FOR OFFICE USE:
Enrollment: FULL MWF TTH
Date of Admission: _______________
Date of Withdrawal:______________
Texas Tech University Child Development Research Center
EMERGENCY CONTACT, RELEASE and CONSENT
Child’s Name: ___________________________________ D.O.B. ________________ Gender: M or F
Address (including zip): _________________________________________ Home Phone: ______________________
Parent/Guardian’s Names: ___________________________________________________________________________
During the time my child is in attendance at the CDRC, I may be reached at:
Parent #1: (Name ________________)
Parent #2: (Name ________________)
Location: _____________________________
Location: __________________________________
Phone: _______________________________
Phone: ____________________________________
Phone: _______________________________
Phone: ____________________________________
e-mail: _______________________________
e-mail: ____________________________________
Tech ID: (students only)___________________
Tech ID: (students only)_______________________
At the end of each day, or during any day, my child may only be released to the following: (Include parent’s names also)
You must complete EACH COLUMN
NAME
ADDRESS
PHONE
RELATION
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
UNDER NO CIRCUMSTANCES WILL A CHILD BE RELEASED TO ANYONE NOT
AUTHORIZED BY THE PARENT.
Names of siblings attending other centers/schools
Child’s Name:
Name of School:
Phone:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Parent Consent Form
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PLEASE LIST FRIENDS/RELATIVES TO CONTACT IN CASE OF EMERGENCY :
You must complete EACH COLUMN
NAME
ADDRESS
PHONE
RELATION
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EMERGENCY MEDICAL TREATMENT:
In the event that my child needs emergency medical attention and I cannot be reached immediately, I give permission for
the CDRC personnel to secure the needed treatment from: You must complete all information requested
Physician: ______________________________________________________________________________
Address: ___________________________________________ Phone: ___________________________
Hospital/Clinic: _________________________________________________________________________
Address: ___________________________________________ Phone: ____________________________
Allergies to drugs: ________________________________________________________________________
Usual reaction: ___________________________________________________________________________
INSURANCE INFO
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Company Name: _________________________________________________________________________
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Address/Phone: __________________________________________________________________________
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Policy/Group #: ___________________________________________________________________________
** Due to the nature and mission of the CDRC, the following items are required as a condition of enrollment –
your initial verifies your understanding and agreement to each item listed**
_______My child may participate in all supervised activities at the CDRC, including art, music, dramatic play, cooking, block
building, woodworking, story-telling and reading, science, math, motor development, and water play (limited to sprinklers,
water tables, and splashing pool, 6” of water or less).
_______My child may participate in daily outdoor play. I will send my child with appropriate clothing and protection in case s of
cold weather (for example.. layers of clothing, warm coats, hats, gloves, etc…)
_______My child may participate in observational research projects sanctioned by the Human Subjects Committee and the CDRC
Director. Parents will be notified of any projects including their child before the child’s participation.
_______The person(s) bringing my child to the CDRC will be certain that he/she is released directly to a teacher.
_______The person(s) picking up my child at the CDRC will be 17 years of age or older and will be certain that a teacher is aware of
his/her departure. (Teachers will not release a child to any one who is under the age of 17)
_______College students who have been approved by CDRC staff may observe and record my child’s development.
_______Though not required, I will make every effort to attend the regularly scheduled parent meetings, parent/teacher conferences,
and other CDRC parent activities.
Parent Consent Form
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_______Pictures and/or videos of my child may be taken and used in displays, bulletin boards, or other types of educational
publications / settings.
_______My child may participate in all supervised, planned and impromptu, field trips. Information on planned field trips will be
provided at least 48 hours beforehand, including date, destination, and times of departure and return. Identical information
on impromptu field trips (walks) will be posted before the departure. Special permission for a field trip off campus will be
obtained for any child under the age of 2.
_______During CDRC field trips, my child may be transported and supervised by CDRC employees . Alternatively, parents may
choose to transport and supervise their own child while on field trips.
______My child’s medical and/or developmental history can be shared among CDRC administration and my child’s classroom
teachers. The CDRC professional staff can determine when and what information is necessary and relevant to share with
students enrolled in the educational program and that are working directly with my child.
______If my child is concurrently enrolled in the ECI DEBT program or is receiving therapy from a private, licensed practitioner,
I give permission for CDRC staff to share developmental information and observations regarding my child with the
practitioner. (You may mark n/a if not applicable to your child)
______Medical and developmental information will not be shared with anyone (other than those included in this consent) unless
specific written permission is obtained or as required by law.
The following items are not required for enrollment but are part of the CDRC and your initial verifies your
understanding and agreement to the following. If you do not agree to the following, please place an “X” in the
designated space.
_______Pictures and/or videos of my child may be taken and used in newspapers, TTU and/or CDRC promotional materials, or
television news stories.
_______ Pictures of my child may be used (without name) on the CDRC website
The CDRC has an agreement with a local pediatrician, Dr. Nawal Zeitouni of Pediatric Associates of Lubbock , to provide
information/consultation and training to the CDRC staff.
_______I give my permission for the CDRC staff to consult with Dr. Zeitouni regarding care in an “urgent care” situation where
parents can not be reached immediately. (For example, a child has received a number of ant bites on the legs during outside
time, the bites are swelling and are very uncomfortable for the child. Despite several attempts, we can not reach the parents.
Dr. Zeitouni can give us permission (based on information provided to her by us) regarding treatment , which may include
proper dosage of medication (like Benadryl or Tylenol in this example) to administer.
It is okay to publish the following in the center directory: (Please initial each)
_____address _____home phone # _____ e-mail address (indicate address) _________________________________
May we contact you by email regarding CDRC events / questions we may have?
_____ No
_____ Yes (indicate address) _________________________________
(indicate address) _________________________________
May we contact you by text message regarding CDRC events / notifications we may have? _____ Yes
Preferred phone #’s ___________________________________
___________________________________
_____ No
PARENT/GUARDIAN SIGNATURE: ______________________________________ DATE: __________________
PARENT/GUARDIAN SIGNATURE: _______________________________________ DATE: __________________
Parent Consent Form
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