Doña Ana County Head Start...Permission_Form/PI/3.06 4.07 3.08 7.08 1.10 5.11 5.13 4/14 4.15 Doña...

Doña Ana County Head Start

Parent Stipend Declination Statement

I ________________________understand that Dona Ana County Head Start

offers parent attendees a stipend to assist with childcare and mileage so I can

attend the monthly Head Start center parent committee.

I also understand that by signing this document I am declining to participate in

receiving a stipend to offset any reasonable expenses related to my attendance

at the Head Start center Parent Committee meeting.

I can at any time change my mind and elect to receive the stipend by completing the

NMSU Vendor Questionnaire Form and submitting a Parent Reimbursement Request

From for Center Parent Committtee Meetings at the time of the Head Start center Par-

ent Committee meeting.

CENTER:_____________________

Reason for declination (optional)__________________________________________________

Parent Signature:______________________________________________________________

Staff Signature:__________________________________________________________________

Date:___________________________

Parent stipend declination 4_29_15

DOÑA ANA COUNTY HEAD START

Parent Agreement

Child’s Name: ___________________________________________ Center: _________________________

Goals and objectives in Head Start can best be met through a cooperative effort between parents and staff. This agreement

highlights staff and parent responsibilities.

Please initial: Parents: _____ I will notify staff if my child will not be attending class and call within one hour of the start of session.

_____ I will ensure that my child attends class daily.

_____ I will drop off and pick up my child at the scheduled time.

_____ I will notify staff if there is a change in address or telephone number for the family, on a monthly basis.

_____ I will notify my child’s center if someone other than parent or on contact list is picking up my child.

_____ I will sign the child in upon arrival and signed out upon departure.

_____ I will become active participant in the collaboration and implementation of a Family Partnership

Agreement.

_____ I will encourage my child to observe safety rules in the classroom and on the playground.

_____ I will notify staff if my child is not allowed to participate in any classroom activity.

_____ I will carry out home learning activities as developed by the teachers and parents.

_____ I will be available for a minimum of (2) home visits to discuss your child’s progress and (2) conferences

(Education).

_____ I will follow through on scheduled parent involvement activities.

_____ I will try to attend parent meetings and activities at the center. Children will not be permitted at monthly

parent meetings or trainings. In lieu, a stipend is offered.

_____ I will report and participate in any concerns about my child or issues about the Head Start program.

_____ I will take my child to physical and dental exams before my child begins attending Head Start class.

The Head Start Program will: _____ Attempt to contact the parent within one hour of program start time if parent has not contacted the program. _____ Welcome and encourage parents to be involved in the classroom.

_____ Assist in obtaining a physical exam and a dental before your child begins attending Head Start class.

_____ Assist family in obtaining physical or dental follow-up, and any other follow-ups, as needed.

_____ Assist family to access a medical/dental healthcare system, if needed.

_____ Work with parents to enhance learning in the home environment.

_____ Schedule a minimum of two home visits to discuss the child’s progress and two conferences with parent at school.

_____ Inform the parents of regularly scheduled activities.

_____ Plan center meetings and organize training with parents on special topics.

_____ Provide information to parents concerning available community services.

_____ Provide monthly newsletters for parents.

_____ Follow-up on issues and concerns brought forth by parents and their children.

_____ Notify parents of changes in scheduled center activities.

_____ Offer parents opportunities to develop and implement individual Family Partnerships.

_____ Provide bus and pedestrian safety trainings to parents and children within 30 days of enrollment.

_____ Talk with their child about the safety rules observed in the center, playground, and the safety bus.

_____ Verify all contact information on a monthly basis.

_____ Offer parents or legal guardian stipend to assist with child care or mileage for parent meetings.

_____ DACHS does not charge fees for services.

_____ Follow up on attendance within one hour of the start of the session

________________________________________ _____________________________

Signature of Parent or Guardian Date

________________________________________ _____________________________

Signature of Head Start Staff Date

Parent Agreement 3.09 5.11 5.12 4.13 6.14 4.15 5.16 3.17 5.17

ENTERED INTO CHILDPLUS

BY: _____________________

DATE: ______/______/______

Child’s Name___________________________________Center__________________________

Child’s Doctor_______________________________Dr’s Phone Number__________________

In the event of an emergency, which hospital do you want your child transported to?__________

