Please complete this form to indicate that you would like to receive telemedicine and teletherapy benefits. Participants who register by the 15th of the month will get an email at the beginning of the following month to complete their enrollment. For example, if someone completes this form on October 12, they will receive an email on November 1 to enroll and begin their benefits. If someone completes this form on October 22, they will be eligible to enroll and begin their benefits on December 1.

This form is for employee registration only. You can enroll your dependents when you complete your enrollment.

Please make sure that all the information you submit is correct. Incorrect or incomplete information can delay your registration.

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* 1. Employee's First Name/Nombre del Empleado

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* 2. Last Name/Appellido del Empleado

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* 3. Email address/Correo Electrónico

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* 4. Phone Number/Número de Teléfono

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* 5. Date of Birth/Fecha de Nacimiento

Date

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* 6. What is your gender?/Género

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* 7. Home Address/Domicilio

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* 8. Center Name/ Nombre del Programa

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* 9. K8 Number/Numero del K8
(If you don't know your program's K8 Number, you can search it here:https://ccl.dhs.ok.gov/ )

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* 10. Center Director Name/Nombre del director del centro

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* 11. Center Director Email/Correo electrónico del director del centro

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* 12. CCR&R Region/CCR&R Región. If you are unsure of your CCR&R region, click here: CCR&R Agency Locations and Counties

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* 13. CECPD Registry ID Number/Número de identificación de registro del CECPD
If you don't have a registry number, please contact us at telehealth@okschoolreadiness.org

For any questions regarding the telehealth program, please email telehealth@okschoolreadiness.org.

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