Oglala Lakota College



Oglala Lakota College

Head Start/Early Head Start Program

P.O. Box 490

Phone (605) 455-6114

Fax (605) 455-6116

Student Application

Head Start and Early Head Start are comprehensive child development programs which serve children from birth to age 5, pregnant women, and their families. They are child-focused programs, and have the overall goal of increasing the social competence of young children in either low-income and homeless families or both. By “social competence” is meant the child’s everyday effectiveness in dealing with either his or her present environment and later responsibilities in school and life. Social competence takes into account the interrelatedness of social, emotional, cognitive, and physical development.

Our goal is to provide a full range of services to meet the needs of Lakota children from 0-5 and their families addressing cognitive, emotional, physical, nutritional, mental health, and Lakota language and culture development of the children and the development needs of families.

Please read this eligibility application carefully and fill it out completely. It contains important information that is used to determine if your child is eligible for Head Start/Early Head Start services based on the federal requirements and the OLC selection criteria is located on page 4 of the attached Student Application.

To be eligible for Head Start services, a child must be at least three years old by the date used to determine eligibility for public school in the community in which the Head Start program is located, except in cases where the Head Start program’s approved grant provides specific authority to serve younger children. Examples of such exceptions are programs serving children of migrant families and Early Head Start programs.

When we receive your eligibility application, it will be reviewed and you will be contacted if we need more information or if your family does not qualify for services. Once your family has been determined eligible you will receive additional documents to fill out to complete the registration process.

Checklist

These documents must be submitted with the attached eligibility application.

Completed Eligibility Application (required for determining eligibility)

Family’s Proof of Income (required for determining eligibility)

Child’s Birth Record (required for determining eligibility)

Immunization Record (current for age as required by SD school immunization law 13-28-7.1)

Dental Examination Physical Examination

Copy of Medical Insurance

Child Health History

Allergy Form MD Slip

Attendance Policy

Parental Permission to Participate

Program Request Form Program Release Form

WIC Release Form

Fluoride Varnish Administrating Consent Lead/Hemoglobin Screening Consent

Cavity Prevention Consent

CACFP Form

Circle of Smiles Registration

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|Center Applying for: ___________________________________________ |

|ELIGIBLE CHILD DEMOGRAPHICS: |

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|First: _________________________________ Middle: __________________________ Legal Last Name: _________________________________ |

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|DOB: ______ /______ /______ SSN: ______–______–_______ Race: _________________________ Ethnicity: _________________________ |

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|Gender (Circle): Male / Female Language (Check): English 1st / 2nd Lakota 1st / 2nd Spanish 1st / 2nd Other |

|FAMILY MEMBERS DEMOGRAPHICS: |

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|#1 Parent/Guardian – First: _________________________________ Middle Initial: _______ Last Name: _________________________________ |

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|DOB: ______ /______ /______ Race: _________________________ Marital Status (Circle): Single / Separated / Married / Divorced |

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|Gender (Circle): Male / Female Language (Check): English 1st / 2nd Lakota 1st / 2nd Spanish 1st / 2nd Other |

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|Living Address: _____________________________________________ Mailing Address: _____________________________________________ |

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|City: ______________________________________State: _____ Zip Code: ________________ Mobile Phone: ____________________ |

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|#1 Home Phone: ____________________ #2 Home Phone: ____________________ Work Phone: ____________________ |

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|Role in Household (Check One Below): Relationship Details (Check One Below): |

|Mother/Mother Figure No Longer a Family Member Emergency Contact Authorized to Receive Child |

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|Father/Father Figure Family Member Residing at Different Address No Contact Allowed |

|***If no contact, please provide documentation |

|Occupation (Check One Below): |

|Employed Full-time/In-school Part-time School Full-time Unemployed N/A Occupation Start Date: ______ /______ /______ |

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|In-school Full-time/Employed Part-time Employed Other In Job Training Program |

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|Education (Check One Below): |

|Elementary – 4th / 5th / 6th / 7th / 8th High School – 9th / 10th / 11th / 12th No Diploma Other CDA |

