Form 10-380 Child Registration Intake Form

OMB Control No. 2900-XXXX
Estimated Burden: 15 Minutes
Expiration Date: XX/XX/20XX

Veterans Child Care Assistance Program (VCAP)

CHILD REGISTRATION INTAKE FORM

VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
The OMB control number for this project is 2900-XXXX, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at
[email protected]. Please refer to OMB Control No. 2900-XXXX in any correspondence. Do not send your completed VA Form 10-380 to this email address.
PRIVACY ACT STATEMENT: The information requested on this form is solicited under authority of Title 38 United States Code, Sections 5701 and 7332, and will be used to assist VA in
determining your entitlement to VCAP child care services. The information collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974. This form is part
of the system of records identified as 24VA19 “Patient Medical Record – VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at https://www.gpo.gov/privacy.
Information collected will not be used for any other purpose. Your disclosure of information is voluntary; however, failure to furnish the required information will result in our inability to provide
services or process your claim. Your failure to furnish this information will have no adverse effect on any other benefit to which you may be entitled.
1. VETERAN'S NAME (Last, First, Middle Initial)
3. VETERAN'S CELL PHONE NUMBER

5. EMAIL

2. VETERAN'S VA IDENTIFICATION NUMBER (or Last 4 of SSN)

4. VETERAN'S ADDRESS

6. VETERAN'S GENDER

7. VETERAN'S RACE

8. NEXT EMERGENCY CONTACT (Secondary Caretaker) FOR CHILD
FIRST
EMERGENCY
CONTACT

SECOND
EMERGENCY
CONTACT

A. NAME

B. CELL PHONE

C. ADDRESS

D. RELATIONSHIP TO CHILD

E. NAME

F. CELL PHONE

G. ADDRESS

H. RELATIONSHIP TO CHILD

9. LIST OF ALL CHILDREN FOR WHICH CHILD CARE MAY BE NEEDED (Provide this information for each child)

#

A. CHILD'S FULL NAME

(Last, First)

B. CHILD'S
DATE OF BIRTH

(MM/DD/YYYY)

C. ANY KNOWN
ALLERGIES

D. IN CASE OF
EMERGENCY, I AUTHORIZE
CHILD CARE PERSONNEL
TO ADMINISTER
PRESCRIBED MEDICATION,
PROVIDED BY THE CHILD
CARETAKER

E. PHYSICAL DESCRIPTION

(1) HAIR
COLOR

(2) EYE
COLOR

(3) HEIGHT

F. CONSENT TO
CAPTURE
PHOTO OF
CHILD FOR
IDENTIFICATION
(4) WEIGHT
PURPOSES
ONLY

1

2

3

4

5

6

7

8

VA FORM
AUG 2024

10-380

VCAP

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10. ADDITIONAL INFORMATION

INITIALS
11. In the event my child experiences an emergency, I give consent to VA Kids Care to call 911. Please note, transportation will be coordinated through 911 to
the nearest emergency room.
12. I understand that there is a three hour maximum for each episode of child care provided by VA Kids Care and that I am not authorized to leave the VA health
care campus while my child is in the care of VA Kids Care.

CERTIFICATION
By signing this form, I am acknowledging that I understand and agree to the terms in the VA Kids Care enrollment application.
13. SIGNATURE

VA FORM 10-380, AUG 2024

14. DATE (MM/DD/YYYY)

VCAP

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