_____________________________________________________________________________

Are these contacts in addition to your current emergency contacts on file? Y / N

Parent One/Guardian:__________________________________________________________

May Pick up/Drop off Child? Y / N May We Share Information? Y / N May Make Decisions? Y / N

Home Number: ____________________Cell:__________________Work:__________________

Physical Address: _______________________________________________________________

Parent Two/Guardian:__________________________________________________________




Emergency Contact #1:_________________________________________________________




Relationship to the child? _________________________________________________________

Emergency Contact #2: _________________________________________________________




Relationship to the child? _________________________________________________________

Parents/Guardian Signature: _____________________________________Date: ____________

Staff Signature: _______________________________________________Date:___________

Emer_Contact_Change/FamSer/5.09 11.10 5.12 4.15 2.16 3.17

Emergency Contact Changes


BY: _____________________

DATE: ______/______/______

I give permission for _________________________________ to participate and receive the following:

Name of child

All children must have the required immunizations before they can attend the Doña Ana County Head Start Program.

Children who do not have the required immunizations cannot attend the center. A copy of your child’s shot record must be

submitted during enrollment interview. If your child requires additional immunizations during the program year, you must

provide Head Start with an updated record in order for your child to continue attending.

Children enrolled in Head Start should obtain medical and dental services. We ask that the dental and physical exams be

completed before your child begins attending Head Start class.

If your child has received a physical and/or dental examination in the last 6-8 months, please give the physical and/or dental form

to the doctor or dentist to be completed. Return completed form(s) to Head Start immediately.

(Please check appropriate response to allow your child to participate in the following)

1. __ Yes __ No Emergency transportation by an ambulance to a facility (hospital) in the event of a medical emergency

2. __ Yes __ No Developmental Screening (i.e. Denver II) used as a baseline to determine educational goals for your child

3. __ Yes __ No Social/Emotional Screening (i.e. ASQ:SE) used as a baseline to determine social/emotional goals for your child.

4. __ Yes __ No My child will receive a vision, hearing, blood pressure and growth screening.

5. __ Yes __ No My child will be screened for speech and language by LCPS or NMSU speech Department staff/students.

6. __ Yes __ No My child will be observed by the Mental Health and/or Disabilities Specialist.

In some/all of our classrooms we have video surveillance cameras and we conduct classroom videotaping. The purpose of the video

cameras is for your child’s safety as well as the Head Start parents and for professional development of staff. We take pride in providing

the best childcare and learning environment. Our preventative measure is to video tape your children in their classrooms.

Head Start has posted video surveillance signs in the classrooms and around the Head Start buildings to inform the general public of the

Head Start video cameras. Extreme care is enforced in safeguarding these surveillance tapes against unauthorized use.

PUBLIC RELATIONS CONSENT FORM

Doña Ana County Head Start Program has the opportunity to publicize in the Las Cruces/Anthony community through the

radio, TV, website, or newspaper. Due to our affiliation with NMSU, we also have students/staff working in the classrooms,

doing observations or case studies on individual children or families, taking photographs, slides, or videotapes for use in

professional displays or books. If no, please notify your child’s teacher in writing. This does not include video

surveillance/taping for professional development.

I will not hold Doña Ana County Head Start or any of its personnel, volunteers or substitutes responsible for any accident or

illness to my child. In case of illness or accident, I grant permission to those in charge to take steps for the proper treatment

and care of my child.

________________________________________ _____________________________

Signature Parent/Guardian Date _______________________________________________ __________________________________

Relationship to Child Signature of Head Start Staff

Permission_Form/PI/3.06 4.07 3.08 7.08 1.10 5.11 5.13 4/14 4.15


Permission Form

* I have received an information sheet explaining the purpose of the screenings.

ENTERED INTO CHILD PLUS

BY:________________________

DATE: _____________________

VIDEO SURVEILLANCE/VIDEO TAPING


FAMILY SITUATION POLICY

Child’s Name: ______________________________ Center: ______________________________ Parents, guardians or custodians of children dropped off to be served by DACHS program must be specific about who may see, pick up children, make decisions or share information. In the majority of cases the children are dropped off by one adult; mother, father or other adult. Issues of DACHS’s responsibility arises when a non-authorized adult arrives and demands either to see the child or pick up the child. The purpose of this policy is to provide guidance to staff in the event of a conflict or potential conflict among parents, grandparents or other adults concerning children left in the care of DACHS. Each DACHS facility shall, as part of the intake procedure during the enrollment process record a history of the family situation. It must be stressed to the adult enrolling the child in the program that they must clearly designate that any other adults be allowed access to, allowed to pick up child, or make decisions or share information about the child (unless otherwise instructed in writing by the adult who enrolled the child). If the adult who enrolled the child does not list the father or mother on the emergency contact list, DACHS will not release the child to them regardless if the father or mother’s name is on the Birth Certificate. We will not release a child enrolled in DACHS to a person under the age of eighteen (18). The exception will be if the parent is under eighteen (18). Do not add an emergency contact that is under the age of eighteen (18) as DACHS staff will not release the child to a minor. _________________________________________ Date: ________________ Parent or Guardian Signature _________________________________________ Date: ________________ Staff Signature Policy Council Approval December 14, 2010 FamilySit/Policies/5.07 6.08 8.10 5.11 4.15 6.16


LEAD RISK QUESTIONNAIRE TODAY’S DATE: _____________

Child’s Name _______________________________________________________________________ Last First MI

Gender: Male Female

Date of Birth: _____ / _____ / _____ Center: ____________________________ Month Day Year

PATIENT EXPOSURE INFORMATION

Check ( ) YES, NO, or NOT APPLICABLE for each question. Y N NA

1. Does your child live in or regularly visit a house built before 1960? This could include a child care center, preschool, or the home of a relative or baby sitter.

2. Does your child have a brother, sister, playmate, parent, or

housemate with lead poisoning?

3. Does your child live with someone who works with lead in either

a job or hobby?

Examples include: Repairing radiators Soldering Lead Smelting or casting metals

Repairing or restoring cars Stripping or sanding old paint Welding or using a cutting torch

Using indoor firing ranges Glazing pottery or ceramics Machining or grinding metals

Remodeling homes Making stained glass Manufacturing/recycling batteries

Refinishing furniture Using lead weights for fishing

Demolishing old structures Casting fishing weights or bullets

4. Does your child take any of the home remedies listed below?

Azarcon (Alarcón) Coral Pay-Loo-Ah Al Kohl Liga

Greta Ghasard Bala Gol Rueda

5. Does your child play with toys made in China?

6. Do you use ceramic pottery from Mexico or another country for

cooking, serving, or storing food or drinks?

7. Does your child live with someone who smokes cigarettes?

Lead Risk/HN/8.06 4.07 7.08 5.11 5.13 3.17


BY:_____________________

DATE:___________________


Nutrition Information

Today’s Date:_______________

Child’s Name ______________________________________ Birth Date _____________

Please fill out the following survey to the best of your knowledge. It is important that we have the

most accurate information possible so that we can ensure the safety of your child and help your

child receive the best nutrition possible. Thank you!

1. Are there any foods your child cannot eat due to religious, cultural, or medical

reasons? ____ Yes ____ No

If yes, what foods? _____________________________________________

2. Does your child have any allergies to foods? ____ Yes ____ No

If yes, what foods? ___________________________________________________

What reaction does your child have? ______________________________

Emergency Medications (e.g. EpiPen)? ____________________________

3. Are there any foods your child dislikes? ____ Yes ____ No

If yes, what foods? ______________________________________________

4. Does your child take vitamin or mineral supplements? ____ Yes ____ No

If yes, what kind are they? _________________________________________

Was it prescribed by a Doctor? ____ Yes ____ No

5. Is your child on a special diet? ____ Yes ____ No

If yes, what kind of diet? __________________________________________

Was it prescribed by a Doctor? ____ Yes ____ No

6. Does your child have any other special food needs? ____ Yes ____ No

If yes, what are they? _____________________________________________

7. Has your child been weaned from the bottle? ____ Yes ____ No

If yes, when? ___________________________________________________

8. Does your child drink milk? ____ Yes ____ No

9. Does your child have difficulty chewing or swallowing? ____ Yes ____ No

10. Do you have concerns about what your child eats? ____ Yes ____ No

11. Does your child ever eat non-food items, such as clay, dirt, or paint chips?

____ Yes ____ No

12. Are you interested in learning more about healthy foods, cooking and nutrition?

____ Yes ____ No

Nutrin3_4.21.10 5.11 5/13 Reviewed 7.15 3.17

ENTERED INTO

CHILDPLUS

BY: _____________________

DATE: ______/______/______


Permission to Release Dental and Physical Exam Forms

I, _______________________________, give permission for the Health/Nutrition (Print Name of Parent/Guardian)

Specialist from the Doña Ana County Head Start program to communicate, request and

receive my child’s _____________________________ , ______________ completed (Birth Name or Child’s Name Used at Dr’s office) (Child’s Date of Birth) physical exam form and/or completed dental form and any follow-up.

Health Ins. Medicaid State Ins. Private Ins. Other Ins. No Ins.

The following are the names of the doctor and dentist for my child:

______________________________ ____________________________

(Doctor’s Name) (Dentist’s Name)

______________________________ ____________________________

(Phone #) (Phone #)

______________________________ ____________________________

(Date of last Physical Exam) (Date of last Dental Exam)

______________________________ ____________________________

(Signature of Parent/Guardian) (Date)

Consentimiento para exámenes dentales y físicos

Yo, _____________________________, le doy autorización a la especialista de Salud/ (Nombre del padre o tutor)

Nutrición del programa de Head Start del Condado de Doña Ana, que contacte y pida

las formas correspondientes de salud, dental y consiguientes de mi hijo _____________ (Nombre de Pila ó nombre que usa en la oficina del Doctor)

__________________ Los nombres del médico y dentista de mí hijo son: (Fecha de nacimiento de niño)

______________________________ ______________________________

(Nombre del medico) (Nombre del dentista)

______________________________ _____________________________

(Teléfono) (Teléfono)

______________________________ _____________________________

(Fecha del ultimo examen físico) (Fecha del último examen dental)

______________________________ ____________________________

(Firma del padre o tutor) (Fecha) PTR/HN/4.05/5.06 6.06 5.07 6.08 8.16 Reviewed 4.15

seguro de salud Medicaid seguros de su estado seguro privado otro seguro sin seguro

ENTERED INTO

CHILDPLUS

BY: _____________________

DATE: ______/______/______

Please Submit to:

Doña Ana County Head Start / Health Specialist

Address: 2540 El Paseo, Suite B, Las Cruces, NM

Phone: 575-647-8733 Ext. 116 Fax: 575-647-8734


BY:_____________________

DATE:___________________

Doña Ana County Head Start FEDERAL REQUIREMENT #1304.20 Physical Exam Form

Parent/Guardian fill this section Padre/Guardián llene esta sección

Child's Name/ Nombre del Niño: Sex / Sexo: □ M □ F

Date of Birth/ Fecha de nacimiento: Center: □ AM □PM

How do you pay for health care? Check all that apply:

¿Cómo paga por el cuidado de la salud? Favor de marcar todo lo que aplique:

□ Medicaid □ Private Insurance / Aseguranza privada □ CHIPS

□ No Insurance / Sin Aseguranza □ Sliding Scale / Escala de cálculo

Permission for Release of Information / Permiso de Proveer Información

I give permission for the healthcare provider to release the requested information to DACHS Head Start.

Yo doy permiso a mi doctor para dar la siguiente información a DACHS Head Start.

Parent or Guardian Signature / Firma: Date / Fecha:

Health Care Providers – please complete sections below Blood Lead Level: Collected Date:

Hgb / HCT: Collected Date:

Blood Pressure: Date:

Vision: □ Pass □ Fail □ Refer Hearing:□Pass □ Fail □ Refer

BMI: <5% WNL >95%

Is the child receiving treatment for:

□ Anemia □ Asthma □ Overweight □ High Lead Levels

□ Diabetes □ Food Allergy □ Vision Difficulties □ Hearing Problems

□ Other: please indicate severity and treatment.____________________________________________

Does the child need a follow-up appointment? □Yes □ No Date of follow-up?_____/_____ /_____

If so, please indicate:

Any Concerns? □ Yes □ No Is this child up-to-date on the EPSDT schedule? □ Yes □ No

Is the Medicaid periodicity schedule being followed? □ Yes □ No

Immunization Status: □ Up-to-date □ Catch-up-schedule Patient Needs:

Physical Examination Completed by: (please print name) ____ __

Exam Date:

Phone: Fax: Signature:

Health/Phy_Exam/4.12 3.17

Head Start Oral Health Form—Children

Patient Information

Child’s name Child’s date of birth This practice is the child’s dental home: Yes No Date of Service:____________________

Current Oral Health Status

Does the child have any teeth with untreated decay? Yes (decay) No (decay free) Does the child have any teeth that have previously been treated for decay, including fillings, crowns, or extractions? Yes No Are there treatment needs? Yes, urgent Yes, not urgent No treatment needs

Oral Health Care Services Delivered During Visit

Diagnostic/Preventive Services Counseling/Anticipatory Guidance Restorative/Emergency Care

Examination: Yes No Yes No Fillings: Yes No X-rays: Yes No Crowns: Yes No Risk assessment: Yes No Refer ral to Specialty Care Extractions: Yes No Cleaning: Yes No Yes No Emergency care: Yes No Fluoride varnish: Yes No

Other: Dental sealants: Yes No (Please specify specialist) (Please specify)

Future Oral Health Care Services

All treatment completed: Yes No Next recall date: / (month/year) More appointments needed for treatment? Yes No If yes: Approximate number of appointments needed: Next appointment: Date: Time:

Permission for Release of Information / Permiso de Proveer Información

I give permission for the healthcare provider to release the requested information to DACHS. Yo doy permiso a mi doctor para dar la siguiente información a DACHS.

Parent or Guardian signature/Firma: _________________________________________ Date/Fecha:_____________

Oral Health Provider’s Contact Information and Signature

Provider name (please print) Phone number Fax number

Practice name Address

Provider signature


Date: By:

This document was prepared under grant #9OHC0005 for the U.S. Department of Health and Human Services, Administration for Children and Families, Office of

Head Start, by the National Center on Health. This publication is in the public domain, and no copyright can be claimed by persons or organizations.

Doña Ana County HEAD START New Mexico State University

College of Education 2540 El Paseo, Suite B, Las Cruces, NM 88001

Phone: 575-647-8733 ext. 1мс

Fax: 575-647-8734

Does child currently take any medication? ___ YES ___ NO

PRIMARY HEALTH COVERAGE

OTHER HEALTH COVERAGE MEDICAID NUMBER

A CONDITION YES NO CONDITION YES NO CONDITION YES NO

1 Allergies 18 German Measles 35 Polio

2 Anemia 19 Hearing Problems 36 Problems with Urinating

3 Asthma 20 Heart Disease 37 Rheumatic Fever

4 Cancer 21 Hemophilia 38 Rotavirus

5 Chicken Pox 22 Hepatitis B 39 Scarlet Fever

6 Cleft Palate 23 Hepatitis A 40 Serious Accident

7 Depression 24 High Fever 41 Serious Illness

8 Diabetes 25 HIV-AIDS 42 Seizures

9 Diarrhea/Vomiting 26 Impetigo 43 Sickle Cell Disease

10 Ear Aches/Infections 27 Jaundice 44 Speech Problems

11 Eczema/Skin Problems 28 Kidney Trouble 45 Stomach Pain

12 Encephalitis 29 Liver Disease 46 Surgery/Hospitalization

13 Epilepsy 30 Measles 47 Tuberculosis

14 Fainting 31 Meningitis 48 Uncontrollable Anger

15 Frequent Colds 32 Mononucleosis 49 Vision Problems

16 Frequent Cough 33 Mumps 50 Whooping Cough

17 Frequent Sore Throat 34 Muscular Dystrophy 51 Eye Glasses

B YES NO

1

2

3

4

5

6

7

8

C YES NO

1

2

3

4

5

6

Page 1 of 2

Does child snack on sweets or soda pop? How often?

