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Fillable Printable Child Registration Form - Virginia

Fillable Printable Child Registration Form - Virginia

Child Registration Form - Virginia

Child Registration Form - Virginia

DIVISION OF LICENSING PROGRAMS
DEPARTMENT OF SOCIAL SERVICES
CHILD REGISTRATION FORM
Name Nickname Date of Birth Sex
Address Home Phone
Chronic Physical Problems/Pertinent Developmental Information/Special Accommodations Needed
Previous Child Day Care Programs and Schools Attended
If Child Attends this Center and Another School/Program, Give Name of School/Program Grade
PARENT(S)/GUARDIAN(S)
Father Place Employed Business Phone
Home AddressHome Phone
Mother Place Employed Business Phone
Home AddressHome Phone
Person(s) or Agency Having Legal Custody of Child
Home AddressHome Phone
Business Address Business Phone
EMERGENCY INFORMATION
Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency
Child’s Physician Phone
Two People to Contact if Parent(s) Cannot
Be Reached
1.
Address
1.
Phone
1.
2.
2.
2.
Person(s) Authorized to Pick Up Child
Person(s) NOT Authorized to Pick Up Child *
* Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.
* NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the
noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of
such noncustodial parent, as an emergency contact for events occurring during school or day care activities.
032-05-252/11 (06/05)(over)
AGREEMENTS
1. The child day care center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the
parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.
2. The parent(s)/guardian(s) authorize the child day center to obtain immediate medical care if any emergency
occurs when the parent(s)/guardian(s) cannot be located immediately. **
3. The parent(s)/guardian(s) agree to inform the center within 24 hours or the next business day after his child or
any member of the immediate household has developed a reportable communicable disease, as defined by the
State Board of Health, except for life threatening diseases which must be reported immediately.
SIGNATURES
_____________________________________________________ _____________________
Parent(s) or Guardian(s) Date
_____________________________________________________ _____________________
Administrator of Center Date
Date Child Entered Care: __________________ Date Child Left Care: _________________
** If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or
guardian(s) that states the objection and the reason for the objection.
OFFICE USE ONLY
IDENTITY VERIFICATION
If proof of identity is required and a copy is not kept, please fill out the following.
Place of Birth Date of Birth Birth Certificate Number Date Issued
Other Form of Proof Date Documentation ViewedPerson Viewing Documentation
Date of Notification of Local Law-Enforcement Agency (when required proof of identity is not provided): __________
Date
Proof of the child’s identity and age may include a certified copy of the child’s birth certificate, birth registration card,
notification of birth (hospital, physician or midwife record), passport, copy of the placement agreement or other proof
of the child’s identity from a child placing agency (foster care and adoption agencies), record from a public school in
Virginia, certification by a principal or his designee of a public school in the US that a certified copy of the child’s birth
record was previously presented or a copy of the entrustment agreement conferring temporary legal custody of a child
to an independent foster parent. Viewing the child’s proof of identity is not necessary when the child attends a public
school in Virginia and the center assumes responsibility for the child directly from the school (i.e., after school program)
or the center transfers responsibility of the child directly to the school (i.e., before school program). While the
programs are not required to keep the proof of the child’s identity, documentation of viewing this information must be
maintained for each child.
Section 63.2-1809 of the Code of Virginia states that proof of identity, if reproduced or retained by the child day
program or both, shall be destroyed upon conclusion of the requisite period of retention. The procedures for the
disposal, physical destruction or other disposition of the proof of identity containing social security numbers shall
include all reasonable steps to destroy such documents by (i) shredding, (ii) erasing, or (iii) otherwise modifying the
social security numbers in those records to make them unreadable or indecipherable by any means.
032-05-252/11 (06/05)
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