Form Ocfs-Ldss-0792 - Day Care Registration
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2OCFS-LDSS-0792 (1/2005) FRONT
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
DAY CARE REGISTRATION
Child’s Full Name:
PHOTO OF CHILD
(Optional)
Does your child have any allergies?
Yes
No
If Yes, what is your child allergic to?
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 with your child-care provider.
Child’s Source of Medical Care/Primary Care Physician’s Name:
Telephone Number:
Child’s Source of Dental Care/Dentist’s Name:
Telephone Number:
Name Of Medical Care Facility/Hospital:
Telephone Number:
Would you like information on Child Health Plus?
Yes
No
RELATIONSHIP
CONTACT NAME
TELEPHONE NUMBER DURING CHILD CARE
OTHER TELEPHONE NUMBER (Check type)
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Cell
Other
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Cell
Other
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Cell
Other
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Cell
Other
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Parent category: Legal