HS-EHS Intake Packet English | Family Development Services

English Enrollment Form

Please fill out the information below. If you have any questions, please contact our office.

Step 1 of 9

Family Engagement Contract
By enrolling your child, you are joining us to achieve our program’s mission: To improve the lives of children by providing high quality, early childhood education and comprehensive family focused services. To reach our shared mission, and recognizing your hopes and dreams for your child, we need to work together as equal partners. Please officially join us in partnership by signing and following through on this Family Involvement Contract.
Child's Name*
First Middle Last
Center:*
One hope or dream I have for my child is...*
Our program will do the following for you and your child:
● Provide an excellent education program – every day – for all of our students.
● Guide you through the process of learning and doing high-quality parent-child activities that support your child’s learning at home.
● Support you to keep your child healthy and well.
● Honor your family’s unique strengths, needs and circumstances.
● Build an environment that welcomes ALL families as partners in our program.
● Welcome your voice…and create opportunities for you to provide feedback and to be heard
● Offer many ways for you to participate and volunteer at our program.
I,
Parent/Guardian Name*
First Middle Last
will do the following:
● Bring my child to school on time and every day because attendance is the key to success.
● Participate in my child’s learning by completing each week’s home school connection packet and by volunteering time in the center.
● Read with my child every night to encourage a love of learning and to build their vocabulary.
● Attend center activities to help build community and to advocate for my child and family.
● Partner with our program to keep my child healthy.
Partnership Agreement: We agree that we will work together as equal partners to achieve my child’s school readiness goals. We will also help you to reach your own family’s goals.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY

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Emergency Information & Authorization for Release Card
Child's Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Change of Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Change
MM slash DD slash YYYY
Parental Status*
- One Parent
- Two Parents
Primary Parent/Guardian Name*
First Middle Last
Primary Phone Number*
Secondary Phone Number
Email*
Change of Phone Number
Date of Change
MM slash DD slash YYYY
Primary Phone Number
Secondary Phone Number
Second Parent/Guardian Name*
First Middle Last
Primary Phone Number*
Secondary Phone Number
Email*
Change of Phone Number
Date of Change
MM slash DD slash YYYY
Primary Phone Number
Secondary Phone Number
Health Insurance Name*
Policy/Medicaid #*
Child's Allergies*
Health Concerns/Accommodations*
Daily Medications*
In case of an accident or emergency contact:
Doctor/Clinic*
Phone*
In case of an accident or emergency please take my child to (Hospital)*
*
Family Development Services has my authorization to provide transportation and obtain medical treatment for my child in the event of a medical, health, or building emergency.
*
I provide permission for my child to participate in extracurricular activities/events at the child care center on and off the premises.
Signature of Parent/Guardian*
Date*
MM slash DD slash YYYY
The following persons are authorized to pick-up my child from the classroom. Please include parent/guardians on this pick up list. Photo Identification is required for release of child.
*
First & Last Name Phone Relationship to Child Can this person seek Medical Care for my child? Date of Removal from Pick-up List
*
I understand I am the only one who can make changes to this list, and any changes made must be by me and completed in person.
*
I authorize anyone on this list who is a minor between the ages of 14-17 to receive my child from the classroom pending showing a valid photo I.D.
Signature of Parent/Guardian*
Date*
MM slash DD slash YYYY

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Income Verification Statement
I,
Parent/Guardian Name*
First Middle Last
The Parent/Guardian of,
Child's Name*
First Middle Last
state that I receive:
Amount ($)*
*
- Per Week
- Per Month
- Per Year
The source of my income is:*
Or I am being cared for by (name of Caretaker)
Comments
*
By signing, I certify that the information provided on this verification form is accurate and truthful to the best of my knowledge. I am also aware that I may be subject to termination from the program if the information verified causes me to become ineligible.
Signature of Parent/Guardian*
Date*
MM slash DD slash YYYY
Please attach any income documents
You may also use the Notebloac app to format any documents you have.
Max. file size: 1 GB.

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Asthma Screening Tool
Is your child at risk? Ask yourself the following questions:
1. When the seasons change, does your child require medication and/or a breathing treatment?
2. Has albuterol been used to treat your child for a medical condition in the past six months? (For example: Bronchitis or respritory infection, croup, whooping cough
3. Has your child been diagnosed with asthma or reactive airway disease by a medical provider?
4. Has your child been prescribed an albuterol medciation such an inhaler or albuter sulfate nebulizer solution to use ongoing as needed?
● An asthma attack is generally defined as shortness of breath that interrupts your well being, requiring either medication or some other form of treatment, such as a nebulizer, to allow you to breathe normally again. If you suspect that your child is suffering from asthma, you must visit a doctor as soon as possible. Asthma can be a life threatening illness if not properly controlled. ● If you suspect that your child may be even slightly asthmatic, take him/her to the doctor for advice as soon as possible. Please do not ignore any symptoms and dismiss it as a “one-time” event; the next one could be more serious. ● Often young children cannot perform a lung test, but a doctor is usually able to tell if a child has asthma from either the symptoms that are present or by giving a trial of an asthma treatment to see if the problem is reduced. ● In infants and children, asthma may appear as cough, rapid or noisy breathing, or chest congestion.
If you answered “yes” to any of the above questions your child may be at risk for asthma or their asthma may not be well managed. Call your doctor and schedule a check-up for your child.
Asthma Screening Confirmation Sheet
The Asthma Screening Tool was presented to the parent/guardian of:
Child's Name*
First Last
State that my child*
- Does not have asthma
- Does has asthma
*
I understand that I am required to provide an asthma action plan and current medication before my child can enroll in school.
Parent/Guardian Signature*
Comments

