OCFS-LDSS-0792 (08/2019) FRONT
NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES DAY CARE ENROLLMENT
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PROGRAM NAME:
ADDRESS:
PHONE NUMBER:
Format: (000) 000-0000.
CHILD'S FULL NAME:
DATE OF BIRTH:
-
Month
-
Day
Year
Date
GENDER:
PREFERRED NAME/NICKNAME:
CHILD'S HOME ADDRESS:
NAME OF PERSON ENROLLING CHILD:
RELATIONSHIP TO CHILD:
Parent
Guardian
Caretaker
Relative
Other
PHONE NUMBER(S) OF PERSON ENROLLING CHILD:
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ADDRESS OF PERSON ENROLLING CHILD (IF DIFFERENT THAN CHILD):
EMAIL ADDRESS:
example@example.com
Rows
EMERGENCY CONTACT NAMES / ADDRESSES
Authorized to Pick Up Child
PRIMARY PHONE NUMBER
OTHER PHONE NUMBER / EMAIL
INFO EMERGENCY
INFO EMERGENCY
INFO EMERGENCY
FOR PROGRAM USE ONLY DATE OF ENROLLMENT:
-
Month
-
Day
Year
Date
FOR PROGRAM USE ONLY DATE OF DISENROLLMENT:
-
Month
-
Day
Year
Date
OCFS-LDSS-0792 (08/2019) REVERSE
CHILD'S FULL NAME:
DATE OF BIRTH:
-
Month
-
Day
Year
Date
Check boxes below to indicate if your child has any special needs/services:
Early Intervention/Special Education
Occupational Therapy
Speech/Language
Physical Therapy
None
Allergies (Please list)
Other
Please provide information here AND discuss with your child care provider:
CHILD'S PRIMARY CARE PHYSICIAN'S NAME/GROUP:
PHONE NUMBER:
Format: (000) 000-0000.
PREFERRED HOSPITAL:
PHONE NUMBER:
Format: (000) 000-0000.
CHILD'S DENTAL CARE:
PHONE NUMBER:
Format: (000) 000-0000.
Child health care information is available by calling toll-free 1-800-698-4543 or the NYS Health Marketplace website: https://nystateofhealth.ny.gov/
AGREEMENTS
I consent to emergency medical treatment for my child.
Yes
No
I consent for my child to take part in neighborhood trips (i.e., library, park and playground) away from the program under proper supervision.
Yes
No
I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips.
Yes
No
I provided information on my child's special needs to the program to assist in caring for my child.
Yes
No
I understand the program must give parents, at the time of enrollment of a child, a written policy statement as required by regulation.
Yes
No
I agree to review and update this information whenever a change occurs and at least once every year.
Yes
No
SIGNATURE - PARENT OR PERSON(S) LEGALLY RESPONSIBLE:
DATE:
-
Month
-
Day
Year
Date
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