ࡱ> pro3 bjbj .|l(((ttttt|t e A =$ (C "e  9h8 ( a(a  Cttaa<~0aa< \OCFS-LDSS-0792 (1/2005) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES DAY CARE REGISTRATIONChild s Full Name:  FORMTEXT      Does your child have any allergies?  FORMCHECKBOX  Yes  FORMCHECKBOX No If Yes, what is your child allergic to?  FORMTEXT      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:  FORMTEXT      Telephone Number:  FORMTEXT      Child s Source of Dental Care/Dentist s Name:  FORMTEXT      Telephone Number:  FORMTEXT      Name Of Medical Care Facility/Hospital:  FORMTEXT      Telephone Number:  FORMTEXT      Would you like information on Child Health Plus?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoEMERGENCY DATARELATIONSHIPCONTACT NAMETELEPHONE NUMBER DURING CHILD CAREOTHER TELEPHONE NUMBER (Check type) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Pager  FORMCHECKBOX  Cell  FORMCHECKBOX  Other  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Pager  FORMCHECKBOX  Cell  FORMCHECKBOX  Other  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Pager  FORMCHECKBOX  Cell  FORMCHECKBOX  Other  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Pager  FORMCHECKBOX  Cell  FORMCHECKBOX  Other  Provider/Day Care Facility Name and Address:  FORMTEXT      CHILD S FULL NAME:  FORMTEXT      SEX:  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleCHILD S HOME ADDRESS:  FORMTEXT      DATE OF BIRTH:  FORMTEXT      HOME TELEPHONE NUMBER:  FORMTEXT      DATE OF ACCEPTANCE:  FORMTEXT      DATE OF DISCHARGE:  FORMTEXT      NAME OF PERSON APPLYING FOR CHILD:  FORMTEXT        FORMCHECKBOX  Parent  FORMCHECKBOX  Guardian  FORMCHECKBOX  Caretaker  FORMCHECKBOX  Relative  FORMCHECKBOX  Other  FORMTEXT      Home Telephone Number:  FORMTEXT      Daytime Telephone Number:  FORMTEXT      Address of Person Listed Above: (If different from child s):  FORMTEXT      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.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 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.  FORMCHECKBOX  Yes  FORMCHECKBOX  No I have provided information on my childs 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.  FORMCHECKBOX  Yes  FORMCHECKBOX  No I agree to review and update this information whenever a change occurs and at least once every six months.  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSIGNATURE  PARENT OR PERSON(S) LEGALLY RESPONSIBLE DATE:  FORMTEXT      OCFS-LDSS-0792 (1/2005) REVERSE PHOTO OF CHILD (Optional) <>@  ",.0248:NPR\^`bdλҫһ҈һxһhjbCJOJQJU^JjCJOJQJU^JjvCJOJQJU^J$jCJOJQJU^JmHnHujCJOJQJU^JjCJOJQJU^J 5CJ\5\CJOJQJ^JCJjCJUmHnHuCJOJQJ^J5CJOJQJ\^J(<@^h r$$Ifl40 L,`D `t"0,4 la $If $d8$Ifa$ $<$Ifa$(0wo($If $$Ifa$ $<$Ifa$r$$Ifl40 L, D  t"0,4 la024``wl d$If d<$If $<$Ifa$r$$Ifl40 L, D t"0,4 la`bdL w d8<$If $<$Ifa$r$$Ifl40 L, D t"0,4 ladL N   , . 0 : < > @     b d x z | jCJOJQJU^JjBCJOJQJU^JjCJOJQJU^JjRCJOJQJU^J$jCJOJQJU^JmHnHujCJOJQJU^JjCJOJQJU^J5\CJOJQJ^J/L N  > zzx$If $$Ifa$r$$Ifl4X0 L, D t"0,4 la> @   b zzzzp x<$Ifx$If $$Ifa$r$$Ifl40<L,0,4 la > @ \ ^ ` r t 6 }wmgZmJmgj5CJU\mHnHuj5CJU\ 5CJ\j5CJU\ 5CJ\5CJOJQJ\^JCJ5\j CJOJQJU^JjCJOJQJU^JjCJOJQJU^JCJOJQJ^JCJOJQJ^J$jCJOJQJU^JmHnHujCJOJQJU^Jj2CJOJQJU^J 6 ~ }}rg $<$Ifa$ $<$Ifa$$<$If]a$$d$If]^a$_$$Ifl4PL,,0,4 la~ VlK===$d<$Ifa$ $x$Ifa$$$Ifl4r<L,l;~0,4 la  $&BDFTVrtvǾǛǾuejCJ OJQJU^JjpCJ OJQJU^JCJ OJQJ^JjCJ OJQJU^J$jCJOJQJU^JmHnHujCJOJQJU^JCJOJQJ^JjCJOJQJU^JjCJUjCJUmHnHujCJUCJ jCJU! 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