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Special Dietary Needs Form
Complete and submit this form to Family Development Services. The parent/guardian/adult participant will complete part 1 and 2, and the physician or medical authority (physician's assistant or nurse practitioner) will complete part 3. Refer to the information below for clarification. Attach a sheet with additional information if necessary. If changes are needed, the parent/guardian/adult participant is required to submit a new form.
Disability: USDA requires substitutions or modifications in CACFP meals for participants whose disabilities restrict their diets. The definition of the term "disability" has broadened and nearly all physical and mental impairments constitute a disability.
Section 504 of the Rehabilitation Act, the Americans with Disabilities Act, and Departmental Regulations at 7 CFR Part 15b define a person with a disability as any person who has a physical or mental impairment which substantially limits one or more "major life activities," has a record of such impairment, or is regarded as having such impairment. (See 29 USC § 705(9)(b); 42 USC § 12101; and 7 CFR 15b.3.) "Major life activities are broadly defined and include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working, "Major life activities" also include the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. (See 29 USC § 705(9)(b) and 42 USC § 12101.)
A physical or mental impairment does not need to be life-threatening to constitute a disability. It is enough that the impairment limits a major life activity. Further, an impairment may be covered as a disability even if medication, or another mitigating measure, may reduce the impact of the impairment.
Forms or medical statements for disabilities must be signed by a licensed physician, physician's assistant, or nurse practitioner and must identify the child's medical condition; an explanation of why the disability restricts the child's diet; the major life activity affected by the disability; the food or foods to be omitted from the child's diet, and the food or choice of foods that must be substituted.
Special Dietary Needs That Are Not a Medical Condition: Food service may make food substitutions, at their discretion, for individual children who do not have a disability/medical condition, but who have special dietary needs for other reasons such as religious, cultural, or other preferences. CACFP participating organizations are encouraged to accommodate reasonable requests but are not required to do so. For these requests, the form may be signed by a parent/guardian/adult participant.
The form should include an identification of the special dietary need that restricts the diet; the food or foods to be omitted; and the food or choice of foods to be substituted.
Part 1
To be completed by a Parent, Guardian, or Authorized Representative
Child's Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Parent, Guardian, or Authorized Representative*
First Middle Last
Primary Phone Number*
Secondary Phone Number
Address*
Street Address Address Line 2 City State ZIP Code
Part 2
Describe the participant's special dietary need:*
Foods to be omitted:*
Substitutions:*
Please list additional information regarding the diet:*
Parent/Guardian/Adult Participant/rep. of Adult Participant Signature*
Date*
MM slash DD slash YYYY
Part 3
**If this is a Food Allergy – a Food Allergy Action Plan is required to be completed in addition to this form.**
Describe the patient's medical condition and the major life activities that are affected:
Food to be omitted:
Substitutions:
Please list additional information regarding the diet (including texture changes such as chopped, ground, pureed, etc.):
Licensed physician, physician's assistant or nurse practitioner signature
Date
MM slash DD slash YYYY
Name
First Middle Last
Title
Phone Number

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HOME SCHOOL CONNECTION AGREEMENT
The federal government requires Head Start programs to generate In-Kind dollars from parents and the community. An In-Kind donation is any gift given to our program from our parents or the community. We ask that you help us earn In-Kind by working with your children at home and/or volunteering your time at the centers. Our program earns $14.29 an hour towards our In-Kind requirement when you do educational activities with your child at home. Our In-Kind goal is to reach $4 million a year for our agency. We need your help and commitment to keep our program operating and providing free preschool.
What can you do as a parent? We have a homework program for your child. Each week we send a calendar of activities home for you to do with your child. These are school readiness activities that you can easily do at home with your child.
If your home language is other than English, we encourage you to do these activities in your home language. Research shows that there are many cognitive, social emotional and learning benefits. Bilingual learners have greater success in school and life when they continue to develop their home language.
We would like for you to participate in our Home School Connection program and do the following:
● Review the activity calendar weekly. ● Complete at least 5 hours of educational activities per week With your child ● Fill in the calendar with the number of hours for the activities you completed each week. ● Submit the activities calendar into your teacher by the BEGINNING OF EACH WEEK.
Your time counts as money; therefore, your cooperation is requested and appreciated. If we do not have enough help from parents, our agency could lose funding, meaning we may have to reduce the number of children attending our program.
*
As a parent of a child receiving free high-quality services, I agree to participate in the Home School Connection program and to turn in the necessary paperwork each week.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY

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Acknowledgement of Receipt of the 2020-2021 Family Handbook and Annual Notice
Dear Head Start Director,
I hereby acknowledge that I have been given a copy of the Family Development Services Head Start and Early Head Start Family Handbook, which contains the 2020 – 2021 annual notice concerning my rights under 45 C.F.R. § 1303, Subpart C – Protections for the Privacy of Child Records regarding my child’s personally identifiable information held by Family Development Services. I understand that I have the right to inspect and request amendments to those records, and that those records may be released without my consent in a limited set of situations.
Child's Name
First Last
Center
Printed Parent Name
First Last
Parent Signature
Date
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

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English Enrollment Form

Step 1 of 9

Family Engagement Contract

Emergency Information & Authorization for Release Card

Income Verification Statement

Asthma Screening Tool

Asthma Screening Confirmation Sheet

Consent for Services

Authorization for Release and Receipt of Child Records

Special Dietary Needs Form

Part 1

Part 2

Part 3

HOME SCHOOL CONNECTION AGREEMENT

Acknowledgement of Receipt of the 2020-2021 Family Handbook and Annual Notice

First & Last Name	Phone	Relationship to Child	Can this person seek Medical Care for my child?	Date of Removal from Pick-up List