Form 2935 - Admission Information Page 2
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1
2Texas Dept of Family
Form 2935
ADMISSION INFORMATION
and Protective Services
Page 1 of 2
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
HEALTH REQUIREMENTS
Name of Child:
Name of Child:
Name of Child:
Name of Child:
Name of Child:
Name of Child:
Date of Birth:
Date of Birth:
Date of Birth:
Date of Birth:
IMMUNIZATIONS
IMMUNIZATIONS
Date / dose 1
Date / dose 2
Date / dose 2
Date / dose 3
Date / dose 4
Date / dose 4
Date / dose 4
Date / booster
Hepatitis B
Hepatitis B
Rotavirus
Rotavirus
Diphtheria, Tetanus,
Diphtheria, Tetanus,
Pertussis
Pertussis
Haemophilus influenzae
Haemophilus influenzae
type b
type b
Pneumococcal
Pneumococcal
Conjugate Vaccine
Conjugate Vaccine
Inactivate Poliovirus
Inactivate Poliovirus
Influenza
Influenza
Measles, Mumps,
Measles, Mumps,
Rubella
Rubella
Varicella
Varicella
(see below)
(see below)
Hepatitis A
Hepatitis A
Meningococcal
Meningococcal
TB TEST (if required)
TB TEST (if required)
Positive
Negative
Negative
Date:
Date:
Date:
Date:
Date:
Signature or stamp of a physician or public health
Signature or stamp of a physician or public health
Signature or stamp of a physician or public health
Signature or stamp of a physician or public health
Signature or stamp of a physician or public health
Signature or stamp of a physician or public health
Signature or stamp of a physician or public health
Signature or stamp of a physician or public health
personnel verifying immunization information above.
personnel verifying immunization information above.
personnel verifying immunization information above.
personnel verifying immunization information above.
personnel verifying immunization information above.
personnel verifying immunization information above.
personnel verifying immunization information above.
personnel verifying immunization information above.
Signature
Signature
Signature
Date
Date
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement:
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.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
My child had varicella disease (chickenpox) on or about (date) _____________________ and does not need varicella vaccine.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
Parent’s signature
Parent’s signature
Parent’s signature
Parent’s signature
Parent’s signature
Parent’s signature
Parent’s signature
Parent’s signature
Parent’s signature
Parent’s signature
Date
Date
Date
Date
Date
Date
Date
Date
Date
Date
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
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.
notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
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
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
For additional information regarding immunizations contact the Department of State Health Services at
school_info.html
school_info.html
school_info.html
school_info.html
school_info.html
school_info.html
school_info.html
school_info.html
school_info.html
school_info.html
ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following
ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following
ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following
ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following
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.
must be presented when your child is admitted to the child-care operation or within one week of admission.
must be presented when your child is admitted to the child-care operation or within one week of admission.
must be presented when your child is admitted to the child-care operation or within one week of admission.
must be presented when your child is admitted to the child-care operation or within one week of admission.
Please check only one option:
Please check only one option:
Please check only one option:
Please check only one option:
Please check only one option:
1.
1.
1.
1.
1.
HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is
HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is
HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is
HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is
HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is
physically able to take part in the day care program.
physically able to take part in the day care program.
physically able to take part in the day care program.
physically able to take part in the day care program.
physically able to take part in the day care program.
Health Care Professional's Signature
Date
2.
2.
2.
2.
2.
A signed and dated copy of a health care professional’s statement is attached.
A signed and dated copy of a health care professional’s statement is attached.
A signed and dated copy of a health care professional’s statement is attached.
A signed and dated copy of a health care professional’s statement is attached.
A signed and dated copy of a health care professional’s statement is attached.
3.
3.
3.
3.
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
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
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
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
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.
have attached a signed and dated affidavit stating this.
have attached a signed and dated affidavit stating this.
have attached a signed and dated affidavit stating this.
have attached a signed and dated affidavit stating this.
Name of health care professional:
Name of health care professional:
Name of health care professional:
Name of health care professional:
Name of health care professional:
Address:
Address:
Address:
Address:
Address:
Phone:
Phone:
Phone:
Phone:
Phone:
VISION (required for 4, 5, Kinder,
R 20/ ________
R 20/ ________
L 20/ ________
L 20/ ________
PASS
FAIL
1
st
, 3
rd
,5
th
, and 7
th
)
SIGNATURE ____________________________________________
SIGNATURE ____________________________________________
SIGNATURE ____________________________________________
DATE _____________________________________
DATE _____________________________________
DATE _____________________________________
HEARING (required for 4, 5, Kinder,
1000 Hz
2000 Hz
2000 Hz
4000 Hz
1
st
, 3
rd
,5
th
, and 7
th
)
PASS
FAIL
R
L
SIGNATURE ___________________________________________
SIGNATURE ___________________________________________
SIGNATURE ___________________________________________
DATE ______________________________________
DATE ______________________________________
DATE ______________________________________
Required of 1
Required of 1
st
st
, 3
, 3
rd
rd
, 5
, 5
th
th
, 7
, 7
th
th
grade
grade
Acanthosis nigricans screen
PASS
FAIL
students
students
SIGNATURE ____________________________________________
SIGNATURE ____________________________________________
SIGNATURE ____________________________________________
DATE _____________________________________
DATE _____________________________________
DATE _____________________________________
Scoliosis Screening
Required of 6
th
grade students
PASS
FAIL
SIGNATURE ___________________________________________
SIGNATURE ___________________________________________
SIGNATURE ___________________________________________
DATE ______________________________________
DATE ______________________________________
DATE ______________________________________
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