Re-Enrollment Packet English | Family Development Services

English Re-Enrollment Form

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

Step 1 of 15 - Emergency Information & Authorization for Release Card

Emergency Information & Authorization for Release Card
Child's Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Child's Address*
Street Address Address Line 2 City State ZIP Code
Parental Status*
- One Parent
- Two Parents
Primary Parent/Guardian*
First Middle Last
Primary Phone #*
Secondary Phone #*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Second Parent/Guardian*
First Middle Last
Primary Phone #*
Secondary Phone #*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Child's Allergies*
Health Concerns/Accommodations*
Daily Medications*
In case of accident or emergency contact Doctor/Clinic:*
Phone*
In case of accident or emergency please take my child to (Hospital):*
Consent*
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 parents/guardians on this pick up list. Photo Identification is required for release of child.*
First & Last Name Phone Number Relationship to Child Can this person seek Medical Care for my child? Date of Removal from Pick-up List
Consent*
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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Indiana University School Of Optometry Vision For The Future Consent To Treat Minor Patient
This form provides authorization by a parent or legal guardian for the Indiana University School of Optometry (IUSO} to provide routine vision care to the minor listed at a Marion Head Start. IUSO provides full FREE comprehensive eye exams to students that did not pass the FREE vision screening for the purpose of providing access to vision care services to students
Child's Name*
First Middle Last
Date of Service*
MM slash DD slash YYYY
Allergies*
Current Medications*
Chronic Conditions or Health Concerns*
List the individuals authorized to accompany the minor*
First Name Last Name Relationship to Patient
I authorize the Indiana University School of Optometry (IUSO} and Its personnel to deliver routine vision care and services, including a comprehensive eye exam and dilation, to the minor, when accompanied by an individual listed on this form. A comprehensive eye exam includes the use of eye drops to dilate the pupil to examine the lens, retina, and optic nerve inside the eye and to measure a prescription for glasses, as needed. I have read and understand information regarding the risks, benefits, and alternatives of dilation.
I authorize IUSO to share the results of the eye exam with the student's Head Start center.
I understand IUSO is an educational institution and I agree that student interns (in training to be optometry doctors) may assist in providing the services and the minor's optometry records may be used for the purposes of research, education and patient care.
I have been given the opportunity to review the IUSO Notice of Privacy Practices and I understand that I may request copy of this notice should I so choose.
I understand the services provided are paid for by the Nina Mason Pulliam Charitable Trust.
Name of Parent or Legal Guardian*
First Middle Last
Phone Number*
Signature of Parent or Legal Guardian*
Date*
MM slash DD slash YYYY
INDIANA UNIVERSITY SCHOOL OF OPTOMETRY VISION FOR THE FUTURE DILATION INFORMATION
An important part of the eye/visual examination is a dilated fundus exam. Dilation uses eye drops to make the pupils larger. This makes it easier to look at the structures inside the eye, such as the lens, retina, and optic nerve and to measure the prescription for glasses. This component of the exam helps in the early detection of congenital eye problems including cataracts, glaucoma, and other retinal disorders. What are the benefits of dilating your eyes? • Dilation helps us find conditions such as cataracts, retinal disease and detachment, glaucoma, aging changes, and other conditions that may affect the Inside of your eye, but which may be hard to see without dilation. • Dilation allows us to measure the true glasses prescription. There are many times where in order to finalize the glasses prescription this step is necessary to ensure the proper glasses prescription will be provided. What are the risks of dilating your eyes? • After dilation, there may be sensitivity to light, and up-close vision may be blurry. Disposable sunglasses will be offered to help with the brightness. Both of these effects will usually last 3-6 hours, but may last longer (or shorter) depending on the individual and the type of drops used. • Be extra careful walking (especially on stairs) while the eyes are dilated. Are there other procedures that do the same thing? • No. While we can look Inside of the eye without dilating the pupils, we are limited in how much we can see. The bigger the pupil, the more that we can see inside the eye. If you are concerned once you. leave the clinic you may call (317) 321-1470, 24 hours a day, 7 days a week and talk to a doctor of optometry.

