OCFS-LDSS-0792 Day Care Registration Form

OCFS-LDSS-0792 (1/2005) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES DAY CARE REGISTRATION Child’s Full Name: PHOTO OF CHILD (Optional) Does your child have any allergies? Yes No If Yes, what is your child allergic to? Children who have special health care needs are those who have chronic physical, developmental, behavioral or emotional conditions expected to last 12 months or more and who also require health and related services of a type beyond that required by children generally. If your child does have special health care needs please discuss these with your child-care provider. Child’s Source of Medical Care/Primary Care Physician’s Name: Telephone Number:

Child’s Source of Dental Care/Dentist’s Name: Telephone Number:

Name Of Medical Care Facility/Hospital: Telephone Number:

A T A D

Would you like information on Child Health Plus? Yes No Y C

N RELATIONSHIP CONTACT NAME TELEPHONE NUMBER DURING CHILD CARE OTHER TELEPHONE NUMBER (Check type) E

R Pager

E Cell

M Other

E Pager Cell Other

Pager Cell Other

Pager Cell Other OCFS-LDSS-0792

Provider/Day Care Facility Name and Address: (1/2005) REVERSE PERSONAPPLYING OF NAME FOR CHILD: ACCEPTANCE:DATE OF AGREEMENTS PERSONLISTED ADDRESS OFCHILD’S): DIFFERENT ABOVE: (IF FROM HOME CHILD’S ADDRESS: NAME:FULLCHILD’S SIGNATURE OR – SIGNATURE PERSON(S) PARENT LEGALLY RESPONSIBLE it which operates.under ChildrenFamilyof and the Services regulations theand Office theprovided by facility, and services fees, transportation medications, theadvisedof havepolicies this regardingthe and of listed above enrollment administration child in been facility consent the to I I agree to review and update this information whenever a change occurs and at least once every six months. six months. every change least informationwhenever at once reviewa this toand update agreeoccurs and I providedDisabilities, the information needs MedicalInformation) to haveon child’s(Allergies, Diet,provider, my /or I special and child. and my properof fornecessary well-being health the othercard) physicians, surgeon this on side of or the the(listed hospital by hospitalization/or and advised andcare allsurgical any accident of and emergency medical, orIdental, injury, authorize case In supervision. properplayground)underlibrary, the and park facilityneighborhood(i.e. take toaway from childpart in my trips give consent for I as may be necessary to assist the facility in properly caring for my child in case of an emergency. my caringcasean inforof emergency. the may in assist facility properlychild asbe to necessary

Yes Yes Yes Yes

Other Caretaker Parent DATEOF DISCHARGE:

Guardian Relative TELEPHONE DAYTIMENUMBER: TELEPHONE NUMBER:HOME TELEPHONE NUMBER:HOME BIRTH: DATE OF DATE: Yes Yes SEX: SEX: Yes Yes

No Female Male No