Smiley Faces Registration Form

Registration Form
Child Information
Photo of Enrolled Child (Optional)
Child's Full Name*
Child's Preferred Name/Nickname*
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*
Childs Grade (i.e. 3rd grade)*
Child's School Name*
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Care Giver Information
Name of Person Enrolling Child*
ParentGuardianRelative/Other
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
I consent to receiving text messages about my enrolled child
Email*
example@example.com
Address of Person Enrolling Child (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Primary Contact name

First NameLast Name
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By checking this box I consent to receive text messages to the number above regarding the enrolling child.
YesNo
(1) I would like to add one person as an emergency contact for the enrolling child(2) I would like to add two other people as emergency contacts for the enrolling child
Secondary Contact name

First NameLast Name
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By checking this box I consent to receive text messages to the number above regarding the enrolling child.
YesNo
3rd Contact name

First NameLast Name
3rd Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By checking this box I consent to receive text messages to the number above regarding the enrolling child.
YesNo
Special Needs and Allergies
NoneFamily Intervention / Special EducationOccupational TherapySpeech / LanguagePhysical Therapy
NoYes (input below)
If there is anything else you'd like us to know concerning the welfare of your child, please explain below:
Medical Information
Child health care information is available by calling toll-free 1-800-698-4543 or the NYS Health Marketplace website: https://nystateofhealth.ny.gov
Preferred Hospital
Hospital Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Childs Primary Care Physician's Name/Group
Primary Care Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Childs Dental Care
Dental Care Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please provide additional information here AND discuss with your child care provider

Agreements

Rows	Yes	No
I consent to emergency medical treatment for my child
I consent for my child to take part in neighborhood trips (I.e., library, park and playground) away from the program under proper supervision
I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips
I provided information on my child’s special needs to the program to assist in caring for my child
I understand the program must give parents, at the time of enrollment of a child a written policy statement as required by regulation
I agree to review and update this information whenever a change occurs and at least once every year.

Signature of personal Legally Responsible for Child*
Todays Date*

MonthDayYear
Date
Should be Empty:

Registration Form

Child Information

Care Giver Information

Emergency Contact Information

Special Needs and Allergies

Medical Information