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*
Relationship to Child*

ParentGuardianRelative/Other
Contact Phone Number*
Please enter a valid phone number.
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.
Primary Contact Secondary Phone Number
Please enter a valid phone number.
By checking this box I consent to receive text messages to the number above regarding the enrolling child.
Is this person authorized to pick up your child?

YesNo
Would you like to add additional emergency contacts for this child? If so please select from the list below.

(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.
By checking this box I consent to receive text messages to the number above regarding the enrolling child.
(Secondary Contact) Is this person authorized to pick up your child?

YesNo
3rd Contact name

First NameLast Name
3rd Contact Phone Number
Please enter a valid phone number.
(3rd Contact)

By checking this box I consent to receive text messages to the number above regarding the enrolling child.
(3rd Contact) Is this person authorized to pick up your child?

YesNo
Special Needs and Allergies
Check boxes below to indicate if your child has any special needs/services

NoneFamily Intervention / Special EducationOccupational TherapySpeech / LanguagePhysical Therapy
Does your child have any allergies?

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.
Childs Primary Care Physician's Name/Group
Primary Care Physician's Phone Number
Please enter a valid phone number.
Childs Dental Care
Dental Care Phone Number
Please enter a valid phone number.
Please provide additional information here AND discuss with your child care provider

Agreements

	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*

Clear
Todays Date*

MonthDayYear
Date
Should be Empty:

Registration Form

Child Information

Care Giver Information

Emergency Contact Information

Special Needs and Allergies

Medical Information