Staff Forms | Family Development Services

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
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
Phone
This field is for validation purposes and should be left unchanged.

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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
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.
Phone
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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 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
Comments
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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*
Phone
This field is for validation purposes and should be left unchanged.

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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*
Phone
This field is for validation purposes and should be left unchanged.

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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
Comments
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Appointment Wrap Up (English)

Appointment Wrap Up (Spanish)

Employment/School Verification Statement

Name and Address of Employer/School:

Family Partnerships Folder Checklist

File Transfer Form

Verifications (Agency Use Only)