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NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICESREFERENCES Child Day Care ProgramInstructions: Please provide complete information for two people (one employment reference and one personal reference) we can contact. Relatives may NOT be used as references If you have been employed outside the home, please include an employer as one of your referencesPlease PRINT clearlyProgram Name: FORMTEXT ?????FACILITY ID Number: FORMTEXT ?????Name: FORMTEXT ?????TYPE OF PROGRAMFamily Day Care, Group Family Day Care and Small Day Care CentersDay Care Center and School-Age Child CareROLE IN PROGRAM FORMCHECKBOX Provider FORMCHECKBOX Assistant FORMCHECKBOX Substitute FORMCHECKBOX Director FORMCHECKBOX Teacher FORMCHECKBOX VolunteerReference #1 (Required)Please check appropriate reference type: FORMCHECKBOX Personal FORMCHECKBOX Employment FORMCHECKBOX Mr. FORMCHECKBOX Mrs. FORMCHECKBOX Ms.NAME (Last, First, MI): FORMTEXT ?????BUSINESS NAME: FORMTEXT ?????APT: FORMTEXT ?????flOOR: FORMTEXT ?????ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP: FORMTEXT ?????daYtIME PHONE:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????E-MAIL: FORMTEXT ?????Does reference speak English? FORMCHECKBOX Yes FORMCHECKBOX No If NO, please specify language spoken: FORMTEXT ?????Reference #2 (Required)Please check appropriate reference type: FORMCHECKBOX Personal FORMCHECKBOX Employment FORMCHECKBOX Mr. FORMCHECKBOX Mrs. FORMCHECKBOX Ms.NAME (Last, First, MI): FORMTEXT ?????BUSINESS NAME: FORMTEXT ?????APT: FORMTEXT ?????flOOR: FORMTEXT ?????ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP: FORMTEXT ?????daYtIME PHONE:( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ?????E-MAIL: FORMTEXT ?????Does reference speak English? FORMCHECKBOX Yes FORMCHECKBOX No If NO, please specify language spoken: FORMTEXT ?????Reference #3 (Optional)Please check appropriate reference type: FORMCHECKBOX Personal FORMCHECKBOX Employment FORMCHECKBOX Mr. FORMCHECKBOX Mrs. FORMCHECKBOX Ms.NAME (Last, First, MI): FORMTEXT ?????BUSINESS NAME: FORMTEXT ?????APT: FORMTEXT ?????flOOR: FORMTEXT ?????ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP: FORMTEXT ?????daYtIME PHONE:( FORMTEXT ?????) FORMTEXT ?????- FORMTEXT ?????E-MAIL: FORMTEXT ?????Does reference speak English? FORMCHECKBOX Yes FORMCHECKBOX No If NO, please specify language spoken: FORMTEXT ????? ................
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