Good Shepherd Registration Form

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These forms below need to be completed and saved or printed. You will then need to upload these forms towards the end of the series of questions. These forms are required in order for your child to attend school. If your child is 3 years or older, you will need to complete the Dental Form and the Vision/Hearing Form. These forms are located at the end of the series of questions. These two forms must be filled out and then uploaded.

The New York State Child in Care Medical Statement

Emergency Contacts
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Student Name
First Name
Middle Name
Last Name
3
Birth Date
Month
Day
Year
4
Gender
Male
Female
N/A
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Sibling(s)
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
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Other Members of the household(Relationship and Age)
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Parent Main Contact E-mail
example@example.com
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Parent/Guardian(s)
Parent/Guardian Name
Occupation/Employer
Home Phone
Cell Phone
Parent/Guardian Name
Occupation/Employer
Home Phone
Cell Phone
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Age at which child:
Crawled Age Sat alone Age    Walked alone
Slept through the night Age    Toilet trained Age
Does child self dress?    Undress self?
What time does your child go to bed and awaken?
Does your child sleep well?    Yes     No
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Child's favorite indoor activities
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Child's favorite outdoor activities
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Does your child play alone?
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Does your child play in groups?If yes, how?
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How does your child share toys?
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How does your child handle conflict?How do you respond?
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What do you do together as a family?
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How do you provide structure, at home, for your child?
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What techniques do you use to discipline/are they effective?
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How does your child react when a parent leaves?
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Has your child been separated from a parent for any length of time?Please describe
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How does your child react to new situations?Please describe
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Does your child speak understandably?
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Are you concerned about your child's speech?
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What languages are spoken at home?
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Has your child ever attended Nursery School?If so, which one? Please list dates of attendances, other group experiences and reaction
Huge
Large
Normal
Small
Ok
Ok
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What goals/expectations do you have regarding your child's school experience?
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Is there anything else you feel would be important for your child's teacher to know? (Recent divorce, new sibling, special fears...)
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Are there any cultural or linguist variances that you would like us to be aware of or would like to share in the classroom?
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Do you have any concerns about your child's development?
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Is your child receiving any special services? Please explain.
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Rest PolicyDay Care Regulations require us to create a Rest Policy Agreement with families. Children who attend our half day programs do not attend school long enough to require a built-in rest period. However, children attending a 4’s full day class are offered the opportunity to rest “re-charge their batteries” for a few minutes after the lunch period. Typically, children sit upon their blanket/mat to either read a book or to chat quietly with a friend. Children may also play with a quiet toy or read at a table. Rest time lasts for about 10 minutes. In all other classes, should a child wish to sleep/fall asleep, which rarely occurs, they will be offered a soft rest mat to lay upon. Children who are feeling unwell are taken to the Nursery School office to rest until an adult can pick them up. In both cases, a parent is notified during pick-up that their child rested. Please indicate your understanding of and agreement with our Rest Policy by choosing below:
YESNO
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Child Medical InstructionsDear Health Care Provider, This child attends a New York State Office of Children and Family Services licensed child care center. Day Care Center Regulations require parents to submit a completed Child In Care Medical Statement Form (see attached) and immunization record. Please note & ensure that all of the following information is provided: 1. Tuberculin Test: If not performed - indicate low risk or not indicated. 2. Lead Screen: As per NYS law, a blood test is required at 1 & 2 years of age & whenever there is a risk of lead poisoning - Include all test dates & results. 3. The medical statement form must be signed by a health care provider and state that the child is able to participate in child day care. and is free from contagious or communicable disease - see highlighted area on the back of form; only valid if yes box is checked. Children will not be permitted to attend child care unless this form is properly completed. Thank you for your time & consideration.
YESNO
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Download this form to be filled out and upload below
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Dental Form Upload
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Max. file size: 10.6MB
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Download this to be filled out and upload below
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Vision and Hearing Form Upload
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Medical Form UploadNEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES CHILD IN CARE MEDICAL STATEMENT
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Emergency Contacts
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