Dental Agreement
Enrollment &Permission Agreement
Student Name:____________________________________________________________________ Yes No
I agree that my child may participate in the following screenings as outlined in the Federal Head Start Guidelines: dental screenings, vision, auditory, health & weight screenings, and preventative mental health observations. In the case of an emergency, I give my permission to Joseph Brumskill ECAP to secure the necessary emergency care if a parent/guardian cannot be immediately located. I agree to inform Joseph Brumskill ECAP if any custody agreements change during the school year. I agree to inform Joseph Brumskill ECAP if my address or contact information changes during the year. I agree to allow Joseph Brumskill ECAP to make home visits during the school year at my convenience. I agree to participate in all school visits/conferences. I understand all transportation changes must go through the ECAP Main Office. I understand my child must attend the program 85% of the time or may be withdrawn from the program. That my child may accompany their class on scheduled field trips. At the end of the school day, my child will be released only to the person(s) whose name appears on the Emergency Cards and Transportation Forms. Our family agrees to attend a minimum of two parent meetings (PAWS) per year.
Dental Agreement
We are mandated by the Federal Headstart Guidelines in all areas of our program. All ECAP students are required to have a dental examination. If your child has not been to the dentist and/or you do not have a dentist, please contact ECAP for dental resources.
CHECK ONE BOX
ONLY My child HAS been to the dentist. I am submitting my child's dental exam results today. My child HAS been to the dentist. I will submit my child's dental results within 30 days of registration.
My child HAS NEVER been to the dentist. I will make the arrangements with my family dentist to get regular screenings. My child HAS NEVER been to the dentist. I would like any available resources to begin dental screenings for my child.
Signature of Parent/Guardian
__________________ Date
OFFICE USE ONLY _____ Dental Provided _____ No Dental Provided _____ Never Been to the Dentist _____ Dental Form Given to Parent _____ Dental appointment scheduled for: _________________________
_______________________________________________________________________ Signature of ECAP Representative
__________________ Date
Preschool Authorized Person Pick-Up
SCHOOL YEAR: _________
PROGRAM: ECAP
All preschool students must be met at school or the bus stop by an Authorized Adult.
The Bus Driver, Bus Attendant or School Personnel may require identification to release your student.
Student:
School Program: ECAP
Parent/Guardian: Home Address:
Home Phone:
Student Information for appropriate child seat as determined by Transportation Department.
Age:
Height:
Weight:
Persons Authorized to take custody of child at Bus Stop or at School in addition to above parent (s):
Name
Relationship
Phone Number
Day Care Information To be completed only if student is transported to or from Day Care by a school bus Name of Day Care: Day Care Phone: Day Care Address:
PICK UP: Home Day Care Parent
DROP OFF: Home Day Care Parent
Regular Stop location/intersection associated with indicated addresses.
_______________________________________________ Parent Signature
_______________________________________________ Signature of Case Manager
_________________________________________________ Date
_________________________________________________ Principal
CONSENT FORM ? PHOTO/FILM/INTERVIEW
From time to time, the Brandywine School District receives requests from the media to publicize its educational programs and student activities. In addition, your student's teacher and/or district officials appreciate the opportunity to photograph, quote, and videotape our students for use in district/school newsletters, calendar, website, social media, and other promotional or training/education materials. We ask for your consent to allow your student(s) to participate if and when this should happen.
I hereby authorize the Brandywine School District or the media to photograph, videotape, or film my student and to include my student's name with such. I also authorize permission for the Brandywine School District to use statements, endorsements and/or comments about the programs, services, conditions and personnel associated with my student's experience with the Brandywine School District.
I understand and agree that the Brandywine School District and its employees will bear no responsibility for the content of any news media coverage in which such filmed interview, film, videotape, or photograph may be used.
Student Name:
Last
First
Parent/Legal Guardian's Name:
Last
First
SELECT ONE OF THE BELOW:
I DO CONSENT TO THIS REQUEST I DO CONSENT FOR MY CHILD'S PICTURE TO BE USED ONLY IN THE CLASSROOM. PICTURES
AND VIDEOS MAY ALSO BE USED TO DOCUMENT STUDENT PROGRESS AND ON CLASS DOJO, BUT NOT ON DISTRICT SOCIAL MEDIA.
I DO NOT CONSENT TO THIS REQUEST
SIGNATURE OF PARENT/LEGAL GUARDIAN
DATE
CONSENT FORM ? PHOTO/FILM/INTERVIEW
Page 1 of 1
Income Verification & Parent Information
Information required under Federal Head Start Guidelines
Mother: ________________________________________________________________ Lives With: Yes No
Place of Employment: ___________________________________ Paid: (Chose one) Weekly Bi-Weekly Monthly
Other Income: (Check all that apply) (documentation required)
____Tanif
_____SSI
_____Child Support: _____ Unemployment
Mother's Education: (Check ALL that apply)
___High School Diploma ___GED ___Job Training ___Vocational School ___Attending College ___Attending Vocational School
___Associate's Degree ___ Bachelor's Degree ___ Master's Degree
Father: ________________________________________________________________ Lives With: Yes No
Place of Employment: ___________________________________ Paid: (Choose one)Weekly Bi-Weekly Monthly
Other Income:
Check all that apply. (documentation required)
_____Tanif
_____SSI
_____Child Support: _____ Unemployment
Father's Education: (Check ALL that apply)
___High School Diploma ___GED ___Job Training ___Vocational School ___Attending College ___Attending Vocational School
___Associate's Degree ___ Bachelor's Degree ___ Master's Degree
Guardian: _______________________________________________________________ Lives With: Yes No
(Guardianship documentation required)
Relationship to Student: _____________________________________________________________________
Place of Employment: ___________________________________ Paid: (Choose one) Weekly Bi-Weekly Monthly
Other Income:
Check all that apply. (documentation required)
_____Tanif
_____SSI
_____Child Support: _____ Unemployment
Other Received Services: Check all that apply.
_____Purchase of Care
_____Housing Authority
_____Food Stamps
Family Size: ____________________ (this includes mom, dad and children who live at the provided address)
I certify that the income that I have provided is true and correct. Should there be any change in this amount, I will notify Joseph Brumskill ECAP.
Parent Signature: ______________________________________________ Date: _____________________
................
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