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Parent Engagement Agreement
Child's Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
1. I understand that any information parents or visitors learn while in the center, for any reason, is considered confidential and may not be shared. Anyone who enters a Head Start or Early Head Start Center must respect the privacy of all children, parents, and staff.
2. I understand that a current address, home phone number, cell phone number, email address, and emergency number must be made available to the Early Head Start/Head Start Program at all times. I understand that I must maintain my employment or inschool status in order for my child to remain enrolled in the Early Head Start/Head Start Fullday Program.
3. The program’s Core Hours are 9am-3pm. Families can have up to 12 tardies and/or early pickups per year before returning to the waiting list.
4. Transportation is not provided. Community Resources may be available.
5. I understand that I must sign my child in and out of their class each day and I must be sure that a staff member is aware of my child’s arrival and departure. I understand that a child will only be released to the parent/guardian or the designated person listed on the child’s emergency card. I understand that photo identification is required. I understand if my child is not picked up from school and I fail to contact the Early Head Start /Head Start Program before class dismissal, my child will be turned over to Child Protective Services and/or the law enforcement agency.
6. I understand that my child’s attendance must be at 85% or better. If my child’s attendance falls below the mandated 85%, my child’s status will be reviewed for other possible program options. I will call the Attendance Hotline number, 317-217-1415, when my child will be absent from school.
7. I agree to have my child’s complete physical examination and immunization record turned into Early HeadStart/Head Start within 30 days of my child’s entry into the program. I understand that if physical examination forms or current immunization records are not received within 30 days of entry into the program, my child will be returned to the waiting list. I understand that my child is required to be up to date on receiving all immunizations (if applicable).
8. I agree to submit the requested paperwork and my child’s medication to the Family Advocate/Family Support Specialist within 5 business days of being offered a spot in the program. I understand that medication must be current and within its expiration date for use. I understand that if I do not submit both the paperwork and the medication within 5 business days of being offered a spot in the program, my child will be returned to the waiting list.
9. I understand that Early Head Start/Head Start staff as well as myself will notify one another of any significant occurrence or problem that may affect their child (including exposure to communicable diseases).
10. I understand that the Early Head Start/Head Start program uses positive disciplinary approaches with children. Disciplinary problems will be addressed with parents and documented in the child’s file.
11. I understand that if child abuse is suspected, neither the child nor the perpetrator will be questioned beyond gathering information; however, any and all incidents will be immediately reported to Child Protective Services. (IC 31335)
12. I understand that my child's Family Child Educator will be completing (2) home visits and the Family Advocate/Family Support Specialist will be completing home visits as needed for my child’s attendance while participating in the Early Head Start/Head Start program.
13. Weather postings will be on our website and/or social media.
Parent/Guardian Signature:*
Date*
MM slash DD slash YYYY

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Family Engagement Contract
Child's Name*
First Middle Last
Center*
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.
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,*
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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Home School Connection
Child's Name*
First Middle Last
The federal government requires Head Start programs to generate InKind dollars from parents and the community. An InKind donation is any gift given to our program from our parents or the community. We ask that you help us earn InKind by working with your children at home and/or volunteering your time at the centers. Our program earns $14.29 an hour towards our InKind requirement when you do educational activities with your child at home. Our InKind 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 to 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 highquality 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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CACFP Enrollment Form
EngPolicy Instruction 05-03
Name of Institution:*
IDOE/CACFP
Sponsor ID Number:
Child's Name*
First Middle Last
Please indicate which session your child will be attending*
- Head Start. Full day session (Monday – Friday, 8:30 am - 3:30 pm) - he/she would receive breakfast, lunch and afternoon snack while attending Head Start.
- Head Start.Full day session (Monday – Friday, 8:30 am - 5:30 pm) - he/she would receive breakfast, lunch and afternoon snack while attending Head Start.
- Early Head Start. Full day session (Monday – Thursday, 7:30 am - 5:30 pm) - he/she would receive breakfast, lunch and afternoon snack while attending Early Head Start.
Family Advocate:
This information is required by CACFP federal regulations at §226.15(e)(2) and (3) for each enrolled participant and must be updated annually.
Parent/Guardian Name*
First Middle Last
Signature of Parent or Guardian*
Phone Number*
Date*
MM slash DD slash YYYY
This institution is an equal opportunity provider.

