The Oregon Registry Enrollment Form is a great way to ensure that your child has access to the best education possible. The form is simple to complete, and provides all of the information needed to enroll your child in the Oregon Registry. Completing the form online is easy and takes just a few minutes. Be sure to fill out the form accurately, as this will help ensure that your child receives appropriate educational services. For more information on the Oregon Registry, be sure to visit our website today.
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| Question | Answer |
|---|---|
| Form Name | Oregon Registry Enrollment Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | oregon resgistry |
OREGON REGISTRY ONLINE ENROLLMENT FORM
This form will enroll you in the Oregon Registry Online system, which is a tool you can use to track your professional development in the field of childhood care and education.
Section 1: Individual Information
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Last Name |
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First Name |
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Middle Name |
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Gender Male |
Female |
Date of Birth (mm/dd/yyyy) |
Former Name(s) |
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Physical Address |
I would like the Child Care Division to update my address on file for the Central Background Registry. My Registry number is: R__________________ |
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(street address, apt no) |
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City |
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State |
Zip Code |
County of Residence |
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Mailing Address (if different than above) |
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City |
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State |
Zip Code |
City of Birth |
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Home Phone No |
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Work Phone No |
Fax No |
Email Address |
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Section 2: Optional Enrollment Information
(Completing the information below is optional. It is collected in an effort to track our success in being inclusive of all populations)
Check below what racial/ethnic background best describes you. If you do not identify with any of the choices given, please check the OTHER box and list your preferred choice.
American Indian/Alaskan Native |
Black or African American |
Asian |
Hispanic/Latino/Spanish |
Other: (please list) ___________________________________
Native Hawaiian or other Pacific Islander White
1.What is your primary language?
________________________________________________________________________________________
2. Do you speak any other language(s) in addition to your primary language? |
Yes |
No |
If yes, please list any other language(s) that you speak fluently: |
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3.What language do you speak most often with the children that you work or volunteer with?
________________________________________________________________________________________
Section 3: Workforce Information
What is your Position(s)? |
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Administrative Support |
Director |
Teacher |
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Aide 1 |
Driver |
Nanny |
Teacher’s Aide |
Aide 2 |
Executive Director |
Operator |
Volunteer |
Assistant 1 |
Education Coordinator |
Provider |
Other: (please list) |
Assistant 2 |
Head Teacher |
Substitute Provider |
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Consultant |
Health/Mental Health Worker |
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Cook |
Manager |
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Level of Education |
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Less than High School Diploma |
High School Diploma |
General Educational Development (GED) |
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Certificate from college, school, or professional association in: ____________________________________________
Master’s degree- MA/MS/MED or other in: ____________________________________________________________
PhD, EdD or other doctoral degree in: ________________________________________________________________
Other (please list degree and field of study): _________________________________________________________________
Continued on back (signature required)
July 2014
Section 4: Employment/Volunteer Information
Check below what best describes the facility you work or volunteer for:
Child Care Resource & Referral College or University
EI/ECSE
Head Start and/or OPK Health or Mental Health Healthy Start ODE/CACFP Sponsor
Child Care Center/Preschool
Relief Nursery
School District- Elementary or High School Education Family Child Care Provider
State of Oregon Child Care Division
Other: (please list) ______________________________
Name of Facility (list business name. If family child care, list provider’s name)
Facility Phone No
Facility Physical Address (street address, apt no, city, state, zip)
Fax No
Mailing Address (if different than above)
County
Section 5: Childcare Facility Information (Complete this section if you work/volunteer with children)
1. |
Is the facility that you volunteer or work for licensed by the Child Care Division? |
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Yes |
No/Exempt |
Don’t know |
2. |
If yes, check the type of licensed child care facility you are associated with: |
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Registered Family Child Care Home (RF) |
Certified Family Child Care Home (CF) |
3.If known, please list the facility’s license number: _____________________
Certified Child Care Center (CC)
4. Check below what best describes your work setting:
Child care center |
Child’s own home |
Provider’s home |
Other: (please list) _____________________________________________________
5. Check below the maximum number of hours per day a child may attend the facility:
Four hours or less
More than four hours
6. Check below the maximum number of months in a year that a child may attend the facility:
7. What age groups of children do you work with (check all that apply)?
Infant
Toddler
Preschool
None of the above
Section 6: Enrollment Authorization
Oregon Registry Online (ORO) is a system that will manage your training and education records for licensing requirements and personal professional development. ORO representatives will undertake all necessary precautions to ensure that only authorized personnel will be able to access confidential information. Confidential information will not be disclosed for any purposes other than described here and as authorized by law. By your signature, you consent to the disclosure of your individual contact and training/education information to authorized personnel with the Oregon Office of Child Care, Oregon Center for Career Development, Department of Human Services, and/or the Central coordination of Child Care Resource and Referral at the Teaching Research institute and local child care resource and referral programs.
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Applicant’s Signature |
Printed Name |
Date Signed |
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July 2014 |