DA Form 4719 Child Development Services (Cds) Registration Card

DA Form 4719 - also known as the "Child Development Services (cds) Registration Card" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 4719 - was last revised on June 1, 2009. Download an up-to-date fillable PDF version of the DA 4719 down below or look it up on the Army Publishing Directorate website.

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DATE
CHILD DEVELOPMENT SERVICES (CDS) REGISTRATION CARD
For use of this form, see AR 608-10; the proponent agency is ACSIM.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, United States Code, Section 3013
AUTHORITY:
To provide child and family program eligibility and background information; sponsor consent for access,
PRINCIPAL PURPOSE(S):
to emergency medical care; data required by USDA food program.
Information is furnished the attending physician when it is necessary for a child to be taken to a medical
ROUTINE USES:
facility by someone other than the parent. Information on immunization and medical problems will be used as part
of the program admission screening procedure. Family income data will be used to determine USDA
food program qualification and rate structures.
Disclosure of requested information is voluntary, however, if information is not provided, individuals may not be
DISCLOSURE:
allowed to participate in CDS programs.
DECLARATION OF NONDISCRIMINATION
Services will be made available to all children in attendance, without regard to race, color, religion, national origin, ancestry, or sex, within the limits of
AR 608-10. CDS programs participating in the USDA Food Program shall offer meals without physical segregation of, or discrimination against any child
regardless of ability to pay.
GRADE
NAME OF SPONSOR (Last, first, MI)
SERVICE (Check One)
SOLE PARENT
YES
RET
CIV
ACT
NO
HOME ADDRESS OF SPONSOR (Include ZIP Code)
DUTY/EMPLOYER ADDRESS (Include ZIP Code)
ON POST
HOME PHONE
OFF POST
DUTY PHONE
SERVICE (Check One)
NAME OF SPOUSE (Last, first, MI)
GRADE
DUAL MILITARY
SPONSOR
RET
CIV
ACT
HOME ADDRESS OF SPOUSE (Include ZIP Code)
HOME PHONE
DUTY/EMPLOYER ADDRESS (Include ZIP Code)
ON POST
OFF POST
DUTY PHONE
EMERGENCY NOTIFICATION DESIGNEE
HOME PHONE
DUTY PHONE
CHILD RELEASE DESIGNEE
FAMILY SIZE
GROSS INCOME
USDA CATEGORY (Check One)
MULTIPLE CHILD DISCOUNT
FD
PD
HR
FCC
N/A
FULL
REDUCED
PAID
CDS PROGRAM RATES
FCC HOME
B/A SCHOOL
FULL DAY
PRESCHOOL
HOURLY
DA FORM 4719, JUN 2009
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00 ES
DATE
CHILD DEVELOPMENT SERVICES (CDS) REGISTRATION CARD
For use of this form, see AR 608-10; the proponent agency is ACSIM.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Title 10, United States Code, Section 3013
AUTHORITY:
To provide child and family program eligibility and background information; sponsor consent for access,
PRINCIPAL PURPOSE(S):
to emergency medical care; data required by USDA food program.
Information is furnished the attending physician when it is necessary for a child to be taken to a medical
ROUTINE USES:
facility by someone other than the parent. Information on immunization and medical problems will be used as part
of the program admission screening procedure. Family income data will be used to determine USDA
food program qualification and rate structures.
Disclosure of requested information is voluntary, however, if information is not provided, individuals may not be
DISCLOSURE:
allowed to participate in CDS programs.
DECLARATION OF NONDISCRIMINATION
Services will be made available to all children in attendance, without regard to race, color, religion, national origin, ancestry, or sex, within the limits of
AR 608-10. CDS programs participating in the USDA Food Program shall offer meals without physical segregation of, or discrimination against any child
regardless of ability to pay.
GRADE
NAME OF SPONSOR (Last, first, MI)
SERVICE (Check One)
SOLE PARENT
YES
RET
CIV
ACT
NO
HOME ADDRESS OF SPONSOR (Include ZIP Code)
DUTY/EMPLOYER ADDRESS (Include ZIP Code)
ON POST
HOME PHONE
OFF POST
DUTY PHONE
SERVICE (Check One)
NAME OF SPOUSE (Last, first, MI)
GRADE
DUAL MILITARY
SPONSOR
RET
CIV
ACT
HOME ADDRESS OF SPOUSE (Include ZIP Code)
HOME PHONE
DUTY/EMPLOYER ADDRESS (Include ZIP Code)
ON POST
OFF POST
DUTY PHONE
EMERGENCY NOTIFICATION DESIGNEE
HOME PHONE
DUTY PHONE
CHILD RELEASE DESIGNEE
FAMILY SIZE
GROSS INCOME
USDA CATEGORY (Check One)
MULTIPLE CHILD DISCOUNT
FD
PD
HR
FCC
N/A
FULL
REDUCED
PAID
CDS PROGRAM RATES
FCC HOME
B/A SCHOOL
FULL DAY
PRESCHOOL
HOURLY
DA FORM 4719, JUN 2009
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00 ES
NAME OF CHILD (Last, first, MI)
NAME OF CHILD (Last, first, MI)
NAME OF CHILD (Last, first, MI)
PHYS EXAM DATE
BIRTH DATE SEX
PHYS EXAM DATE
BIRTH DATE
SEX
PHYS EXAM DATE BIRTH DATE
SEX
IMMUNIZATION DATES
IMMUNIZATION DATES
IMMUNIZATION DATES
DPT
DPT
DPT
TOPV
TOPV
TOPV
MMR
MMR
MMR
TINE
TINE
TINE
MEDICAL PROBLEMS
MEDICAL PROBLEMS
MEDICAL PROBLEMS
ALLERGIES
ALLERGIES
ALLERGIES
REGISTRATION INFORMATION
REGISTRATION INFORMATION
REGISTRATION INFORMATION
PROGRAM
BLDG/RM
ENROLL
TERMIN
PROGRAM
BLDG/RM
ENROLL
TERMIN
PROGRAM
BLDG/RM
ENROLL
TERMIN
FULL DAY
FULL DAY
FULL DAY
HOURLY
HOURLY
HOURLY
PRESCH
PRESCH
PRESCH
B/A SCH
B/A SCH
B/A SCH
FCC HOME
FCC HOME
FCC HOME
OTHER
OTHER
OTHER
SPONSOR CONSENT: I
(parent)(guardian) of
give consent for an authorized CDS representative to take my child/children for care, medical or dental, in an emergency situation where the child's condition
represents a serious or imminent threat to his/her life, health, or well-being. I understand that a conscientious effort will be made to notify me prior to such
action and the expense, if any, will be borne by me. Treatment at an Army medical facility may be provided without additional consent under the provision of
AR 40-3, paragraph 2-24b.
DATE
SIGNATURE OF SPONSOR
APD LC v1.00ES
REVERSE OF DA FORM 4719, JUN 2009
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