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|High School Diploma or Equivalent Degree – AA / BS / MA / PHD / Some College – No Diploma |

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|Education Start Date: ______ /______ /______ |

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|Applicant currently pregnant? (Circle One): Yes / No Due Date: _____ /_____ /_____ |

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|#2 Parent/Guardian – First: _________________________________ Middle Initial: _______ Last Name: _________________________________ |

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|DOB: ______ /______ /______ Race: _________________________ Marital Status (Circle): Single / Separated / Married / Divorced |

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|Gender (Circle): Male / Female Language (Check): English 1st / 2nd Lakota 1st / 2nd Spanish 1st / 2nd Other |

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|Living Address: _____________________________________________ Mailing Address: _____________________________________________ |

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|City: ______________________________________State: _____ Zip Code: ________________ Mobile Phone: ____________________ |

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|#1 Home Phone: ____________________ #2 Home Phone: ____________________ Work Phone: ____________________ |

|[pic] |

|Role in Household (Check One Below): Relationship Details (Check One Below): |

|Mother/Mother Figure No Longer a Family Member Emergency Contact Authorized to Receive Child |

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|Father/Father Figure Family Member Residing at Different Address No Contact Allowed |

|***If no contact, please provide documentation |

|Occupation (Check One Below): |

|Employed Full-time/In-school Part-time School Full-time Unemployed N/A Occupation Start Date: ______ /______ /______ |

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|In-school Full-time/Employed Part-time Employed Other In Job Training Program |

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|Education (Check One Below): |

|Elementary – 4th / 5th / 6th / 7th / 8th High School – 9th / 10th / 11th / 12th No Diploma Other CDA |

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|High School Diploma or Equivalent Degree – AA / BS / MA / PHD / Some College – No Diploma |

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|Education Start Date: ______ /______ /______ |

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|Applicant currently pregnant? (Circle One): Yes / No Due Date: _____ /_____ /_____ |

|CHILD INFORMATION: |

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|Concerns about child’s overall health and development (Circle One): Yes / No Describe concerns: _________________________________ |

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|Concerns expressed by (Check One): EHS Staff / HS Staff / Family Member / Medical Provider / Other Person or Agency |

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|Child to be care for by someone other than the Head of Household (Check Appropriate Boxes Below): |

|Adult relative in child’s own home Relative Public School Pre-K program |

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|Older sibling age 12 or older Unrelated adult in child’s own home Child Care Center |

|FAMILY INFORMATION: |

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|Head of Household (Check One Below): Family Type (Check One Below): |

|#1 Parent/Guardian Foster Parent Single Parent (Mother Figure Only) |

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|#2 Parent/Guardian Two Parent Family Single Parent (Father Figure Only) |

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|Family Housing Type (Check One Below): |

|Apartment Community Shelter House Other |

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|BIA School Housing Mobile Home/Trailer OSLA Housing |

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|Housing Payment Type (Check One Box): Own Housing / Rent Housing / Make No Payment for Housing / Other |

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|Length of Time at Current Address (Check One Box): 1-2 Years / 6-12 Months / Less than 6 Months / More Than 2 Years |

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|During the enrollment year was the Family homeless? (Circle): Yes / No Family Acquired Housing During Enrollment Year (Circle): Yes / No |

|[pic] |

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|Family Currently has Means of Transportation (Circle): Yes / No |

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|Transportation Used (Check One Below): |

|Private Vehicle (car,truck,van) – Primary / Secondary |

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|Parent Transport – Primary / Secondary |

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|Friend’s or Relative’s Vehicle – Primary / Secondary Referral Source (Check One Below): |

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|School Bus – Primary / Secondary Child Welfare Agency Hospital/Health Clinic Self Referral |

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|Other – Primary / Secondary Friends/Family Outreach/Recruitment |

|INVOLVED ADULTS / EMERGENCY CONTACTS: |

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|#1 Adult – First: _________________________________ Middle Initial: _______ Last Name: _________________________________ |

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|DOB: ______ /______ /______ Race: _________________________ Gender (Circle): Male / Female |

