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Appointment Wrap Up (English)
Thank you for completing the Eligibility Intake for your child ________________________. You have now completed the second process to enrolling your child into Early Head Start/Head Start.
Child's Name
First
Last
Today you met with:
Name of Family Advocate/Family Support Specialist/Intake Assistant
First
Last
Location
At this time you are applying for your child to be placed on the waiting list at the following locations and school schedule:
Head Start - Monday to Friday 8:30am to 5:30pm
Head Start - Monday to Friday 8:30am to 3:30pm
Early Head Start - Monday to Thursday 7:30am to 5:30pm
Center
C.A.F.E.
Eagledale
Goodwin
Hamilton County
Pike Plaza
Service Center 2
Southeast
Southwest
Windsor Village East
Windsor Village West
Today you brought:
Birth Certificate
Employment/School Verification
Income Verification
Immunization Record
Physical
Dental
Insurance Information
Asthma Action Plan
Food Allergy Plan
Individualized Health Plan
Non Allergy Food Plan
Seizure Plan
Special Dietary Needs Form
We need you to bring the following:
Birth Certificate
Employment/School Verification
Income Verification
Immunization Record
Physical
Dental
Insurance Information
Asthma Action Plan
Food Allergy Plan
Individualized Health Plan
Non Allergy Food Plan
Seizure Plan
Special Dietary Needs Form
At this time, your child:
Is on the waiting list at this time
Is not on the waiting list at this time
Please be sure to bring these items back as soon as possible to ensure your child is placed on the waiting list. Thank you for making the step to better your child’s future! Once your child has been added to the Waiting list, your child will be up for selection. If your child is selected a letter will be sent home to your home address or you will be contacted by phone or email. Please ensure your address, phone number and email is updated during this process.
Family Advocate/Support Specialist/Intake Assistant Phone Number
Family Advocate/Support Specialist/Intake Assistant Fax Number
Email
This field is for validation purposes and should be left unchanged.
Appointment Wrap Up (Spanish)
Gracias por haber llevado a cabo todas las citas de admisión para su hijo ________________________.
Nombre del niño
First
Last
Usted ha completado la segunda parte del proceso para inscribir a su hijo en Early Head Start/Head Start. Hoy usted se reunió con
Nombre del representante de la familia/especialista de apoyo familiar/asistente de admisiones
First
Last
Ubicación
En este momento usted está solicitando que su hijo sea colocado en la lista de espera en los siguientes lugares y horario escolar:
Head Start de lunes a viernes de 8:30am a 5:30pm
Head Start de lunes a viernes de 8:30am a 3:30pm
Early Head Start lunes a jueves de 7:30am a 5:30pm
Centro
C.A.F.E.
Eagledale
Goodwin
Hamilton County
Pike Plaza
Service Center 2
Southeast
Southwest
Windsor Village East
Windsor Village West
Usted trajo hoy:
Acta de nacimiento
Comprobante de empleo/escuela
Comprobante de ingresos
Registro de vacunación
Examen físico
Examen dental
Información del seguro
Plan de acción del asma
Plan de acción de alergia a alimentos
Plan de salud individualizado
Plan de acción de alergias no relacionadas con alimentos
Plan de convulsiones
Formato de necesidades dietéticas especiales
Necesitamos que usted traiga lo siguiente:
Acta de nacimiento
Comprobante de empleo/escuela
Comprobante de ingresos
Registro de vacunación
Examen físico
Examen dental
Información del seguro
Plan de acción del asma
Plan de acción de alergia a alimentos
Plan de salud individualizado
Plan de acción de alergias no relacionadas con alimentos
Plan de convulsiones
Formato de necesidades dietéticas especiales
En este momento su niño
Está colocado en la lista de espera este momento.
No está en colocado la lista de espera en este momento.
Por favor, asegúrese de traer documentos indicados tan pronto como sea posible para asegurarse de que su hijo sea colocado en la lista de espera. ¡Gracias por dar el paso para mejorar el futuro de su hijo! Una vez que su hijo haya sido agregado a la lista de espera, su niño entrará en las rondas de selección de inscripciones. Si su hijo es seleccionado, se le enviará una carta a su domicilio o se le contactará por teléfono o correo electrónico. Asegúrese de que su dirección, número de teléfono y correo electrónico se actualicen durante este proceso.
Comments
This field is for validation purposes and should be left unchanged.
Employment/School Verification Statement
Date
Date Format: MM slash DD slash YYYY
Child's Name
First
Last
Parent/Guardian Name
First
Last
Name and Address of Employer/School:
Employer/School Name
Employer/School Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer/School Telephone Number
Days of Employment
Hours of Employment
Documentation used to verify employment/school status:
Recent check stub
Statement from employer
School schedule
Business Card
Unemployed and/or Not in School
Other
If other, please specify
I acknowledge, with my signature, that I examined the above documents to verify employment/school status.
