Oregon Registry Step Application Details

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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QuestionAnswer
Form NameOregon Registry Enrollment Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesoregon resgistry

Form Preview Example

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

 

Last Name

 

 

 

First Name

 

Middle Name

 

 

 

 

 

 

 

 

 

 

Gender Male

Female

Date of Birth (mm/dd/yyyy)

Former Name(s)

 

 

 

 

 

 

 

 

 

 

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__________________

 

(street address, apt no)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

Zip Code

County of Residence

 

 

 

 

 

 

 

Mailing Address (if different than above)

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

Zip Code

City of Birth

 

 

 

 

 

 

 

 

Home Phone No

 

Work Phone No

Fax No

Email Address

 

 

 

 

 

 

 

 

 

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:

 

 

________________________________________________________________________________________

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)?

 

 

 

Administrative Support

Director

Multi-Site Coordinator

Teacher

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

 

Consultant

Health/Mental Health Worker

 

 

Cook

Manager

 

 

Level of Education

 

 

 

Less than High School Diploma

High School Diploma

General Educational Development (GED)

Certificate from college, school, or professional association in: ____________________________________________

2-year college degree- AA/AS/AAS or other in:_________________________________________________________

4-year college degree- BA/BS or other 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 (for/not-for-profit child care and education) Parent (eg Nanny)

Relief Nursery

School District- Elementary or High School Education Family Child Care Provider (self-employed)

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?

 

Yes

No/Exempt

Don’t know

2.

If yes, check the type of licensed child care facility you are associated with:

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

K-12 school building

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:

0-4 months

5-9 months

10-12 months

7. What age groups of children do you work with (check all that apply)?

Infant

Toddler

Preschool School-Age

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.

______________________________

___________________________________

_____________________

Applicant’s Signature

Printed Name

Date Signed

 

 

July 2014