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|Language (Check): English 1st / 2nd Lakota 1st / 2nd Spanish 1st / 2nd Other |

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|Living Address: _____________________________________________ Mailing Address: _____________________________________________ |

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|City: ______________________________________State: _____ Zip Code: ________________ Mobile Phone: ____________________ |

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|#1 Home Phone: ____________________ #2 Home Phone: ____________________ Work Phone: ____________________ |

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|#2 Adult – First: _________________________________ Middle Initial: _______ Last Name: _________________________________ |

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|DOB: ______ /______ /______ Race: _________________________ Gender (Circle): Male / Female |

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|Language (Check): English 1st / 2nd Lakota 1st / 2nd Spanish 1st / 2nd Other |

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|Living Address: _____________________________________________ Mailing Address: _____________________________________________ |

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|City: ______________________________________State: _____ Zip Code: ________________ Mobile Phone: ____________________ |

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|#1 Home Phone: ____________________ #2 Home Phone: ____________________ Work Phone: ____________________ |

|[pic] |

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|#3 Adult – First: _________________________________ Middle Initial: _______ Last Name: _________________________________ |

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|DOB: ______ /______ /______ Race: _________________________ Gender (Circle): Male / Female |

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|Language (Check): English 1st / 2nd Lakota 1st / 2nd Spanish 1st / 2nd Other |

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|Living Address: _____________________________________________ Mailing Address: _____________________________________________ |

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|City: ______________________________________State: _____ Zip Code: ________________ Mobile Phone: ____________________ |

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|#1 Home Phone: ____________________ #2 Home Phone: ____________________ Work Phone: ____________________ |

|ABOUT YOUR INCOME: |

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|This is required information: Please fill out completely and attach copies (not originals) of forms that provide proof of your income. Proof of income can be |

|presented through W-2 forms, Individual Tax Form 1040, pay stub/pay envelopes, current public assistance receipt (notice of Action forms) Written employers statement,|

|Social Security, and/or forms that verify income from other sources (child support, etc). |

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|Types of Services or Financial Assistance Received (Check All Boxes Below That Apply): |

|Supplemental Security Income (SSI) Foster Care/Adoption Subsidy WIC |

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|Medical Financial Assistance (i.e., Medicaid/Medicare) Child Support/Alimony No Services Received |

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|Supplemental Nutrition Assistance Program (SNAP) aka Food Stamps |

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|Are you currently receiving service through TANF, or have you in the past year? (Circle): Yes / No |

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|Are you currently a foster parent of the child wishing to enroll in Head Start/Early Head Start? (Circle): Yes / No |

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|Are you currently receiving SSI or have been in the past year? (Circle): Yes / No |

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|I declare under penalty of perjury that the information provided is true and correct to the best of my knowledge. |

|I will notify the agency immediately if there is any change in my income, family size, residence, employment, or reason for needing child development services. |

|I understand that the information about my eligibility may be reviewed by representatives of the State of South Dakota, The Federal Government, independent auditors, |

|or others as necessary for the administration of the program. |

|I understand that I will receive a notice of approval or disapproval of my eligibility application. |

|I understand that this certification is not complete until all documentation is submitted and this form has been reviewed, signed, dated by an agency representative |

|and signed and dated by me. |

|I understand there is additional paperwork for me to fill out if my child is approved for Head Start/Early Head Start. |

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|___________________________________________________ ______ /______ /______ |

|Parent/Guardian Signature Date |

HEAD START FAMILY INCOME GUIDELINES FOR 2013

Children are eligible to participate in Head Start if they are from families with incomes below the

Federal poverty level or if their families are eligible for public assistance. The 2013 Family Income

Guidelines must be used to determine eligibility for Head Start for families who are eligible because

they have low incomes.

2013 - 2014 Income Guidelines

|Size of Family Unit |Total Annual Income cannot exceed.. |

|1 |$11,490 |

|2 |15,510 |

|3 |19,530 |

|4 |23,550 |

|5 |27,570 |

|6 |31,590 |

|7 |35,610 |

|8 |39,630 |

For family units with more than 8 members, add $4,020 for each addition member

Source: promis2.