Staff Signature
Staff Name
First
Last
Date of Signature
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
Family Partnerships Folder Checklist
Name
First
Last
Birth Date
Date Format: MM slash DD slash YYYY
Tab 1
Folder Checklist
Application
Copy of Birth Certificate
Copy of Adoption/Guardianship/Foster/Other
Verifications (Agency Use Only)
Proof of Income
Income Verification Statement*
Child Plus: Family Certification
Employment/School Verification Statement*
Over-Income Approval Form*
Third Year Verification Forms*
Homeless Determination Checklist*
Two-Way Release - Eligibility*
Tab 2
Emergency Card
Court Ordered Documents*
Consent
Photography/Video Consent Form
Tab 3
Physical Form
Immunization Records
Oral Health Condition Form
Two-Way Release - Health/IEP/IFSP
Asthma Action Plan*
Food Allergy Action Plan*
Non-Food Allergy Action Plan*
Special Dietary Needs Form*
Individual Health Plan*
Seizure Action Plan*
Other Medical Documents*
IEP/IFSP*
Tab 4
CACFP Enrollment Form
Infant Feeding Plan* (EHS Only)
MCPHD Form (Lead and Smile Mobile)*
Consent to Blood Lead Screening*
Dental Safari Consent*
Asthma Screening Tool
Well-Child Consent
Vision for the Future Consent
Tab 5
Family Goal Setting Resource
Road Map
Family Outcome - Family Profile
Parent Engagement Agreement
Family Engagement Contract
Home School Connection Agreement
Annual Notice
Tab 6
Change of Status Form*
Letters & Other Documents*
CPS Referrals*
Incident Reports*
Accident Reports*
Illness Reports*
Family Engagement Home Visit Form*
Medication Logs*
Medicine Paperwork*
Doctor/Dental Excuse Notes*
Email
This field is for validation purposes and should be left unchanged.
File Transfer Form
Staff Transferring File
Staff Receiving File
Date
Date Format: MM slash DD slash YYYY
Name
First
Last
Birth Date
Date Format: MM slash DD slash YYYY
Tab 1
Folder Checklist
Application
Copy of Birth Certificate
Copy of Adoption/Guardianship/Foster/Other
Verifications (Agency Use Only)
Proof of Income
Income Verification Statement*
Child Plus: Family Certification
Employment/School Verification Statement*
Over-Income Approval Form*
Third Year Verification Form*
Homeless Determination Checklist*
Two-Way Release-Eligibility*
Tab 2
Emergency Card
Court Ordered Documents*
Consent
Photography/Video Consent Form
Tab 3
Physical Form
Immunization Records
Oral Health Condition Form
Two-Way Release-Health/IEP/IFSP
Asthma Action Plan*
Food Allergy Action Plan*
Non Food Allergy Action Plan*
Special Dietary Needs Form*
Individual Health Plan*
Seizure Action Plan*
Other Medical Documents*
IEP/IFSP*
Tab 4
CACFP Enrollment Form
Infant Feeding Plan* (EHS Only)
MCPHD Form (Lead and Smile Mobile)*
Consent to Blood Lead Screening*
Dental Safari Consent*
Asthma Screening Tool
Well-Child Consent
Vision for the Future Consent
Tab 5
Family Goal Setting Resource
Road Map
Family Outcome-Family Profile
Parent Engagement Agreement
Family Engagement Contract
Home School Connection Agreement
Annual Notice
Tab 6
Change of Status Form*
Letters & other documents*
CPS Referrals*
Incident Reports*
Accident Reports*
Illness Reports*
Family Engagement Home Visit Form*
Medication Logs*
Medicine Paperwork*
Doctor/Dental Excuse Notes*
Name
This field is for validation purposes and should be left unchanged.
Verifications (Agency Use Only)
Child's Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Current Income: $
Size of Family Unit
Income Eligible
Yes
No
Eligibility Type
Check One:
Income: Below federal poverty guidelines
Over-Income
Foster Care/Ward of the State
Public Assistance - TANF/SSI
Homeless
Income Verification: (What documentation was used to determine eligibility?)
1040 Tax Statement
Pay Stubs
Documentation of No Income
Income Declaration (wage inquiry)
Unemployment
Employment Letter
Child Support
W-2 Statement
Social Security Disability
Foster Care documentation
SSI Documentation
TANF Documentation
Pell Grant
Other
If other, please specify
NOTE: By signing below I acknowledge I examined the above documents to verify family’s income.
By signing below I acknowledge I reviewed the file and database for Eligibility and completed a Quality Assurance Child File Audit Form.
Staff Signature
Income Collection Date
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.