The Oregon Registry Enrollment form is a crucial document designed to enroll individuals in the Oregon Registry Online system. This system serves as a valuable tool for tracking professional development in childhood care and education. By completing this form, you ensure that your training and education records are properly managed and accessible for licensing requirements.
The Oregon Registry Enrollment form serves as a vital gateway for individuals working in childhood care and education to track their professional development. This comprehensive form encompasses several sections that gather essential information about the individual, including personal details such as name, gender, and date of birth, as well as contact information. Notably, it allows individuals to request updates to their address on file with the Central Background Registry, ensuring that their records remain current. Furthermore, the form includes optional demographic questions aimed at fostering inclusivity, allowing participants to identify their racial or ethnic backgrounds and primary languages spoken. It also seeks to understand the professional landscape by collecting information about the individual's position, level of education, and the nature of their employment or volunteer work within the field. Additionally, there is a section dedicated to the childcare facility where the individual works or volunteers, including its licensing status and the age groups of children served. Finally, the form concludes with an authorization section, where individuals consent to the management of their training and education records, emphasizing the commitment to confidentiality and the responsible handling of personal information. This enrollment process is not just a formality; it is a step towards enhancing the quality of care and education provided to children across Oregon.
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 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)
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?
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
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