Staff Use Only

Applicant’s Name______________________________________

ELIGIBILITY WORKSHEET

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|Age Documentation: DOB: ______ /______ /______ |

|Check One or More |

|Birth Certificate |

|Baptismal Record |

|Other: _________________________________ |

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|Income Documentation: |

|Check One or More |

|Pay Stubs (latest) or written statements from employers |

|Letter of Notice of Action from DHS, AFDC, TANF Case #: _____________________________ Date: ______ /______ /______ |

|Supplemental Social Security Income documentation |

|Unemployment Compensation |

|Income Tax Form 1040A or 1040, for year: ______________________________________ |

|Other – Specify: _____________________________ |

|Documentation of no income: ____________________________________________________________________ |

|Foster care reimbursement: _______________________________________________________________________ |

|Comments___________________________________________________________________________________________________________________ |

|Income (List by family member) |

|Family Member Pay Stub Total (Gross) Average Total Multiply (X) by |

|Annual Family Income |

|A. |

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|AGE ELIGIBILITY |

|Applicant meets Age Eligibility for EARLY HEAD START |

|Applicant meets Age Eligibility for HEAD START |

|Applicant is NOT Age Eligible to participant in EARLY HEAD START OR HEAD START |

|INCOME ELIGIBILITY |

|Applicant DOES meet the Head Start Income Guidelines, and is considered INCOME ELIGIBLE |

|Applicant does NOT meet the Head Start Income Guidelines and is considered OVER INCOME. |

SELECTION CRITERIA

|The following is a list of points awarded to families based on priority factor. A family that is receiving public assistance (TANF or SSI) |

|or a child in foster care is eligible even if the family exceeds the income guidelines. A Total of 95 points are available. |

|Federal Eligibility Requirements: Points |OLC Program Priorities: Points |

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|1. Income |1. Other Factors (circle all that apply) |

|HS Family Income Guidelines 30 |Single parent family 5 |

| |TANF 30 |

|2. Disability |Multi-families in one dwelling 5 |

| |Homeless 30 |

|Diagnosed Disability 10 |Parent disability 5 |

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|3. Child Age: | |

|Prenatal applicant Yes |2. Social Service Referral (circle all that apply) |

|Early Head Eligibility birth to 3 yrs of age 15 |Foster Parent Care 5 |

|Head Start Eligibility 3 to 5 yrs of age 15 |Grand Parent Care 5 |

| |Parent/Guardian Treatment 5 |

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| |3. Returning Child 10 |

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| |4. Native American 5 |

| Selection Criteria Total Points: |

I have examined the above documentation and certify the eligibility of the family according to sections 645(a)(1)(A) and 645(c) of the Head Start Act, as amended by the Improving Head Start for School Readiness Act of 2007. Also, I understand the consequences of violating eligibility determination requirements. (Copies of the documents are attached.)

___________________________________ ______ /______ /______ __________________________________ ______ /______ /______

Staff Name/Title Date Supervisor Name/ Title Date

Oglala Lakota College

Head Start/Early Head Start Program

Child Health History

Date form completed: ______ /______ /______ Original Modified Head Start Early Head Start

Name of Child: _______________________________________ Parent/Guardian name: _______________________________________

|CHILD MEDICAL INSURANCE INFORMATION |

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|Combined SCHIP/Medicaid Program Indian Health Services No Coverage Private Primary Insurance (Circle): Yes / No |

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|Policy Number (Please Attach Copy of Card): _____________________________________ Insurance Effective Date: _____ /_____ /_____ |

|CHILD MEDICAL PROVIDER INFORMATION |

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|Dentist Provider: _________________________________________________ Indian Health Services |

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|Street: _______________________Town/City: ________________________________State: _________________Zip: ____________ |

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|Telephone: ________________________Fax: ___________________________ |

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|Doctor Provider: _________________________________________________ Indian Health Services |

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|Street: _______________________Town/City: ________________________________State: _________________Zip: ____________ |

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|Telephone: ________________________Fax: ___________________________ |

|GENERAL HEALTH HISTORY |

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|Does your child have any of the following health conditions: |

