

No

If yes to DIAGNOSED FOOD ALLERGY, please explain briefly *

Does your child have a food intolerance? *

Yes

No

If yes to food intolerance, please explain briefly *

We understand parents may have specific food preferences. If there is something you would like us to know so we can be helpful, please explain briefly. If none, please type NONE *

List any special care needs your child may have, such as:
Any limitations or restrictions on the child’s activities; Special care the child requires, including: Any reasonable accommodations or modifications; Any adaptive equipment provided for the child, including instructions for how to use the equipment; (iii) Symptoms or indications of potential complications related to a physical, cognitive, or mental condition that may warrant prevention or intervention while the child is in care

I understand that I am required to provide my child's immunization records or state affidavit PROIR to the first day of school. If these are not provided, I understand that my child WILL NOT be allowed to attend. *

Yes

IMMUNIZATION RECORDS *

I will attach a copy of my child's current immunization records.

I will mail/drop off a copy of my child's immunization records.

Attach Immunization Records Here

HEALTH CARE PROFESSION STATEMENT *

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. I will mail/drop off a copy of my child's immunization records.

Attached is a signed and dated copy of a health care professional’s statement.

Attach Health Care Professional Statement Here

MEDICAL EXCLUSION Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization or of reason of conscience, which I adhere to or am a member of; I have attached a signed and dated affidavit stating this. Please answer NO if this does not apply. *

YES

NO

Attach signed and dated medical exclusion affidavit here.

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. Has your child had the chickenpox? *

YES

NO

My child had varicella disease (chickenpox) on or about the following date: * +

AUTHORIZATION FOR 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 either the licensed physician or hospital listed above. I give my consent for the physician or facility to secure any and all necessary emergency medical care for my child.

clear

ACTIVITIES PERMISSION FORM

FIELD TRIPS/TRANSPORTATION: First Steps will provide van transportation for field trips. However, you may arrange to drive your child to the field trip. First Steps may take short walking field trips that are a regular part of the program.

I understand that:

I will be notified in writing before a field trip takes place informing me of the destination and time of the trip.

If I do not wish for my child to participate in a particular field trip, I should keep

him/her home on that day as there will not be adequate supervision for him/her in the classroom.

I understand I must install my child’s car safety seat in the field trip van due to a mandate by the State of Texas to provide transportation.

My child may participate in school sponsored field trips *

YES

NO

PHOTOS: Your child/family may be photographed and/or videoed in his or her classroom or at class parties. We may use these photos for educational and program promotional material. Additionally, we may post these photos to our church’s website: www.firstamarillo.org.

I give permission for my child/family photos and videos to be used in educational and promotional literature and also on FBC Amarillo’s website. *

YES

NO

I give permission for my child’s information to be listed in the class directory. *

YES

NO

WATER FUN: Occasionally, we may have water activities here on campus such as sprinkler play,
splashing/wading pools, slip n slide, inflatables, and water table play. In the event of this you will be notified in writing before the event takes place.

I give my child consent to participate in the following water activities: *

Water Table Play

Sprinkler Play

Splashing/Wading Pools

Aquatic Playgrounds

DIRECTORY: Occasionally, our teachers may decide to put together a Class Directory with your child’s name, address, and phone number listed. This directory is used only for classroom needs such as invitations to birthday parties, thank you cards, etc.

Even though the following questions do not pertain to our program, we are required to include them:

Can your child swim without assistance *

Yes

No

Does your child have any physical, health, behavioral, or other condition that would put them at risk while swimming? *

Yes

No

Do you want your child to wear a life jacket while in or near a pool? *

Yes

No

LUNCH AND SNACKS

I do understand that if my child stays for Extended Preschool, I am responsible for providing my child a lunch *

YES

I do understand that I am responsible for providing my child a daily snack. *

YES

I do understand that First Steps is a peanut/tree nut free facility. I will not include any item containing peanuts/tree nuts in my child's snack or lunch. *

YES

By signing below, I agree to all the above selections for the entire school year, unless I notify the program in writing. *

clear

SECURITY INFORMATION

We are committed to keeping each child safe. We have security protocols in place to ensure this happens. One is the use of security codes. If you or anyone listed in your child’s file cannot pick up your child, please call us and tell us who will be coming and then you will need to give that person your security code. Once we verify their I.D. and hear them say the security code, we will release your child to the approved person. Security codes can be sibling’s names or pet’s names, nicknames, favorite sports team, simply anything you can remember in case of an emergency.

Child's Name *

Security Code *

AUTHORIZED RELEASE #1
I authorize First Steps to release my child to the following individual (other than parents): *

Phone Number: *

AUTHORIZED RELEASE #2
I authorize First Steps to release my child to the following individual (other than parents): *

Phone Number: *

Do not release my child to the following: Please list name(s). If not applicable, please state N/A. *

RECEIPT OF HANDBOOK

The 2024-2025 Operational Policies & Parent Handbook is available on the internet at:
FIRST AMARILLO - FIRST STEPS We are asking that you consider using the internet to access and review the 2024-2025 Handbook. Using the internet to access the handbook will limit the amount of printed paper at the time of registration. If any changes occur in the handbook, a note will be sent home with your child explaining the changes and a sheet for parents to sign.

Please check one box and sign below: *

I will review the 2024-2025 Operational Policies & Parent Handbook on the internet. My signature below acknowledges receipt of the Operational Policies & Parent Handbook.

I prefer a paper copy of the Operational Policies & Parent Handbook.

I acknowledge receipt of the Operation Policies & Parent Handbook. *

clear

PARENT'S RIGHTS

A parent or guardian of a child at a child care facility has the right to:

(1) enter and examine the child care facility during the facility’s hours of operation without advanced notice;

(2) review the child care facility’s publicly accessible records;

(3) receive inspection reports for the child care facility and information about how to access the facility’s online compliance history;

(4) obtain a copy of the child care facility’s policies and procedures;

(5) review, at the request of the parent or guardian, the facility’s:
(A) staff training records; and
(B) any in-house staff training curriculum used by the facility;

(6) review the child care facility’s written records concerning the parent’s or guardian’s child;

(7) inspect any video recordings of an alleged incident of abuse or neglect involving the parent’s or guardian’s child, provided that:
(A) video recordings of the alleged incident are available;
(B) the parent or guardian of the child does not retain any part of the video recording depicting a child that is not their own; and
(C) the parent or guardian of any other child captured in the video recording receives written notice from the facility before allowing a parent to inspect a recording;

(8) have the child care facility comply with a court order preventing another parent or guardian from visiting or removing the parent’s or guardian’s child;

(9) be provided the contact information for the child care facility’s local Child Care Regulation office;

(10) file a complaint against the child care facility by contacting the local Child Care Regulation office; and

(11) be free from any retaliatory action by the child care facility for exercising any of the parent’s or guardian’s rights.

I acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility. *

clear