IRVINGTON CENTERS FOR EARLY EDUCATION IRVINGTON NEW JERSEY ENROLLMENT FORMS CHECKLIST

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1 IRVINGTON CENTERS FOR EARLY EDUCATION IRVINGTON NEW JERSEY ENROLLMENT FORMS CHECKLIST To register for the Abbott Preschool Program child must be 3 or 4 years old on or before November 1 st and must be an Irvington Resident. APPLICATION DATE CHILD S NAME BIRTHDAY LAST FIRST MIDDLE INITIAL AGE PRESCHOOL NAME Birth Certificate / Passport / Visa / Green Card 1. * Immunization Record 2. * Physical / Examination-Health 3. * Lead Test with Result 4. * Proof Residency (official Gov t agency letters, IRS, welfare, food stamps, 5. * unemployment, social security), current Utility bills: Home Phone (no Cell Phone), water, PSE&G, Bank Statement, current pay stub, cable bill excepted only if telephone service included, no credit card bill 6. Notarized Letter with Proof of Residency from whom you reside (see # 5) 7. Custody Papers (if Applicable) 8. Registration and Background Information Form 9. Social Services and Health History / Consent 10. Recorded Voice or Image Release Form * MUST PROVIDE TO REGISTER

2 New Jersey Department of Education Office of Early Childhood Education Abbott Preschool Program Uniform Preschool Enrollment Form English/Spanish/French Version DIRECTIONS TO DISTRICT: The questions in this form must be administered annually to the parent or guardian of every child registering in the Abbott preschool program. Four-year-olds who were previously enrolled in the three-year-old program must have their information updated from the previous year. Districts are encouraged to incorporate the questions into existing registration forms and eliminate any items duplicated in identical form on existing forms, but please do not alter the questions, as the same questions must be asked in every Abbott district. Please interview the child s parent or guardian or have him/her complete a form to obtain responses to the following questions. Print legibly. Responding to the questions in this form is not required for a parent to register a child in the preschool program, except that a parent or guardian must provide proof of child age and residency. However, the parent or guardian should understand that his/her responses to these questions will be of great help to the district and the state in planning a program that meets the unique needs of his/her child. If the parent or guardian declines to respond to a question, leave the item blank and proceed to the next question. If the parent or guardian does not know the answer to a question but is willing to seek out the answer, allow him/her additional time to follow up with a correct response. Upon completion of the interview/form, administer or arrange for a time to administer the approved screening tool to the child. ABOUT THE CHILD / SOBRE EL NIÑO/ AU SUJET DE L'ENFANT 1. Last Name of Child / Apellido del Niño/a *Required Field/ Información necesaria/ Dernier nom d'enfant 2. First Name of Child / Nombre del Niño/a *Required Field/ Información necesaria/ Prénom d'enfant 3. Middle Name of Child If applicable. / Segundo Nombre Si es aplicable./ Deuxième prénom d'enfant 4. Generation Code or Suffix If applicable, for example: Jr., Sr., III. Código de clasificación de la generación o Sufijo Si es aplicable, por ejemplo: Jr., Sr., III. Code ou suffixe de génération - si c'est approprié, par exemple : Jr., Sr., III. 5. Address of Child/Dirección del Niño/a *Required Field/ Información necesaria Street/ Calle / Adresse d'enfant Apartment/Apartamento/ Appartement City, State, Zip/Ciudad, Estado, Codigo Postal/ Ville, État, Fermeture éclair Abbott Uniform Preschool Enrollment Form Final Draft Page 1 of 4

