RITE CHOICE EARLY LEARNING CHILD CARE, LLC

OCFS-LDSS-0792 OFFICE OF CHILDREN AND FAMILY SERVICES (1/2005) FRONT NEW YORK STATE DAY CARE REGISTRATION
					Child’s Full Name:
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
EMERGENCY DATA	RELATIONSHIP	CONTACT NAME	TELEPHONE NUMBER DURING CHILD CARE	OTHER TELEPHONE NUMBER (Check type)
	Pager Cell Other
	Pager Cell Other
	Pager Cell Other
	Pager Cell Other

Provider/Day Care Facility Name and Address:	CHILD’S FULL NAME:			SEX:		Male Female
	CHILD’S HOME ADDRESS:		DATE OF BIRTH:
			HOME TELEPHONE NUMBER:
	DATE OF ACCEPTANCE:		DATE OF DISCHARGE:
	NAME OF PERSON APPLYING FOR CHILD:	Parent Guardian Caretaker Relative Other			HOME TELEPHONE NUMBER:
					DAYTIME TELEPHONE NUMBER:
	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 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. Yes No 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 No I agree to review and update this information whenever a change occurs and at least once every six months. Yes No
							SIGNATURE – PARENT OR PERSON(S) LEGALLY RESPONSIBLE	DATE: