HEAD START - cciu.org

1 Cciuhs mar17 HEAD START 351 Kersey Street, Coatesville, PA 19320 (610) 383-6800 Fax: (610) 343-1614 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. Admission is open to all qualifying families regardless of race, color, national origin, sex, age, or disability. 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.

2 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. If you should have any questions, please feel free to contact our office at 610-383-6800. Sincerely, Chester County Head START *The application process can begin with these items. Required Information: o enrollment Application* o Emergency Contact Information o Authorization for Release of Health Information o Child Health and Nutrition Assessment o Birth Certificate* o Four Consecutive Weekly or Two Consecutive Biweekly Pay Stubs* o Proof of Public Assistance Income o Child s Health Insurance Card o Immunization Records (You can get this with physical exam documentation from your child s healthcare provider) o Physical Form (An exam is required every year while your child is enrolled) o Results of a Blood Lead Test (One result is needed while your child is enrolled) o Results of a Hemoglobin Test (You can get this from your child s healthcare provider or WIC ) o Private Dentist Report (An exam is required every 6 months while your child is enrolled) A Chester County Intermediate Unit Program Programs(OFFICE USE ONLY)Center:Classroom/Home Visitor:Pregnant Woman: START Date.

3 Child's First Name or Unborn Child? Middle NameLast NameDate of Birth or Unborn Child Due DatePrimary LanguageGenderRaceStreet Address, Apartment Number, City, State, ZipMailing Address, if differentSchool DistrictName of Child Care/BabysitterChild Care LocationChild Care Phone NumberName of Mother or Legal GuardianDate of BirthPrimary LanguageSecondary LanguageRaceCell Phone NumberHome Phone NumberWork Phone NumberEmployer's Name & AddressHighest Level of EducationEmployment StatusName of Father or Legal GuardianDate of BirthPrimary LanguageSecondary LanguageRaceEmployer's Name & AddressCell Phone NumberHome Phone NumberWork Phone NumberHighest Level of EducationEmployment StatusSignature of Parent or Legal Guardiancciu hs / oct16 enrollment ApplicationChester County Head Start351 Kersey StreetCoatesville, PA 19320phone: (610) 383-6800fax: (610) 343-1614 Date male female White Black or AfricanAmerican Hispanic/Latino Biracial/Multiracial Unknown Other, specify: White Black or AfricanAmerican Hispanic/Latino Biracial/Multiracial Unknown Other, specify: Lessthan 5th grade 5th-8thgrade 9th grade 10th grade 11th grade 12th grade(no diploma) HighSchool graduate/GED Associate degree in college Bachelor's degree Some college (no degree) Other, specify: Homemaker Employedfull-time & in school part-time Employedpart-time & in school full-time In school for HS diploma/GED In school for college degree Other, specify: White Black or AfricanAmerican Hispanic/Latino Biracial/Multiracial Unknown Other, specify.

4 Paying job, fulltime Paying job, parttime Seasonal Unemployed, with previous experience Unemployed, with no work experience Disabled Lessthan 5th grade 5th-8thgrade 9th grade 10th grade 11th grade 12th grade(no diploma) HighSchool graduate/GED Associate degree in college Bachelor's degree Some college (no degree) Other, specify: Homemaker Employedfull-time & in school part-time Employedpart-time & in school full-time In school for HS diploma/GED In school for college degree Other, specify: Paying job, fulltime Paying job, parttime Seasonal Unemployed, with previous experience Unemployed, with no work experience Disabled Yes No Yes No Early HeadStart Head START Pre-K Counts(OFFICE USE ONLY)Number of children:Number of children under 3:RelationshipDate of BirthChild Development ConcernsFinancial Services Received (check all that apply)Earned Income Source and Amount (gross for current month)Employment wages:TANF:Foster care:Child support:SSI:Unemployment compensation:Worker's compensation:Other:TOTAL:Head START staff's signature:Date:Parent/Legal guardian's signature:Date:cciu hs / oct16 How did you hear about Head START ?

5 Total Number of Household Members:Names of Household MembersFamily Information (check all that apply)Housing TypeConfidentiality WaiverI have reviewed the family's documentation of household income and verify that the information is 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 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. Two parentfamily Single parent family Foster family Guardian/Other relative Pregnant mother Parent under 18 Suspectedchild 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 Other, specify: WIC Foodstamps (SNAP) Medical financial assistance EPSDT Public assistance/Welfare (cash) Supplemental Security Income (SSI) Unemployment insurance Child supportor Alimony Foster care/adoption subsidy Public housingassistance Energy program assistance No services received Other, specify: Homeless/No housing Community shelter Hotel/Motel room Migrant Housing Apartment Mobile home/Trailer House Other, specify.

6 Speech/Languageimpairment Vision impairment or Blindness Physical impairment Developmental delay Emotional/Behavior disorders No concerns Family/Friends From a Head START parent From a Head START employee PSE Outreach or Recruitment Other, specify:(OFFICE USE ONLY)Income Verification Paystub W-2 statement Written statementfrom employer Social security Publicassistance (TANF, etc.) SSI Unemploymentcompensation Child support/Alimony Fostercare Other, specify: 100-130%Birthdate / Fecha de NacimientoCell Phone / Tel fono CelularHome Phone / Tel fono de CasaWork Phone / Tel fono de TrabajoCell Phone / Tel fono CelularHome Phone / Tel fono de CasaWork Phone / Tel fono de TrabajoCell Phone / Tel fono CelularHome Phone / Tel fono de CasaWork Phone / Tel fono de TrabajoCell Phone / Tel fono CelularHome Phone / Tel fono de CasaWork Phone / Tel fono de TrabajoCell Phone / Tel fono CelularHome Phone / Tel fono de CasaWork Phone / Tel fono de TrabajoPhone / Tel fonoFaxPhone / Tel fonoFaxID Number / N mero de IdentificacionSpecial Conditions / Condiciones EspecialesAllergies / AlergiasDate / FechaDate Updated or Checked / Fecha de actualizaci nSignature of Parent or Legal Guardian / Firma de Padre o Tutor LegalSignature of Parent or Legal Guardian / Firma de Padre o Tutor LegalAs parent/legal guardian, I give consent to have my child receive first aid by facility staff, and.

7 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 of Insurance Plan / Nombre de SeguroDisabilities / DiscapacidadesMedical Information for Emergencies / Informaci n M dica para EmergenciasName of Father or Legal Guardian / Nombre de Padre o Tutor LegalAddress / Direcci nRelation to Child / Relaci n al ni oName of Emergency Contact / Nombre de Contacto de EmergenciaEmployer / EmpleoAddress / Direcci nEmergency Contact Information / Informaci n de Contacto de EmergenciaName of Child / Nombre del Ni oName of Mother or Legal Guardian / Nombre de Madre o Tutor LegalAddress / Direcci nEmployer / EmpleoAddress / Direcci nRelation to Child / Relaci n al ni oName of Emergency Contact / Nombre de Contacto de EmergenciaName of Subscriber / Nombre de SuscriptorAddress / Direcci nName of Pediatrician / Nombre de PediatraAddress / Direcci nRelation to Child / Relaci n al ni

8 OName of Emergency Contact / Nombre de Contacto de EmergenciaName of Dentist / Nombre de DentistaAddress / Direcci nChild's Health Insurance / Seguro de Salud de Ni o (from insurance card / de la tarjeta de seguro)cciu hs / aug13cciuhs sept17 HEAD START 351 Kersey Street, Coatesville, PA 19320 (610) 383-6800 fax: (610) 343-1614 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION Dear Parent or Guardian, Head START can assist you to obtain the required health information from your child s healthcare providers. Additionally, at times, healthcare providers request health information that has been given to the Head START program by you, the parent or guardian. We need your permission to have any information sent to us or for us to release. Please complete this form that you will review and sign each year. Child s Name: Date of Birth: Parent s Name: Name of Physician/Medical Home: _____ Check all authorized below.

9 Physical Exam Immunizations Lead Test Results Hemoglobin Health Action Plan(s) Name of Dentist/Dental Home: _____ Check all authorized below. Dental Exam Summary of Treatment Other: Name of Medical Specialist: _____ Check all authorized below. Results of Hearing Exam Results of Vision Exam Health Action Plan(s) Other: Name of Mental Health Provider: By signing this form, I give permission to the Chester County Intermediate Unit Head START to receive and share my child s health information from and with my child s healthcare providers during the length of his/her enrollment , if not previously revoked. Initial enrollment (year 1) _____ Signature of Parent/Guardian _____ Date Re- enrollment (year 2) _____ Signature of Parent/Guardian _____ Date Re- enrollment (year 3) _____ Signature of Parent/Guardian _____ Date 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 state law.

10 If the records are so protected, federal Regulation (42 CFR Part 2) and PA regulation (4 PA ) 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. A Chester County Intermediate Unit Program !!!1"CCIU Head START CHILD HEALTH AND NUTRITION ASSESSMENT Child s Name: _____ Gender: _____ DOB: _____ Insurance Status: (please circle one) Medicaid CHIP Military Private None Insurance Provider Name: _____ Insurance Card Number: _____ CHILD HEALTH ASSESSMENT The Head START Health Specialist must be notified of any health or nutrition issues. > To have any medication in school, a Health Care Provider must complete an Action Plan.