3 7. Identification Number of Child To be assigned by computer. Número de Identificación del Niño/a Será asignado por la computadora. Numéro d'identification d'enfant - être assigné par ordinateur. 8. Birth Date of Child (Month/Day/Year) /Fecha de Nacimiento del Niño/a (Mes/Día/Año) *Required Field/ Información necesaria Date de naissance d'enfant (Month/Day/Year) Place of Birth of Child País de nacimiento del niño Pays natal d'enfant United States of America Los Estados Unidos de América Les Etats-Unis d'amérique City Ciudad Ville State Estado État Other (Print Country) Otro (País De la Impresión) Autre (Pays D'Impression) 10. What is the child s sex? Mark one box. Cuál es el sexo del niño/a? Marque una respuesta. Quel est le sexe de l'enfant? Marquez une boîte. Female Femenino Femelle Male Masculino Mâle 11. Is the child Spanish, Hispanic or Latino? Mark one or more groups to indicate the child s Spanish/Hispanic/Latino origin. Es el niño Español, Hispano o Latino? Marque uno o más grupos para indicar el origen Español, Hispano o Latino del niño. L'enfant est-il de l'espagnol, l'hispanique ou le Latino? Marquez un ou plusieurs groupes pour indiquer l'enfant Origine de Spanish/Hispanic/Latino. No, not Spanish/Hispanic/Latino. No, no es Español/Hispano/Latino. Non, pas Spanish/Hispanic/Latino. Yes, Mexican, Mexican American, Sí, Mejicano, Mejicano- Oui, Mexicain, Américain Mexicain, Chicano Americano, Chicano Chicano Yes, Puerto Rican Sí, Puertorriqueño Oui, Puerto Rican Yes, Cuban Sí, Cubano Oui, Cubain Yes, other Spanish/Hispanic/Latino (Print group.) Sí, Español/Hispano/Latino de otro grupo (Indique en letra de imprenta el grupo) Oui, l'autre Spanish/Hispanic/Latino (copie groupe.) Abbott Uniform Preschool Enrollment Form Final Draft Page 2 of 4

4 12. What is the child s race? Mark one or more races to indicate the child s race. Cual es la raza del niño/a? Marque uno o más de una respuesta para indicar la raza de su hijo/a. Quelle est la course de l'enfant? Marque une ou plusieurs courses pour indiquer la course de l'enfant. White Blanco Blanc Black or African American Negro o Americano Africano Américain noir ou africain American Indian or Alaska Indio Nativo de América o Nativo Indien d'amerique ou indigène de Native de Alaska l'alaska Asian or Pacific Islander Nativo de la Isla de Asia o del Insulaire asiatique ou Pacifique Pacífico Some other race (Print race.) Otra raza (Indique la raza.) Une autre course (course d'impression.) 13. What language does the child speak most at home? Mark one box. Qué lenguaje habla su hijo/a habla en la casa? Marque una respuesta. Quelle langue l'enfant parle-t-il le plus à la maison? Marquez une boîte. English Inglés Anglais Spanish Español Espagnol Arabic Arabe Arabe Chinese Chino Chinois Creole (Haitian) Creole (Haitiano) Créole (Haïtien) Gujarati Gujarati Gujarati Korean Coreano Coréen Polish Polaco Poli Portuguese Portugués Portugais Russian Ruso Russe Urdu Urdu Urdu Some other language (Print language.) Otro lenguaje (Indique el lenguaje.) Une autre langue (langue d'impression.) 14. Does the child have any chronic medical problems, special needs, or handicapping conditions? Mark one box. Padece el niño de algún problema médico crónico, de necesidades especiales o algún tipo de incapacidad? Marque una respuesta. Fait l'enfant ont tous les problèmes médicaux chroniques, les besoins spéciaux, ou handicapage des conditions? Marque une boîte. No No Non Yes (Print problem or condition.) Sí (Indique en letra de imprenta el Oui (problème ou état d'impression.) problema o condición.) 15. Will the child be enrolling for the entire school day? Mark one box. A six-hour (minimum) program must be offered to every enrolling child. However, once a parent/guardian is made aware of its availability, he/she may opt out of it and choose a half-day program, if available. Su hijo/a será matriculado para el día entero escolar? Seleccione uno. Un programa de seis horas (lo mínimo) debe ser ofrecido a todo niño/a que sea matriculado. Pero una vez que el padre/ guardián sea informado de la posibilidad que haya un programa de medio día, el o ella, puede escoger ese programa. L'enfant s'inscrira-t-il pour le jour entier d'école? Marquez une boîte. Un programme (minimum) de six heures doit être offert à chaque enfant d'inscription. Cependant, une fois qu'un parent/guardian est mis au courant de sa disponibilité, he/she peut quitter lui et choisir un programme de demi-journée, si disponible. Yes, enrolling for the entire school Oui, s'inscrivant pour le jour entier Si, será matriculado el día entero. day. d'école. No, enrolling for half day. No, será matriculado medio día. Non, s'inscrivant pour demi de jour. Abbott Uniform Preschool Enrollment Form Final Draft Page 3 of 4