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Consent to Blood Lead Screening and Authorization to Share Information Form
Childhood Lead Poisoning Prevention Program 3838 N. Rural Street Indianapolis, IN 46205 317-221-2171 www.mchd.com
Child's Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Blood Lead Screening
I understand that a blood screening is necessary because lead poisoning can occur without symptoms. Screening requires a blood sample obtained by a fingerstick or venipuncture.
With a fingerstick, blood is taken from the child's finger. With a venipuncture, blood is taken from the child's arm.
If the fingerstick indicates that my child's blood levels are elevated, a representative from the Marion County Childhood Lead Poisoning Prevention Program will contact me to schedule a venipuncture. This test is necessary to confirm if my child has lead poisoning.
Sharing of Information
I understand that my child's test results are confidential medical information. Under Indiana law, the results of a blood lead test will be shared with other public agencies in a confidential matter. The agencies will take care to protect my and my child's privacy. Sharing information will help my child if lead poisoning is identified.
I understand if lead is present in my child's blood, Indiana Code 16-41-39.4-3 requires the laboratory that analyzes the blood to report the test result and all demographic information to the Indiana State Department of Health (ISDH).
I understand that lead-poisoned children need immediate medical attention. In order to provide this help, ISDH will share this information with other public agencies, which work to prevent and treat lead poisoning. The agencies include the Family and Social Services Administration, the Department of Health and Human Services, the Department of Housing and Urban Development and other housing agencies at the local, state and federal level.
Signature of Verification
By signing below I agree that I have read, understand and authorize the sharing of information regarding my child's blood lead screening and test results.
Parent/Legal guardian name*
First Middle Last
Parent/Legal guardian signature*
Date*
MM slash DD slash YYYY

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Free Well-Child Examination Consent Form
Please complete the following information:
I,
First Last
, give permission for a physician or nurse practitioner licensed in Indiana, to conduct a well-child examination on my child.
*
First Last
Center Enrolled:*
Parents Signature*
Date*
MM slash DD slash YYYY

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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 respiratory 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 medication such an inhaler or albuterol 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 “onetime” 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 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
I, parent/guardian of
Child's Name*
First Middle Last
State that my child*
- does not have asthma.
- does have 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:*
Date*
MM slash DD slash YYYY
Comments:*
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 Re-Enrollment Form

Step 1 of 15 - Emergency Information & Authorization for Release Card

Emergency Information & Authorization for Release Card

Consent for Services

Indiana University School Of Optometry Vision For The Future Consent To Treat Minor Patient

INDIANA UNIVERSITY SCHOOL OF OPTOMETRY VISION FOR THE FUTURE DILATION INFORMATION

PHOTOGRAPHY/VIDEO PARENTIAL/GUARDIAN CONSENT FORM

Parent Engagement Agreement

Family Engagement Contract

Home School Connection

CACFP Enrollment Form

Consent to Blood Lead Screening and Authorization to Share Information Form

Blood Lead Screening

Sharing of Information

Signature of Verification

Marion County Public Health Department Client Registration Form

PATIENT CONTACT AUTHORIZATION

Dental Consent Form

HEALTH HISTORY

Free Well-Child Examination Consent Form

Asthma Screening Tool

Asthma Screening Confirmation Sheet

Authorization for Release and Receipt of Child Records

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

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

Name	Birthday	Relationship	Gender	School	(Staff Use) MCPHD#