ANDERSON COUNTY PRESCHOOL/HEAD START PROGRAM



ANDERSON COUNTY SCHOOLS’ PRESCHOOL

EMPLOYEE CHILD CARE PROGRAM

708 North Main Street

Clinton, Tennessee 37716

Phone: (865) 463-2833

Fax: (865) 463-8876

Dear ACS Employee,

Thank you for applying to Anderson County Preschool/Head Start program.

Accordingly, our program is unable to provide transportation. When children have been accepted into the program, the parents/guardians are responsible for transportation to and from the center.

Before an application can be completed, the following documents must be on file at the preschool office:

• Up-to-date shot record (must be on the Tennessee State Form provided by your doctor)

• Custody papers (if applicable)

• Physical exam (upon enrollment)

Return completed application with the necessary documents to the preschool office at 708 North Main Street, Clinton.

NON-DISCRIMINATION STATEMENT

The Preschool Program does not discriminate against employees or clients because of race, color, religion, sex, language, national origin or handicapping condition.

CONFIDENTIALITY

The Anderson County Preschool Employee Child Care are responsible for maintaining confidentiality and protecting the privacy of personal identifiable information about children and families.

ANDERSON COUNTY PRESCHOOL EMPLOYEE CHILD CARE PROGRAM

|Center: |Home Phone: |

|Child’s Name: Last First Middle |

|Birthdate: |Gender: ___Male ___Female |Primary Language: |

PARENT/GUARDIAN INFORMATION

|Primary Adult Name: Last First Middle |

|Birthdate: |Marital Status: |Gender: ____Male ____Female |Relationship to applicant: |

|Place of Employment: |Work Phone: |Cell Phone: |

|Living Address: |

| |

|Apt. No# Street City Zip Code |

|County |

|Mailing Address: (if different from above) |

| |

|Apt. # Street City Zip Code |

|County |

|E-Mail Address: |

|Secondary Adult Name: Last First Middle |

|(if living in the home) |

|Birthdate: |Marital Status: |Gender: ___Male ___Female |

|Relationship |Last grade in school:______ Diploma ______ GED______ |

|to Applicant: | |

|Place of Employment: |Work Phone: |Cell Phone: |

| | |Can you receive text messages? |

Who will be responsible for paying the fee? Name: ___________________________________________

EMERGENCY INFORMATION

Please list at least 3 names and phone numbers of person to notify in case of an emergency and that can pick up your child:

| | | | | |

| | | | | |

| | | | | |

Last Name First Name Home/Cell# Work# Work Hrs. Relation

DO NOT RELEASE MY CHILD TO:

Last Name First Name Relation

| | |

| | |

| | |

MEDICAL/DEVELOPMENTAL SCREENINGS

The Anderson County Preschool provides the following screenings to enroll children. These screenings are used to determine if there are any health or developmental concerns that need to be addressed.

1. Speech and Language 2. Vision Screening

5. Developmental Assessment

3. Hearing Screening

By my signature below:

• I give my consent to the preschool program to provide the screenings listed above.

• I verify that the information I have furnished in this application is correct to the best of my knowledge.

Parent’s Signature: ____________________________ Date: ____________

MEDICAL/HEALTH INFORMATION

You are required to furnish the Preschool program with an up-to-date immunization record and physical exam documented on the Tennessee State form for your child.

Child's Doctor ____________________________Phone #_________________________

Doctor's address __________________________________________________________

Dentist Name: ____________________________Date of last visit: _______

Dentist address: ___________________________________ Phone#________________

Does your child have any allergies? ___________________________________________

List Child's Allergies: ______________________________________________________

Does your child have any medical or physical needs? Yes___ No___

If yes, explain: ___________________________________________________________

Does child take medication regularly? Yes _______ No _______

If yes list medications and how often taken: ____________________________________

Is child on a special diet? Yes _______ No _______

If yes, explain: ___________________________________________________________

Parent/Guardian Initials __________________

Health and Nutrition History

Child’s Name___________________________ Date of Birth_______________

YES NO Explain “yes” answers

|Did mom have any problems during pregnancy or delivery? | | | |

|Was child born 3 weeks early or late? | | | |

|What was the child’s birth weight? | | | |

|Were there any concerns with child at birth? | | | |

Hospitalization and Illnesses YES NO Explain “yes” answers

|Has child ever been hospitalized or had an operation? | | | |

|Has child ever had a serious accident? | | | |

Physical, Psychological and Social Development

Please list one or two things your child is interested in: ___________________________

Does your child take a nap? ___________

Is child potty trained? ____________ If so, how does he/she tell you they need to use

the toilet? ________________

How does your child act when playing with a group of other children? _______________

Does your child worry a lot or is he/she afraid of anything? ________________________

Do you have any concerns regarding your child’s speech? Yes_____ No _____

If yes, explain____________________________________________________________

Have there been any big changes in your child’s life in the last six months? Yes__ No__

If yes, explain____________________________________________________________

Are you or your family having any problems now that might affect your child? Yes_ No_

If yes, explain ____________________________________________________________

Is there anything else you would like for us to know about your child? _______________

________________________________________________________________________

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DO NOT RELEASE MY CHILD TO: (CUSTODY PAPERS REQUIRED IF APPLICABLE)

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Revised 4/30/2019

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