Night Care Schedule - New York State Office of Children ...
NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICESEmergency Reservation Form Child’s Full Name: FORMTEXT ?????Date of Birth: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????Gender: FORMTEXT ?????Instructions To be completed by parent/guardian prior to emergency reservation. A parent/guardian signature is required.The following questions must be answered: FORMCHECKBOX Yes FORMCHECKBOX No Within the last 14 days, has your child traveled to a country that the federal Centers for Disease Control and Prevention said should be avoided for nonessential travel or where travelers should practice enhanced precautions? (China, Iran, Italy, South Korea, Japan)? FORMCHECKBOX Yes FORMCHECKBOX No Has your child had contact with any person with known COVID-19 or person under Investigation for COVID-19? FORMCHECKBOX Yes FORMCHECKBOX No Does your child have any symptoms of a respiratory infection (e.g., cough, sore throat, fever, shortness of breath)? FORMCHECKBOX Yes FORMCHECKBOX No Are you or anyone in your home in active quarantine status? FORMCHECKBOX Yes FORMCHECKBOX No Is your child enrolled in a school or child care program? If yes, please provide the name(s) of your child’s school and/or child care program: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No Is your child’s school under mandatory closure due to a confirmed case of COVID-19? FORMCHECKBOX Yes FORMCHECKBOX No Is your child’s current program under mandatory closure due to a confirmed case of COVID-19? Contact InformationChild’s Home Address: FORMTEXT ?????Parent’s Name and Address (if different than child): FORMTEXT ?????Parent’s phone contact (home, cell and work): FORMTEXT ?????EMERGENCY CONTACT NAMES/ADDRESSESAuthorized to Pick Up ChildPRIMARY PHONE NUMBER( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????OTHER PHONE NUMBER/EMAIL ( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ????? FORMTEXT ?????Primary Contact: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX ok to text FORMCHECKBOX ok to textEmergency Contact: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX ok to text FORMCHECKBOX ok to textEmergency Contact: FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX ok to text FORMCHECKBOX ok to textHealth SpecificsCommentsDoes your child have any allergies? (Specify) FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ?????Is medication regularly taken? FORMCHECKBOX Yes FORMCHECKBOX No (Specify diet and condition) FORMTEXT ????? FORMTEXT ?????Is a special diet required? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Are there any hearing, visual or dental FORMCHECKBOX Yes FORMCHECKBOX Noconditions requiring special attention? FORMTEXT ?????Are there any medical or developmental FORMCHECKBOX Yes FORMCHECKBOX Noconditions requiring special attention? FORMTEXT ????? FORMTEXT ?????Child’s Healthcare Provider InformationChild’s Primary Care Physician’s Name/Group: FORMTEXT ?????Phone )Number:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Preferred Hospital: FORMTEXT ?????Phone Number:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????Child’s Dental Care: FORMTEXT ?????Phone Number:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????AgreementsI consent to emergency medical treatment for my child. FORMCHECKBOX Yes FORMCHECKBOX NoMy child is up to date with required immunizations. FORMCHECKBOX Yes FORMCHECKBOX NoThe above information regarding my child’s health is true and accurate. To the best of my knowledge, my child is free from contagious and communicable disease and is able to participate in this program.Parent/Guardian Signature:Date: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????Printed Name: ................
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