Please explain any "YES" answers from above except for questions with an asterisks(*) symbol:

Type: ________________ Frequency? ___________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

MEDICAID ELIGIBILITY

Not Eligible

Potential Eligible

On Medicaid

Phone:


CHILD DEVELOPMENTAL HEALTH HISTORY

CHILD'S NAME:_______________________________________ DOB: ____/____/____ CENTER: _________________________

DEVELOPMENTAL DISABILITY

DENTIST INFORMATION

Name:

Phone:

Address:

DOCTOR INFORMATION

Does child require any special appliances, such as braces, shoes, wheel chair, or other equipment?

Do you think your child has any trouble hearing?

Do you think he/she has any trouble talking or being understood?

Do you think your child has trouble seeing?

Has your child had any of the following conditions?

Check all that apply.

ORAL HEALTH

Does parent help child brush his/her teeth? How often? *

Does child have any untreated dental decay?

Name:

Does he/she have trouble doing things with his/her hands? (Holding a cup, coloring, etc.)

Does your child have any trouble walking, running, etc?

Has your child received svcs from Tresco, M.E.C.A, Aprendamos or Early Head Start?

Does child use fluoridated toothpaste when brushing? *

Does child have any suspected or diagnosed developmental delays or disabilities?

Does child use a bottle or take a bottle to bed? How often?

Address:

Does child ever complain of mouth or tooth pain?

D PREGNANCY AND BIRTH YES NO EINFANCY (BIRTH TO 2

YEARS OLD)YES NO

1 Did you have any illnesses during your pregnancy? 1

2 Did you have any accidents during your pregnancy?

3 Did you have any problems during your child's birth?

4 Did you carry your child for a full nine months? *

5 Where was your child born?

6 How much did he/she weigh at birth? _______lbs. _______oz.

7 Did your child have trouble starting to breathe?

8 Was your child treated for any medical problems after birth? 2

9 Did your child go home with you when you left the hospital? *

10 Are you pregnant now? *

11 Were alcohol or drugs used during pregnancy?

12 Did you smoke cigarettes during pregnancy?

F YES NO

1

2

3

4

5

6

7

8

9

10

11

12

12a

12b

12c

13

Please explain any "YES" answers from above except for questions with an asterisks(*) symbol:

Parent/Guardian Signature: __________________________________________ Date: _____/_____/____________

(This information will remain confidential)

__________________________________________________________________

Teacher's Signature Date

HealthHistory/Health/2008 5 11/5.12/6.12/5.13/6.14/4.15

Does your child have frequent nightmares?

Between ages 2 and 4 did your child have any serious medical problems? (i.e. surgeries, major illnesses, etc.)

Does he/she take a nap? *

Does child sleep through the night? *

Did your child

experience any serious

medical problems

(including illnesses,

surgeries, etc.) during

his/her first 2 years of

life?

Is your child toilet trained?

Will your child allow teaching staff to change their pull-up or soiled clothing? (if needed)

As a toddler, has your child had any problems eating?

As a toddler, has he/she had any sleep problems?

Does your child sleep alone? *

BY:________________________

Date: _____/_____/_________


What word does he/she use for urination?

Who took care of your

child during the first 2

years?

What time does your child go to bed? _____ Wake Up? _____

We use gloves during any changing of soiled clothing - does your child have any allergies to latex?

I verify that I have reviewed this health history form and have taken any needed actions

regarding this child: e.g.(Not limited to, but includes actions such as preparing a toileting

plan or contacting the Health Specialist regarding any illnesses or allergies).

FOR TEACHER USE ONLY

What word does he/she use for bowel movement?

Has your child been in daycare or go to a babysitter?

What are the signs prior to your child using the bathroom?

Is there any other information in regards to toileting we need to be aware of? If yes, please explain:

TODDLER (2 TO 4 YEARS OLD)

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