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|Anemia or Sickle Cell Anemia Chronic or Periodic Asthma Diabetes Seizure Disorders High Lead Levels |

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|Allergies To: |

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|Bee Stings Insect Bites Poison Oak Food (Please fill out attached form) Medication (Please fill out attached form) |

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|Sinus / Problems: |

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|Eczema, hives, skin problems Hay fever Seasonal allergies Sinus trouble Frequent running nose Asthma |

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|Bowel / Urinary Track Problems: |

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|Wears diapers Bed wetting Daytime wetting Frequent urination Painful urination |

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|Frequent diarrhea Frequent constipation |

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|Vision Problems: |

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|Born more than 6 weeks premature Squints frequently Rubs eyes frequently |

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|Hearing Problems: |

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|Difficulty hearing Frequent earaches Tubes in ears |

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|Digestion Problems: |

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|Frequent indigestion Frequent stomachaches Frequent vomiting |

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|Other conditions: |

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|Bites when frustrated/angry Fainting spells Hyperactivity Thumb sucking Frequent fevers Lack of energy/tired |

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|Trouble sleeping Frequent sore throat Bone, joint or muscle injury Other If Yes, what type? ____________________________ |

|MEDICATION INFORMATION |

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|Is your child currently taking any medication? Yes No If yes, what type? _________________________________ |

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|Will this medication need to be given during school class time? Yes No |

|***A Medication Authorization form will be filled out for any medication given at all OLC-Head Start/Early Head Start Program. No Medication will be given |

|without a doctor’s order, including over the counter medications |

PLEASE COMPLETE THIS INFORMATION ON THE NEXT PAGE!

Source: promis2.

|NUTRITIONAL INFORMATION |

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|Child’s Current Dietary Habits Date form completed: ______ /______ |

|/______ |

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|Favorite Foods: __________________________________________ Least Favorite Foods: __________________________________________ |

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|Food Allergies: __________________________________________ Foods not eaten for medical, religious, or personal reasons? Yes No |

|[pic] |

|Child takes vitamin/mineral supplements? Yes No Vitamin/mineral supplements contain iron? Yes No |

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|Vitamin/mineral supplements contain fluoride? Yes No Vitamin/mineral supplements were prescribed? Yes No |

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|Child’s appetite has changed in past month? Yes No Child is on special diet? Yes No |

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|Child eats or chews things that are not food? Yes No Child takes bottle? Yes No |

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|Child had trouble chewing and/or swallowing? Yes No Child often has diarrhea? Yes No |

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|Concerns about what child eats? Yes No Child often has Constipation? Yes No |

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|Child needs medical treatment for Chronic Condition? Yes No Received medical treatment? Yes No |

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|Child’s Current Food Group Eating Per Week (Check One For Each Food Group) |

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|A.) Milk, Cheese, Yogurt: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

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|B.) Meat, Poultry, Fish, Eggs, Dried Beans/Peas, Peanut Butter: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

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|C.) Rice, Grits, Bread, Cereal, Tortillas: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

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|D.) Greens, Carrots, Broccoli, Squash, Pumpkin, Sweet Potatoes: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

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|E.) Oranges, Grapefruit, Tomatoes, (fruit/juice): 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

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|F.) Other fruits and vegetables: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

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|G.) Oil, Butter, Margarine, Lard: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

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|H.) Cakes, Cookies, Sodas, Fruit Drinks, Candies: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 7+ |

|CHILD EVALUATION/DISABILITIES INFORMATION |

|Has your child ever received early intervention services from |Yes No |If Yes, Please state where: |

|an outside agency? | | |

|Has your child ever received an evaluation because of concerns |Yes No |If Yes, Please explain and state where evaluation was completed at: |

|of overall health and developmental delay? | | |

|Is your child currently receiving services to address any |Yes No |If Yes, Please state where: |

|special needs or disabilities that he/she might have? | | |

|Is your child currently on an IEP (individual Education Plan) |Yes No |If Yes, Please attach a copy of the IEP or IFSP: |

|or IFSP (Individual Family Service Plan) | | |

|CUSTODY/PROTECTION ORDER INFORMATION |

|Please Note: If you answer YES to these questions below, we will need a copy of the court order for our file. |

|Who has legal custody of this child? |Are there special visitation orders we should be aware of? |