5 16. What kind of health insurance does the child have? Mark one box. Qué clase de seguro médico tiene el niño? Marque una casilla. Quel genre d'assurance médicale maladie l'enfant a-t-il? Marquez une boîte. Private or employment-based health Seguro de salud privado o basado en el insurance empleo Assurance médicale maladie privée ou emploi-basée Medicaid Medicaid Medicaid New Jersey FamilyCare New Jersey FamilyCare New Jersey FamilyCare Some other health insurance Otro tipo de seguro médico Une autre assurance médicale maladie Uninsured No tiene seguro. Non assuré 17. Who does the child live with? Con quién el niño vivo? Avec qui l'enfant de phase? Mother and Father Madre y padre Mère et père Mother Only Madre Solamente Mère Seulement Father Only Padre Solamente Père Seulement Grandmother Abuela Grand-mère Grandfather Abuelo Grand-père Other (Specify) Otro (Especifique) Autre (Indiquez) 18. How did you find out about our Program? Cómo le hizo para descubrir alrededor nuestro programa? Comment vous a fait pour découvrir environ notre programme? Newspaper Ad Anuncio De Periódico Annonce Petite Friend Amigo Ami School Escuela École District Website Page Página del Web site del districto Page de site Web de zone Flyers/Posters Aviadores/carteles Insectes/affiches Other Please Specify): Otro (Especifique Por favor) Autre (Indiquez Svp) Cable Television Bus Advertisement Street Banner/Signs END OF FORM END OF FORM END OF FORM END OF FORM K:\Data\Needs Assessment\Uniform Preschool Enrollment Form v3 FINAL (English & Spanish).doc Abbott Uniform Preschool Enrollment Form Final Draft Page 4 of 4

6 IRVINGTON PUBLIC SCHOOLS Irvington, New Jersey IRVINGTON CENTERS FOR EARLY CHILDHOOD EDUCATION MEDICAL EMERGENCY RELEASE/TREATMENT FORM School: Date: MEDICAL INFORMATION: Existing Medical Problems: Yes ( ) or No ( ) If yes please explain Allergies to Food/Medicine etc: Yes ( ) or No ( ) If yes please explain Does your child take Medication? Yes ( ) or No ( ) If yes give name of medication (s): Child s Doctor/Clinic Name Phone Choice of Hospital when possible Date of child s last tetanus shot Medical Insurance Co. Medicaid number, if applicable ID# Phone Subscriber s Name It is understood that every effort will be made to notify me or at before such action is taken, but if not possible to locate me or the above person, the uninsured expense of this service will be accepted by me. I authorize the child care provider to arrange transportation in case of emergency or acute illness and to arrange for possible medical and/or surgical care at (1) the closest hospital available in case of dire emergency or (2) the hospital of my choice. Parent/Guardian s Signature Date

7 IRVINGTON PUBLIC SCHOOLS Irvington, New Jersey IRVINGTON CENTERS FOR EARLY CHILDHOOD EDUCATION MEDICAL EMERGENCY RELEASE CONTACT FORM School: Date: (Child s Last Name First Middle Initial) Date of Birth Father Name Mother Name Guardian Name Address_ Home Phone Cell/Beeper Number Mother s Name of Employer Work Address Work Phone Work Extention Father s Name of Employer Work Address Work Phone Work Extention IN CASE OF EMERGENCY CALL/CONTACT: Name Address Phone Name Address Phone Name Address Phone Name Address Phone

8 Date School IRVINGTON PUBLIC SCHOOLS Irvington, New Jersey SOCIAL SERVICES AND HEALTH HISTORY Child s Name Date of Birth Age Phone Last Name First Middle Initial Father s Name Mother s Name Guardian s Name 1. How many Adults in the household This child is in the family Brothers Sister Number Number Number Number 2. With whom does the child live? (mother, father, grandparent, guardian, etc.) 3. How is health care provided for this child? Private Insurance ( ) Social Security ( ) Medical ( ) Other ( ) 4. Name of Physician/Clinic Address Phone 5. Does your child have or has your child had a health problem (check all that apply): CONDITION YES NO COMMENT Allergies Asthma Cancer Change in Eating Habits Chicken Pox Chronic Fatigue/Tiredness Clumsiness Congenital Heart Disease Diabetes Dry or Hacking Cough Earache or Ear Infections Eczema Epilepsy or Convulsions Eye or Vision problems Fractures or dislocation of Bones Headache Hearing problems Heart Murmur High Blood Pressure HIV Kidney Disease Lead Poisoning Loss of Weight/Over Weight Mononucleosis Mumps Nose Bleeds Rheumatic Fever Ring Worm Teetis Rubella Scarlet Fever Sickle Cell Anemia Sleeplessness Surgery Toothache or problems Tuberculosis (TB) Ulcers or Stomach problems Other (specify)

9 Date School IRVINGTON PUBLIC SCHOOLS Irvington, New Jersey SOCIAL SERVICES AND HEALTH HISTORY Child s Name Date of Birth Age Phone Last Name First Middle Initial Father s Name Mother s Name Guardian s Name 6. Does any close relative in the child s family have a history of : (check all that apply): Anemia Asthma Birth Defect Cancer Diabetes Epilepsy Heart Disease Learning Problems Mental Impairment Sickle Cell Anemia Other 7. During the pregnancy with this child, did the mother have any medical problem (e.g. High Blood pressure, kidney infection or exposure to other infectious diseases)? Yes ( ) or No ( ) If yes, explain 8. During the pregnancy with this child, did the mother smoke cigarettes? Yes ( ) or No ( ) Did the mother consume alcohol,? Yes ( ) or No ( ) Consume any substance (Drugs or any medication other than vitamins or iron? Yes ( ) or No ( ) 9. Were there any problems during labor or delivery? Yes ( ) or No ( ) Comments 10. How long did labor last? Was the child s breathing normal? Yes ( ) or No ( ) Birth Weigh: 11. How long did the child remain in the hospital? Did the child leave the hospital with his/her mother Yes ( ) or No ( ) 12. What age did you child: Walk alone Talk (2 words together)? Become potty trained? Is bed wetting a problem? Yes ( ) or No ( ) if yes, please explain 13. Has the child been hospitalized for any reason since birth? Yes ( ) or No ( ) If yes, When Why 14. Are there any problems in the home, which might affect your child s learning? Yes ( ) or No ( ) Explain 15. Is there anything more about the child s health that you think is important for us to know? Yes ( ) or No ( ) Explain PERMISSION FOR RELEASE OF RECORDS AND HEALTH SCREENINGS I agree or permit that my child, may participate in the following health activities: Height Yes ( ) or No ( ) Weight Yes ( ) or No ( ) Vision Screening Yes ( ) or No ( ) Hearing Screening Yes ( ) or No ( ) Dental Screening Yes ( ) or No ( ) Physical Examination Yes ( ) or No ( ) If you wish to be present during any screening, please contact school. Parents are notified if a child needs further evaluation. If for some reason a parent is unable to provide for further services please contact the school. My signature indicates that I have the legal right to authorize the release of any medical information to process this application. Parent/Guardian s Signature Date 1/26/10

10 Recorded voice or Image Release I the undersigned, hereby grant full permission to the Irvington Board of Education, Irvington, New Jersey, to record the image of or voice of the herein listed individual while that individual is participating in any school related or sponsored activity. I authorize the copyright, use distribution without limitation of these recordings and their derivatives for the use of the Irvington Board of Education. Child s Name Address Please Print Please Print Please Print Parent Signature Date I certify that I have the legal right to sign for the above mentioned underage individual. Parent s Name Address Please Print Parent Signature Date Irvington Board of Education

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