1. DAY CARE REGISTRATION (OFFICIAL)

DAY CARE REGISTRATION

One per child
REGISTRO DE GUARDERÍA

Uno por niño
Language (el idioma)
Child's Full Name*
Nombre completo del niño*
I want to:

Register my child for childcare for the first timeJust here to update my pickup list
Please take your best pic of {childsFull}! (Por favor, tome su mejor foto de {childsFull}!)*
{childsFull}'s Social Security #
123456789
Seguridad Social # de {childsFull}
123456789
Quiero:

Inscribir a mi hijo en el cuidado de niños por primera vezSolo estoy aquí para actualizar mi lista de recogida
Does your child have any allergies?*

YesNo
¿Su hijo tiene alguna alergia?*

SiNo
What is your child allergic to?
¿A qué es alérgico su hijo?
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 needs with our office.
Los niños que tienen necesidades especiales de atención médica son aquellos que tienen condiciones crónicas físicas, de desarrollo, conductuales o emocionales que se espera que duren 12 meses o más y que también requieren servicios de salud y relacionados de un tipo más allá de lo que requieren los niños en general. Si su hijo tiene necesidades especiales de atención médica, por favor hable de estas necesidades con nuestra oficina.
Pediatrician's Name
Telephone Number

Area Code Phone Number
Child's Dentist's Name
Telephone Number

Area CodePhone Number
Name of Family's Medical Facility/Hospital
Telephone Number

Area CodePhone Number
It might be a good idea for you to authorize someone other than yourself to pickup {childsFull}. If you would like us to release {childsFull} to another trusted person, please indicated that person here:*

Add a pickup personNo, just me
Puede ser una buena idea que autorices a alguien que no sea tú mismo a recoger {ChildsFull}. Si desea que liberemos {childsFull} a otra persona de confianza, por favor indique a esa persona aquí:*

Agregar una persona que recojaNo, sólo yo
Pickup Person's Name #1
For your child's safety and as a part of our SAFE (Secure Authorized Family Entry) program, we now require a photo for each pickup person. Please click here to take or upload a photo of {pickupPersons}!*

Take a pictureUpload a picture
Upload picture

TAP HERE

Cancelof
Take a photo here
Relationship
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area Code Phone Number
Would you like to add another authorize pick-up?

Yes/SiNo
Pickup Person's Name #2
Now a photo for this pickup person. Please click here to take or upload a photo of {contactName45} !*

Take a pictureUpload a picture
Upload picture *

TAP HERE

Cancelof
And now a photo*
Relationship
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Would you like to add another authorize pick-up?

YesNo
Pickup Person's Name #1
Now a photo for this pickup person. Please click here to take or upload a photo of {contactName46}!*

Take a pictureUpload a picture
Upload picture *

TAP HERE (PULSE AQUÍ)

Cancelof
And now a photo:*
Relationship
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area Code Phone Number
Would you like to add another authorize pick-up?

YesNo
Pickup Person's Name #4
Now a photo for this pickup person. Please click here to take or upload a photo of {contactName47}!*

Take a pictureUpload a picture
Upload picture*

TAP HERE

Cancelof
And now a photo!*
Relationship
Cell Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Child's Name: {childsFull}
Nombre del niño: {childsFull}
SEX

MaleFemale
DATE OF BIRTH *

MonthDayYear
Date
{childsFull} HOME ADDRESS *
HOME TELEPHONE NUMBER

Area Code Phone Number
MOTHER'S NAME
MOTHER'S DATE OF BIRTH

MonthDayYear
Date
MOTHER'S SOCIAL SECURITY #
123456789
MOTHER'S TEL #
1234567890
FATHER'S SOCIAL SECURITY #
123456789
FATHER'S TEL #
1234567890
FATHER'S NAME
FATHER'S DATE OF BIRTH

MonthDayYear
Date
WHAT IS THE NAME OF THE PERSON APPLYING ON BEHALF OF {childsFull}?*
Your name in most cases
¿CUÁL ES EL NOMBRE DE LA PERSONA QUE PRESENTA LA SOLICITUD EN NOMBRE DE {childsFull}?*
u nombre en la mayoría de los casos
WHAT IS YOUR RELATIONSHIP TO {childsFull}

ParentGuardianCaretakerRelativeOther
¿CUÁL ES TU RELACIÓN CON {childsFull}?

el Padreel guardiánel cuidadorel parienteOther
HOME TELEPHONE NUMBER

Area Code Phone Number
DAYTIME TELEPHONE NUMBER

Area Code Phone Number
ADDRESS OF THE PERSON APPLYING FOR THE {childsFull}: (IF DIFFERENT ADDRESS)
DIRECCIÓN DE LA PERSONA QUE SOLICITA EL {childsFull}: (SI ES UNA DIRECCIÓN DIFERENTE
AGREEMENTS
EL ACUERDO
I consent to the enrollment of the child listed above in this facility and have been advised of the policies regarding administration of medications, fees, transportation and the services provided by the facility, and the Office of Children and Family Services regulations under which it operates.
Doy mi consentimiento para la inscripción del niño mencionado anteriormente en este centro y he sido informado de las políticas con respecto a la administración de medicamentos, tarifas, transporte y los servicios proporcionados por el centro, y las regulaciones de la Oficina de Servicios para Niños y Familias bajo las cuales opera.
I give consent for my child to take part in neighborhood trips (i.e. library, park and playground) away from the facility under proper supervision.*

YesNo
Doy mi consentimiento para que mi hijo participe en excursiones al vecindario (es decir, biblioteca, parque y patio de recreo) fuera de las instalaciones bajo la supervisión adecuada.*

SiNo
In case of accident or injury, I authorize any and all emergency medical, dental, and /or surgical care and hospitalization advised by the physicians, surgeon or hospital (listed on the other side of this card) necessary for the proper health and well-being of my child.*

YesNo
En caso de accidente o lesión, autorizo cualquier y toda la atención médica de emergencia, dental y/o quirúrgica y hospitalización aconsejada por los médicos, cirujano u hospital (enumerados en el otro lado de esta tarjeta) necesaria para la salud y el bienestar adecuados de mi hijo.*

SiNo
I have provided information on my child's special needs (Allergies, Diet, Disabilities, and /or Medial Information) to the provider, as may be necessary to assist the facility in properly caring for my child in case of an emergency.*

YesNo
He proporcionado información sobre las necesidades especiales de mi hijo (alergias, dieta, discapacidades y / o información medial) al proveedor, según sea necesario para ayudar a la instalación a cuidar adecuadamente a mi hijo en caso de una emergencia.*

SiNo
I agree to review and update this information whenever a change occurs and at least once every six months.*

YesNo
Acepto revisar y actualizar esta información cada vez que ocurra un cambio y al menos una vez cada seis meses.*

SiNo
SIGNATURE PARENT OR PERSON(S) LEGALLY RESPONSIBLE*

Clear
Primary parent's email address:*
Medical Form (attach completed front & back)

Upload your child's medical

Cancelof
DATE

MonthDayYear
Date
Should be Empty:

DAY CARE REGISTRATION

REGISTRO DE GUARDERÍA

AGREEMENTS

EL ACUERDO