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|Is there currently a protection or restraining order in effect that concerns this child? (Circle): Yes / No |

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|SUBMIT COPY OF THE ORDER TO THE OLC – HEAD START/EARLY HEAD START PROGRAM OFFICE |

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|Under the South Dakota Privacy Act (Section 504 of the Rehabilitation Act, 29 U.S.C. § 794d), you have the right to know that the information you provide on |

|your application for agency programming is classified and cannot be disclosed without your permission. The information you provide on this application is used|

|to determine eligibility, and to provide program assistance, if applicable. |

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|I give permission to Oglala Lakota College Head Start/Early Head Start Program, to verify my income and any materials related to my eligibility and supply a |

|copy of this application to other Human Service programs that require this information. To the best of my knowledge the information I have given is accurate |

|and true. |

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|Parent/Guardian Signature: ___________________________________________________ Date: ______ /______ /______ |

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THANK YOU FOR TAKING TIME TO COMPLETE THIS INFORMATION!

Source: promis2.

Oglala Lakota College

Head Start/Early Head Start Program

Allergy Form

Name of Child: ________________________________________________

[pic]

Allergies Only

1. What is your child allergic to? ____________________________________________

a. What symptoms does your child have when they have allergies? _____________

__________________________________________________________________

❖ Please provide a doctor’s statement stating what they are specifically allergic to.

2. Has your child ever taken medications for allergies? Yes No

❖ Please provide a doctor’s statement stating information about the prescription medication

If YES:

a. What medications? ___________________________________________________

b. How often? _________________________________________________________

3. Does your child require an Epi-pen? Yes No

❖ Please provide a doctor’s statement

4. Is your child allergic or sensitive to things that causes skin rashes? Yes No

If YES:

a. What causes rashes? __________________________________________________

Asthma Only

1. Has a physician ever told you your child has asthma? Yes No

2. Has your child ever had an attack of wheezing that made them short of breath? Yes No

If YES:

a. Are they currently taking medications for these attacks? Yes No

b. How often do these attacks occur and for how long? _________________________

3. Does your child require a breathing aid for their asthma? Yes No

Parent/Guardian Signature: ___________________________________________________

Date: ______ /______ /______

Oglala Lakota College

Head Start/Early Head Start Program

Attendance Policy for Children

School Year: 2013-2014

In accordance with the Head Start Performance Standard 1305.8, pg. 246 – When the monthly average daily attendance rate in a center-based program falls below 85 percent, a Head Start/Early Head Start program must analyze the causes of absenteeism. The analysis must include a study of the pattern of absences for each child, including the reasons for absences as well as the number of absences that occur within the current month.

Please help your child to be in school every day. If your child is absent or will be absent, please contact your child’s classroom teacher and/or Family Helper.

Procedures for Child Absenteeism:

❖ First Attempt to Contact: The FAMILY SERVICE WORKER (FSW) will make an attempt to contact the parent/guardian on the 1st day of absenteeism, by phone or in person (when phone is not an option), and will document it on a FAMILY CONTACT FORM. On the same family contact form the FSW will document the follow up with the Teacher or Aide (whomever is available) on the outcome of the contact. When the FSW is not available, the first attempt to contact becomes the TEACHER OR TEACHER AIDE’S responsibility. A completed copy will be submitted to the appropriate staff.

❖ Second Attempt to Contact: The TEACHER OR TEACHER AIDE will make an attempt to contact the parent/guardian on the 2nd day of absenteeism, by phone or in person (when phone is not an option), and will document it on a FAMILY CONTACT FORM. On the same family contact form the TEACHER OR TEACHER AIDE will document the follow up with the FSW. A completed copy will be submitted to the FSW.

