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***BROOKLYN CHILD CARE, INC.***

**CHILD CARE CENTER**

**REGISTRATION FORM**

Located at the

VA NY Harbor Healthcare System

Brooklyn VA Medical Center Campus

800 Poly Place

Brooklyn, NY 11209

718-630-2831

Tanya Lipkin, Director

**BROOKLYN CHILD CARE, INC.**

**800 Poly Place**

**Brooklyn, NY 11209**

**718-630-2831**

**REGISTRATION FORM**

  ----------- --- --- ----- ---------- ------- ------------ ------------ -- -------------------------
  Child\'s                                                                  
  Name                                                                      

  Date of                              Home                                 
  Birth                                Phone                                

  Address                                                                   

                                                                            

  Mother\'s                                                                 
  Name                                                                      

  Mother\'s                                                 Occupation      
  Work Phone                                                                

  Mother\'s                                                                 
  Date of                                                                   
  Birth                                                                     

  Father\'s                                                                 
  Name                                                                      

  Father\'s                                    Occupation                   
  Work Phone                                                                

  Father\'s                                                                 
  Date of                                                                   
  Birth                                                                     

  Where did                 Flyers                                          
  you hear                                                                  
  about us?                                                                 

                            Web Site                                        

                            Banners                                         
  ----------- --- --- ----- ---------- ------- ------------ ------------ -- -------------------------

Current Health Insurance Information:

Name of carrier \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Policy Number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Effective Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Subscriber's Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Primary Care Physician \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(if applicable)

**\* a copy of the card can be attached in lieu of this information**

**Names of individuals authorized by the family to have access to health
information about the child:**

**Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Relationship
\_\_\_\_\_\_\_\_\_\_\_**

**Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Relationship
\_\_\_\_\_\_\_\_\_\_\_**

**Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Relationship
\_\_\_\_\_\_\_\_\_\_\_**

**Persons other than parents who are authorized to pick up my child or
to who Brooklyn Child Care, Inc. can contact in case of emergency:**

  ----- -------------- ------------ -------------- ------- ---------------------------
  1\.   Name                                       Phone   

        Relationship                                       
        to Child                                           
  ----- -------------- ------------ -------------- ------- ---------------------------

  ----- -------------- ------------ -------------- ------- ---------------------------
  2\.   Name                                       Phone   

        Relationship                                       
        to Child                                           
  ----- -------------- ------------ -------------- ------- ---------------------------

  ----- -------------- ------------ -------------- ------- ---------------------------
  3\.   Name                                       Phone   

        Relationship                                       
        to Child                                           
  ----- -------------- ------------ -------------- ------- ---------------------------

**Child\'s Weekly Schedule:**

  ------------ ----------------------------------------------------------
  Monday       

  Tuesday      

  Wednesday    

  Thursday     

  Friday       
  ------------ ----------------------------------------------------------

  ----- --------------------- --------------------------------------------
  Fee   \$                    per month

  ----- --------------------- --------------------------------------------

**[IT IS A POLICY OF THE BCCI NOT TO DESCRIMINATE AGAINST A PERSON AS TO
THEIR RACE,COLOR, ANCESTRY, SEX, AGE,HANDICAP, OR NATIONAL
ORIGIN.]{.underline}**

**Tell Us About Your Child**

***To assist us in better understanding your child, please answer the
following questions.***

1\. Does your child have any allergies or health problems that we should
know about?

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2\. Tell us about your family and tell us who lives in your house.

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**3. Tell us about your friends. List name of clos**e friends your child
might talk about.

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4\. Tell us about your child. How would you describe your child\'s
personality? Any fears that we should be aware of?

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5\. Tell us about your child\'s favorite activities.

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6\. Tell us about your child\'s least favorite activities.

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**7. What language does the child speak with parents/guardians at
home?**

**English Other[\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}**

**8**. Is there anything else we should know?

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**[It is a policy of the BCCI not to discriminate against a person as to
their race, color, ancestry, sex, age, handicap, or national
origin.]{.underline}**

**RELEASE FORM**

***Please check YES or NO after each statement and sign accordingly.***

1\. I give my child permission to go on any walks on the VA grounds as
well as walks to the Fort Hamilton park and surrounding areas. YES NO

2\. I give my permission for my child to have his/her photograph taken
as well as videotaped. These photographs or videotapes may be used in
Brooklyn Child Care, Inc. brochures, for public relations projects, web
site, etc. YES NO

3\. In case of emergencies when I, the parent, cannot be contacted, I
give my permission to the staff of Brooklyn Child Care., Inc. to sign
authorization allowing the Brooklyn VA Medical Center to give my child
the emergency medical attention that he/she requires. YES NO

  ----------------------------------------- -- ---------------------------
  Parent/Guardian Signature                    Date

  ----------------------------------------- -- ---------------------------

**BROOKLYN CHILD CARE, INC.**

**800 Poly Place**

**Brooklyn, NY 11209**

**718-630-2831**

**PARENT AGREEMENT**

  ------------ --------- ---- ---------------------------------------------- -------
  I,                                                                         ,

  the parent                                                                 ,
  of                                                                         

  have read                                                                  
  the Parent                                                                 
  Handbook and                                                               
  agree to the                                                               
  policies                                                                   
  outlined by                                                                
  Brooklyn                                                                   
  Child Care,                                                                
  Inc. As                                                                    
  proof of                                                                   
  this                                                                       
  agreement, I                                                               
  have signed                                                                
  in the                                                                     
  provided                                                                   
  space below.                                                               

                                                                             

  Parent\'s                                                                  
  Signature                                                                  

  Date                                                                       
  ------------ --------- ---- ---------------------------------------------- -------