Form Ocfs-Ldss-0792 - Day Care Registration (Page 2 of 2) in pdf

Form Ocfs-Ldss-0792 - Day Care Registration Page 2

CHILD’S FULL NAME:

Male

SEX:

Female

CHILD’S HOME ADDRESS:

DATE OF BIRTH:

HOME TELEPHONE NUMBER:

DATE OF ACCEPTANCE:

DATE OF DISCHARGE:

HOME TELEPHONE NUMBER:

NAME OF PERSON APPLYING FOR CHILD:

Parent

Guardian

Caretaker

Relative

DAYTIME TELEPHONE NUMBER:

Other

ADDRESS OF PERSON LISTED ABOVE: (IF DIFFERENT FROM CHILD’S):

AGREEMENTS

I consent to the enrollment of the child listed above in this facility and have been advised of the policies regarding administration of

medications, fees, transportation and the services provided by the facility, and the Office of Children and Family Services regulations

under which it operates.

I give consent for my child to take part in neighborhood trips (i.e. library, park and playground) away from the facility under proper

supervision.

Yes

In case of accident or injury, I authorize any and all emergency medical, dental, and /or surgical care and hospitalization advised

by the physicians, surgeon or hospital (listed on the other side of this card) necessary for the proper health and well-being of my

child.

Yes

I have provided information on my child’s special needs (Allergies, Diet, Disabilities, and /or Medical Information) to the provider,

as may be necessary to assist the facility in properly caring for my child in case of an emergency.

Yes

I agree to review and update this information whenever a change occurs and at least once every six months.

Yes

SIGNATURE – PARENT OR PERSON(S) LEGALLY RESPONSIBLE

DATE:

OCFS-LDSS-0792 (1/2005) REVERSE

Form Ocfs-Ldss-0792 - Day Care Registration Page 2