New Admission Application

Texas HHSC Form 2935 · Complete all sections and submit electronically. A copy will be sent to director@excelsouthlake.com

General Info

Consents

Schedule

Child Info

Immunizations

Signatures

Fields marked * are required.

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General Information

Basic details about the child and family

Operation Details

Operation's Name

Director's Name

Child Information

Child's Full Name *

Child's Date of Birth *

Child Lives With *

Both Parents Mom Dad Guardian

Child's Home Address *

Date of Admission

Parent / Guardian Information

Name of Parent or Guardian *

Email Address *

Guardian Address (if different from child's)

Parent 1 Telephone *

Parent 2 Telephone

Guardian's Telephone

Custody Documents on File?

Yes No

Emergency Contact

If parents/guardian cannot be reached, contact the following responsible individual:

Emergency Contact Name *

Phone Number *

Relationship

Authorized Pickup Persons

I authorize the child care operation to release my child ONLY to the following persons (in addition to parents/guardians):

Name

Phone Number

Name

Phone Number

Name

Phone Number

Step 1 of 6

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Days and Times in Care

Enter the days and hours your child will be in care

Day of the Week	AM (Drop-off Time)	PM (Pick-up Time)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday	N/A	N/A
Sunday	N/A	N/A

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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

Phone Number

Address of Physician

Name of Emergency Care Facility

Emergency Facility Address

Emergency Facility Phone

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

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School Age Children

Complete this section only if applicable

School My Child Attends

School Phone Number

My child has permission to:

Walk to/from school or home Ride a bus Be released to care of sibling under 18

Authorized pick-up/drop-off locations (other than child's address)

Step 3 of 6

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Child's Additional Information

Health, allergies, and special needs

          List any special needs 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 caregivers should be aware of:
        

Does your child have diagnosed food allergies? *

Yes No

If Yes — Plan Submitted On

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 within one week of admission. Check only one option:

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. A signed and dated copy of a health care professional's statement is attached. 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. My child has been examined within the past year and is able to participate. Within 12 months of admission, I will obtain a health care professional's signed statement.

Health Care Professional Name

Health Care Professional Address

Step 4 of 6

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Immunization Record

Enter the date your child received each vaccine dose

The following vaccines require multiple doses over time. Please provide the date your child received each dose. Leave blank if not yet received.

Vaccine	Dose	Date Received
Hepatitis B	Birth (1st dose)
	1–2 months (2nd dose)
	6–18 months (3rd dose)
Rotavirus	2 months (1st dose)
	4 months (2nd dose)
	6 months (3rd dose)
Diphtheria, Tetanus, Pertussis (DTaP)	2 months (1st dose)
	4 months (2nd dose)
	6 months (3rd dose)
	15–18 months (4th dose)
	4–6 years (5th dose)
Haemophilus Influenza Type B (Hib)	2 months (1st dose)
	4 months (2nd dose)
	6 months (3rd dose)
	12–15 months (4th dose)
Pneumococcal (PCV)	2 months (1st dose)
	4 months (2nd dose)
	6 months (3rd dose)
	12–15 months (4th dose)
Inactivated Poliovirus (IPV)	2 months (1st dose)
	4 months (2nd dose)
	6–18 months (3rd dose)
	4–6 years (4th dose)
Influenza	Yearly starting at 6 months
Measles, Mumps, Rubella (MMR)	12–15 months (1st dose)
Measles, Mumps, Rubella (MMR)	4–6 years (2nd dose)
Varicella (Chickenpox)	12–15 months (1st dose)
Varicella (Chickenpox)	4–6 years (2nd dose)
Hepatitis A	12–23 months (1st dose)
Hepatitis A	6–18 months after 1st dose (2nd dose)

Varicella Note: If child has had chickenpox disease, enter date:

Leave blank if vaccination was received instead

Vision Screening

Right Eye 20/___

Left Eye 20/___

Pass Fail

TB Screening

Positive Negative

Date of TB Test

Step 5 of 6

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Signatures & Submission

Review and sign to submit your application

          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: HHSC values your privacy. For more information, read our privacy policy at hhhs.texas.gov/policies-practices-privacy#security
        

Parent / Legal Guardian Signature *

By typing your full name below, you confirm that all information provided is accurate and you agree to the terms stated in this form (Texas HHSC Form 2935).

Type your full legal name as your electronic signature:

Child's Parent or Legal Guardian

Date *

Emergency Medical Authorization Signature

Authorizing emergency medical care for child

Date Signed

📧 Application Submission

Upon submission, this application will be sent to director@excelsouthlake.com. You will also be able to download a PDF copy for your records.

Submitting parent email:

Child name:

Step 6 of 6

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Application Submitted!

Thank you! Your application has been automatically sent to Excel Academy. The director will contact you within 1–2 business days. You can also download a PDF copy for your records.

Questions? Call (817) 421-1333 or email director@excelsouthlake.com

Submitting your application...