OCFS-6050 NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICES EMERGENCY RESERVATION FORMChild’s Full Name: Date of Birth: MM slash DD slash YYYY Gender: Instructions To be completed by parent/guardian prior to emergency reservation. A parent/guardian signature is required. The following questions must be answered: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)? Yes No Has your child had contact with any person with known COVID-19 or person under Investigation for COVID-19? Yes No Does Are you or anyone in your home in active quarantine status?child have any symptoms of a respiratory infection (e.g., cough, sore throat, fever, shortness of breath)? Yes No Are you or anyone in your home in active quarantine status? Yes 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: Yes No Is your child’s school under mandatory closure due to a confirmed case of COVID-19? Yes No Is your child’s current program under mandatory closure due to a confirmed case of COVID-19? Yes No Contact InformationChild’s Home Address: Parent’s Name and Address (if different than child): Parent’s phone contact (home, cell and work): EMERGENCY CONTACT NAMES/ADDRESSESPrimary Contact: AUTHORIZED TO PICK UP CHILD Yes No PRIMARY PHONE NUMBEROTHER PHONE NUMBER/EMAILEmergency Contact: AUTHORIZED TO PICK UP CHILD Yes No PRIMARY PHONE NUMBEROTHER PHONE NUMBER/EMAILEmergency Contact: AUTHORIZED TO PICK UP CHILD Yes No PRIMARY PHONE NUMBEROTHER PHONE NUMBER/EMAILHealth SpecificsDoes your child have any allergies? (Specify) Yes No Comments Is medication regularly taken? Yes No (Specify diet and condition) Yes No Comments Is a special diet required? Yes No Comments Are there any hearing, visual or dental conditions requiring special attention? Yes No Comments Are there any medical or developmental conditions requiring special attention? Yes No Comments Child’s Healthcare Provider InformationChild’s Primary Care Physician’s Name/Group Phone Number:Preferred Hospital Phone Number:Child’s Dental Care: Phone Number:AgreementsI consent to emergency medical treatment for my child. Yes No My child is up to date with required immunizations Yes No The 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 MM slash DD slash YYYY Printed Name:
