1530 E. Lincoln Highway, Coatesville, PA (610) fax: (610)

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1 HEAD START A Chester County Intermediate Unit Program 1530 E. Lincoln Highway, Coatesville, PA (610) fax: (610) Dear Parent or Guardian, Thank you for your interest in the Head Start program. By definition, Head Start is a program of the United States Department of Health and Human Services that provides comprehensive early childhood education, health, nutrition, and parent involvement services to low-income children and their families. Once enrolled in the Head Start program, your child will receive a preschool education, nutritious meals, health screenings, and the opportunity to expand his/her social skills. Our services are comprehensive and keep in mind the goal of preparing students for kindergarten. In addition to providing education and services for your child, Head Start also provides services for the families of our students. These services are specific to each family s need. Throughout the school year, a staff member will meet with you to help you identify some of your own goals and will work with you to develop a plan to help you meet those goals. Attached are the registration forms for enrollment into the Head Start program. Before a child can be considered for enrollment, the following forms must be completed. 1. Enrollment Application 2. Emergency Contact Information 3. Authorization for Release of Records and/or Information Copies of the following information must be submitted along with the above information. 1. Birth Certificate or Baptismal Record 2. Immunization Records 3. Four Consecutive Weekly or Two Consecutive Biweekly Pay Stubs 4. Proof of Public Assistance Income Within ninety days of enrollment, the following information must be submitted. 1. Physical Form (physical exam) 2. Private Dentist Report (dental exam) 3. Results of 24-month blood lead test If you should have any questions, please feel free to contact our office at Sincerely, Chester County Head Start The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and, where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or if all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) or (800) (in Spanish). Persons with disabilities, who wish to file a program complaint, please see information above on how to contact us by mail directly or by . If you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.), please contact USDA's TARGET Center at (202) (voice and TDD). USDA is an equal opportunity provider and employer. cciu hs / jan15

2 Enrollment Application Chester County Head Start 1530 East Lincoln Highway Coatesville, PA phone: (610) fax: (610) (OFFICE USE ONLY) Center: Classroom: FSW: Start Date: Child's First Name Middle Name Last Name Date of Birth Primary Language Gender male female Race White Black or African American Hispanic/Latino Biracial/Multiracial Unknown Street Address, Apartment Number, City, State, Zip Mailing Address, if different School District Name of Child Care/Babysitter Child Care Location Child Care Phone Number Name of Mother or Legal Guardian Date of Birth Primary Language Secondary Language Race White Black or African American Hispanic/Latino Biracial/Multiracial Unknown Cell Phone Number Home Phone Number Work Phone Number Employer's Name & Address Highest Level of Education Less than 5th grade 5th-8th grade 9th grade 10th grade 11th grade 12th grade(no diploma) Name of Father or Legal Guardian High School graduate/ged Associate degree in college Bachelor's degree Some college (no degree) Employment Status Paying job, full time Paying job, part time Seasonal Unemployed, with previous experience Unemployed, with no work experience Disabled Homemaker Employed full-time & in school part-time Employed part-time & in school full-time In school for HS diploma/ged In school for college degree Date of Birth Primary Language Secondary Language Race White Black or African American Hispanic/Latino Biracial/Multiracial Unknown Employer's Name & Address Cell Phone Number Home Phone Number Work Phone Number Highest Level of Education Less than 5th grade 5th-8th grade 9th grade 10th grade 11th grade 12th grade(no diploma) Preferred Class Session Date Signature of Parent or Legal Guardian AM PM cciu hs / june14 High School graduate/ged Associate degree in college Bachelor's degree Some college (no degree) Employment Status Paying job, full time Paying job, part time Seasonal Unemployed, with previous experience Unemployed, with no work experience Disabled Homemaker Employed full-time & in school part-time Employed part-time & in school full-time In school for HS diploma/ged In school for college degree

3 (OFFICE USE ONLY) Number of children: Total Number of Household Members: Number of children under 3: Names of Household Members Relationship Date of Birth Family Information (check all that apply) Two parent family Single parent family Foster family Guardian/Other relative Pregnant mother Parent under 18 Suspected child abuse/neglect Documented child abuse/neglect Child previously enrolled in Early Head Start or Head Start Child previously applied/waitlisted for Head Start Child has IEP or IFSP Child Development Concerns Speech/Language impairment Vision impairment or Blindness Physical impairment Developmental delay Emotional/Behavior disorders No concerns Housing Type Homeless/No housing Community shelter Hotel/Motel room Migrant Housing Apartment Mobile home/trailer House Financial Services Received (check all that apply) WIC Food stamps (SNAP) Medical financial assistance EPSDT Public assistance/welfare (cash) Supplemental Security Income (SSI) Unemployment insurance Child support or Alimony Foster care/adoption subsidy Public housing assistance Energy program assistance No services received Earned Income Source and Amount (gross for current month) Employment wages: TANF: Foster care: Child support: SSI: Unemployment compensation: Worker's compensation: Other: TOTAL: (OFFICE USE ONLY) Income Verification Paystub W-2 statement Written statement from employer Social security Public assistance (TANF, etc.) SSI Unemployment compensation Child support/alimony Foster care % Over 130% I have reviewed the family's documentation of household income and verify that the information is correct. Head Start staff's signature: Date: Confidentiality Waiver I hereby give the CCIU Head Start permission to release any information about myself, spouse, and/or my children to other agencies during the course of their work with me. I certify that the information provided is true to the best of my knowledge. I am aware that the information that I have provided is subject to review and verification, and I may have to provide documents to support this application. I am also aware that I am subject to immediate termination if I am found ineligible and may be prosecuted for fraud and/or perjury. Parent/Legal guardian's signature: Date: How did you hear about Head Start? Family/Friends From a Head Start parent From a Head Start employee PSE Outreach or Recruitment cciu hs / june14

4 Name of Child / Nombre del Niño Emergency Contact Information / Información de Contacto de Emergencia Birthdate / Fecha de Nacimiento Name of Mother or Legal Guardian / Nombre de Madre o Tutor Legal Employer / Empleo Name of Father or Legal Guardian / Nombre de Padre o Tutor Legal Employer / Empleo Name of Emergency Contact / Nombre de Contacto de Emergencia Relation to Child / Relación al niño Name of Emergency Contact / Nombre de Contacto de Emergencia Relation to Child / Relación al niño Name of Emergency Contact / Nombre de Contacto de Emergencia Relation to Child / Relación al niño Name of Pediatrician / Nombre de Pediatra Phone / Teléfono Fax Name of Dentist / Nombre de Dentista Phone / Teléfono Fax Child's Health Insurance / Seguro de Salud de Niño (from insurance card / de la tarjeta de seguro) Name of Insurance Plan / Nombre de Seguro ID Number / Número de Identificacion Name of Subscriber / Nombre de Suscriptor Special Conditions / Condiciones Especiales Disabilities / Discapacidades Allergies / Alergias Medical Information for Emergencies / Información Médica para Emergencias As parent/legal guardian, I give consent to have my child receive first aid by facility staff, and, if necessary, be transported to receive emergency care. I understand that I will be responsible for all charges not covered by insurance. I give consent for emergency contact persons listed above to act on my behalf until I am available. I agree to review and update this information whenever a change occurs and at least every six months. / Como padre/ tutor legal, doy consentimento para que mi nino reciba primeros auxilios por el personal, si es necesario, y ser transportado para recibir cuidado de emergencia. Entiendo que seria responsable por todos los cargos no cubierto por el seguro. Doy consentimiento por la persona de contacto de emergencia que esta listada en la parte de arriba para actuar en mi nombre hasta que yo este disponible. Estoy deacuerdo de revisar y poner al dia la informacion cuando ocurra algun cambio por lo menos cada seis meses. Date / Fecha Signature of Parent or Legal Guardian / Firma de Padre o Tutor Legal Date Updated or Checked / Fecha de actualización Signature of Parent or Legal Guardian / Firma de Padre o Tutor Legal cciu hs / aug13

5 HEAD START A Chester County Intermediate Unit Program 1530 E. Lincoln Highway, Coatesville, PA (610) fax: (610) AUTHORIZATION FOR RELEASE OF RECORDS AND/OR INFORMATION During the duration of my child s enrollment of Chester County I.U. Head Start Program, I,, hereby give permission to the Chester County I.U. Head Start to: (Print Parent/ Guardian Name) Communicate, discuss and obtain information for from: (Child s Name) (Name Physician/Medical Home) (Name of Dentist/Dental Home) (Address, City, State, and Zip Code) (Address, City, State, Zip Code) Phone #: Fax #: Phone #: Fax #: This release is for the purpose of the Chester County Intermediate Unit Head Start Program. (MUST INITIAL EACH ITEM THAT MAY BE RELEASED/OBTAINED) Physical Examination Dental Examination Expected Length of Treatment Treatment Plan Summary of Treatment Results of 24-month blood lead test Other, specify: Initial Enrollment: Re-enrollment: Re- enrollment: Signature of Parent/Guardian Signature of Parent/Guardian Signature of Parent/Guardian Date Date Date Witness Witness Witness NOTICE TO RECIPIENT OF INFORMATION This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or stat law. If the records are so protected, federal Regulation (42 CFR Part 2) and PA regulation (4 PA 255.5) prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, of as otherwise permitted by 42 CFR Part 2 and 4 PA A general authorization for the release of medical or other information is NOT sufficient for this purpose.

6 CHESTER COUNTY INTERMEDIATE UNIT HEAD START PROGRAM PHYSICAL FORM Section I - To be Completed by Parent/Guardian Child s Name (Last) (First) Gender q Male q Female Date of Birth Parent/Guardian Name Telephone Number Center Location I give my consent for my child s Physician and Child Care Provider to discuss my child s health concerns. Parent/Guardian Signature Date of Exam Date Section II To be Completed by Health Care Provider Health history pertinent for routine child care including allergies, asthma, seizure disorders and special needs: q None (Please attach and/or complete attached action plan) Height Weight Hearing Vision 24 Month Blood Lead Results: Hemoglobin TB Sickle Cell q Yes q No Polio DTAP/DTP MMR Varicella Influenza HIB Hep B Other Immunizations Date Date Date Date Date Physical Examination Normal Abnormal (Comments) Head/Ears/Eyes/Nose/Throat Teeth Cardio respiratory Abdomen/GI Genitalia/Breasts Extremities/Joints/Back/Chest Skin/Lymph Nodes Neurologic/Tone Developmental (E.G.DDST) Medical Provider: Address: Phone Number: Please Print/Stamp Next Physical Appt. Date: Provider Signature Date Fax Number: Please attach any plans of care to this

7 H COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH PRIVATE DENTIST REPORT OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE NAME OF SCHOOL DATE 20 NAME OF CHILD AGE SEX GRADE SECTION/ROOM Last First Middle M F ADDRESS No. and Street City or Post Office Borough or Township County State Zip REPORT OF EXAMINATION TOOTH CHART RIGHT LEFT UPPER A 5 B 6 C 7 D 8 E 9 F 10 G 11 H 12 I 13 J Upper LOWER T 28 S 27 R 26 Q 25 P 24 O 23 N 22 M 21 L 20 K Lower UPPER Upper LOWER Lower Is The Child Under Treatment Yes No Treatment Completed Yes No Date of Dental Examination Signature of Dental Examiner Print Name of Dental Examiner Address

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