RE-REGISTRATION FORM

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1 RE-REGISTRATION FORM (please print) Name of Child: Male / Female Home Phone #: street city/state/zip Date of Birth: address: Second Mother s Social Security #: Employer s Father s Social Security #: Employer s YOU ARE RE-REGISTERING FOR YOUR CURRENT SCHEDULE. IF YOUR SCHEDULE CHANGES AT ANY TIME, WE REQUIRE A TWO WEEK WRITTEN NOTICE. If the parent/guardian cannot be notified of an illness or emergency, one of the following emergency contact persons will be notified: Telephone #: Telephone #: Your security deposit of two week's tuition, along with a non-refundable registration fee must accompany this registration form. Checks may be made payable to EduKids. Upon receipt of this form and check, a Parent Handbook of policies and program description will be ed to you. If for any reason you fail to start the program you will forfeit your security deposit. How did you hear about EduKids? (FOR OFFICE USE ONLY) Center Attending: OP H LN WS CL RFC CSP NFB HER FR MV EL WM Room:

2 OCFS-LDSS-4433 (Rev. 5/2014) FRONT NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES CHILD IN CARE MEDICAL STATEMENT To Be Completed By Licensed Physician, Physician s Assistant or Nurse Practitioner Name of Child: Date of Birth: Date of Examination: Immunizations required for entry into day care Medical Exemption The physical condition of the named child is such that one or more of the immunizations would endanger life or health. Attach certification specifying the exempt immunization(s). Diphtheria, Tetanus and Pertussis (DPT) Diphtheria and Tetanus and acellular Pertussis (DTaP) Polio (IPV or OPV) 1 st Date 2 nd Date 3 rd Date 4 th Date 5 th Date 1 st Date 2 nd Date 3 rd Date 4 th Date Yes No Haemophilus influenzae type B (Hib) Pnuemococcal Conjugate (PCV) for those born on or after 1/1/08) Hepatitis B 1 st Date 2 nd Date 3 rd Date 4 th Date OR 1 st Date (if given on or after 15 months of age) 1 st Date 2 nd Date 3 rd Date 4 th Date 1 st Date 2 nd Date 3 rd Date Measles, Mumps and Rubella (MMR) Varicella (also known as Chicken Pox) 1 st Date 2 nd Date 1 st Date 2 nd Date Other Immunizations may include the recommended vaccines of Rotavirus, Influenza and Hepatitis A Type of Immunization: Type of Immunization: Type of Immunization: Type of Immunization: Type of Immunization: Type of Immunization: Tests Tuberculin Test / / Mantoux Results: Positive Negative mm TB Tests are at the physician s discretion. Acceptable tests include Mantoux or other federally approved test. If positive, or if x-ray ordered, attach physician s statement documenting treatment and follow-up. Lead Screening / / Attach lead level statement Lead Screening (Include All Dates and Results) 1 year / / Result: mcg/dl Venous Capillary 2 years / / Result: mcg/dl Venous Capillary Most recent date of lead screening (if different from above): / / Result: mcg/dl Venous Capillary Per NYS law, a blood lead test is required at 1 and 2 years of age and whenever risk of lead poisoning is likely. If the child has not been tested for lead, the day care provider may not exclude the child from child day care, but must give the parent information on lead poisoning and prevention, and refer the parent to their health care provider or the county health department for a lead blood screening test. (Continued on reverse side)

3 OCFS-LDSS-4433 (Rev.5/2014) REVERSE CHILD IN CARE MEDICAL STATEMENT (continued) Health Specifics Comments Are there allergies? (Specify) Yes No Is medication regularly taken? (Specify drug and condition) Yes No Is a special diet required? (Specify diet and condition) Yes No Are there any hearing, visual or dental conditions requiring special attention? Yes No Are there any medical or developmental conditions requiring special attention? Yes No Summary of Physical Exam Include special recommendations to child day care providers On the basis of my findings as indicated above and on my knowledge of the named child, I find that: he/she is free from contagious and communicable disease and is able to participate in child day care. Yes No Signature of Examiner Address Please Print Name City, State, Zip ( ) Title Phone Date Religious Exemptions Public Health law Section 2164 allows a child to be religiously exempted from immunization. A written and signed statement from a parent, parents or guardian of the child stating that they object of the immunization of their child due to their sincere and genuine religious beliefs should be submitted to the day care owner, operator or administrator who shall determine whether the statement of religious belief is acceptable.

AUTHORIZED PERSONS FOR PICK UP Child s Child s Date of Birth: Center: For safety reasons, EduKids will only release a child to those individuals that have been designated by the child s parent(s) or

4 AUTHORIZED PERSONS FOR PICK UP Child s Child s Date of Birth: Center: For safety reasons, EduKids will only release a child to those individuals that have been designated by the child s parent(s) or legal guardian(s) as authorized to pick up the child. Legal counsel has informed us that unless a parent has secured an Order of Protection, both parents have equal rights to pick up the child. If an Order of Protection exists, EduKids must be provided with an original copy of the Order. EduKids must be informed of any individual(s) to whom the child should not be released. The following person(s) are authorized to pick up my child: RELATIONSHIP NAME ADDRESS/PHONE 1. Parent/Guardian 2. Parent/Guardian I understand that my child will only be released to the individuals I have listed above. I also understand that if my circumstances change, it is my responsibility to notify EduKids and update the above list. Parent Signature:

5 RE-REGISTRATION FORM BEFORE & AFTER SCHOOL (please print) Name of Child: Male / Female Home Phone #: street city/state/zip Date of Birth: address: Second Mother s Social Security #: Employer s Father s Social Security #: Employer s If the parent/guardian cannot be notified of an illness or emergency, one of the following emergency contact persons will be notified: Telephone #: Telephone #: (FOR OFFICE USE ONLY) Center Attending: OP H LN WS CL RFC CSP NFB HER FR MV EL WM

6 BEFORE & AFTER SCHOOL PARENT CONTRACT Grammar School Attending: Please check the days and times your child will attend and enter below. Monday am pm Tuesday am pm Wednesday am pm Thursday am pm Friday am pm I understand that I will be billed at the beginning of each month for the previous months care. Payments must be postmarked by the 15 th of the month or a late fee may be assessed to your account. There will be a charge for any returned check. Payments can be brought to the Center Director s office or mailed to: I understand that I am responsible to pay for all billed hours. ATTN: Billing EduKids, Inc Seneca Street Buffalo, NY I have read, understand and agree to comply with all policies and guidelines as listed above and in the EduKids Parent Handbook. Signature: Parent or Legal Guardian Person Responsible for Payment: Social Security #: Signature: Social Security #: Signature: (FOR OFFICE USE ONLY) Administrator s Signature:

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