OCFS-LDSS-0792 (10/2018) FRONT

PHOTO OF CHILD (Optional)	NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES DAY CARE ENROLLMENT
Child’s Full Name: Preferred Name/Nickname:	Date of Birth: / /	Gender:
Child’s Home Address:
Name of Person Enrolling Child:	Relationship to Child: Parent Guardian Caretaker Relative Other
Phone Number(s) of Person Enrolling Child: ( ) - ok to text Email Address:	Address of Person Enrolling Child (if different than child):
EMERGENCY INFO	EMERGENCY CONTACT NAMES / ADDRESSES	Authorized to Pick Up Child	PRIMARY PHONE NUMBER	OTHER PHONE NUMBER / EMAIL
Primary Contact:	Yes No	ok to text	ok to text
Yes No	ok to text	ok to text
Yes No	ok to text	ok to text
For Program Use Only Date of Enrollment: / /	For Program Use Only Date of Disenrollment: / /

OCFS-LDSS-0792 (10/2018) REVERSE

Child’s Full Name:	Date of Birth: / /
Check boxes below to indicate if your child has any special needs/services: None Early Intervention/Special Education Occupational Therapy Speech/Language Physical Therapy Allergies (list) Other Please provide information here AND discuss with your child care provider:
Child’s Primary Care Physician’s Name/ Group:	Phone Number: ( ) -
Preferred Hospital:	Phone Number: ( ) -
Child’s Dental Care:	Phone Number: ( ) -
Child health insurance information is available by calling toll-free 1-800-698-4543 or the NYS Health Marketplace website: https://nystateofhealth.ny.gov/
AGREEMENTS ● 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…………………….	Yes Yes Yes Yes Yes Yes	No No No No No No
SIGNATURE – PARENT OR PERSON(S) LEGALLY RESPONSIBLE:	DATE: / /