❖ Third Attempt to Contact: The TEACHER OR TEACHER AIDE will make an attempt to contact the parent/guardian on the 3rd day of absenteeism, by phone or in person (when phone is not an option), and will document it on an INCIDENT REFERRAL FORM. The completed original form will be submitted to the FSW. The FSW will fill out an ATTENDANCE LETTER, and mailed or delivered to the parent/guardian noting both contact attempts.

❖ Fourth Attempt to Contact: The FAMILY SERVICE WORKER will make an attempt to contact the parent/guardian on the 4th day of absenteeism to encourage the family to keep the child enrolled. The outcome will be documented on the same original INCIDENT REFERRAL FORM submitted by the Teacher or Teacher Aide. The completed original will be given to the Teacher or Teacher Aide, and a copy will be kept for FSW files. The INCIDENT REFERRAL FORM and the two FAMILY CONTACT NOTES will be faxed to ADMIN for review.

Teachers: When the Family Service Worker is unavailable, you will follow up with or refer to appropriate ADMIN staff.

Please sign below to indicate you have read and understand the Attendance Policy.

_______________________________________________________ ______ /______ /______

Parent/Guardian Signature Date

(Give To Parent)

Oglala Lakota College

Head Start/Early Head Start Program

Attendance Policy for Children

School Year: 2013-2014

In accordance with the Head Start Performance Standard 1305.8, pg. 246 – When the monthly average daily attendance rate in a center-based program falls below 85 percent, a Head Start/Early Head Start program must analyze the causes of absenteeism. The analysis must include a study of the pattern of absences for each child, including the reasons for absences as well as the number of absences that occur within the current month.

Please help your child to be in school every day. If your child is absent or will be absent, please contact your child’s classroom teacher and/or Family Helper.

Procedures for Child Absenteeism:

❖ First Attempt to Contact: The FAMILY SERVICE WORKER (FSW) will make an attempt to contact the parent/guardian on the 1st day of absenteeism, by phone or in person (when phone is not an option), and will document it on a FAMILY CONTACT FORM. On the same family contact form the FSW will document the follow up with the Teacher or Aide (whomever is available) on the outcome of the contact. When the FSW is not available, the first attempt to contact becomes the TEACHER OR TEACHER AIDE’S responsibility. A completed copy will be submitted to the appropriate staff.

❖ Second Attempt to Contact: The TEACHER OR TEACHER AIDE will make an attempt to contact the parent/guardian on the 2nd day of absenteeism, by phone or in person (when phone is not an option), and will document it on a FAMILY CONTACT FORM. On the same family contact form the TEACHER OR TEACHER AIDE will document the follow up with the FSW. A completed copy will be submitted to the FSW.

❖ Third Attempt to Contact: The TEACHER OR TEACHER AIDE will make an attempt to contact the parent/guardian on the 3rd day of absenteeism, by phone or in person (when phone is not an option), and will document it on an INCIDENT REFERRAL FORM. The completed original form will be submitted to the FSW. The FSW will fill out an ATTENDANCE LETTER, and mailed or delivered to the parent/guardian noting both contact attempts.

❖ Fourth Attempt to Contact: The FAMILY SERVICE WORKER will make an attempt to contact the parent/guardian on the 4th day of absenteeism to encourage the family to keep the child enrolled. The outcome will be documented on the same original INCIDENT REFERRAL FORM submitted by the Teacher or Teacher Aide. The completed original will be given to the Teacher or Teacher Aide, and a copy will be kept for FSW files. The INCIDENT REFERRAL FORM and the two FAMILY CONTACT NOTES will be faxed to ADMIN for review.

Teachers: When the Family Service Worker is unavailable, you will follow up with or refer to appropriate ADMIN staff.

Oglala Lakota College

Head Start/Early Head Start Program

Parental Permission to Participate

I __________________________________________________ give permission for

(Printed Name of Parent/Guardian)

my child ____________________________________________ DOB: ______ /______ /______

(Printed Name of Child)

enrolled at the _______________________________________________ EHS/HS Center in the

___________________________________classroom to participate in the following:

|Yes No |I authorize my child to accompany his/her class on field trips or other socialization activities. All children will be supervised by the |

| |staff, parents/guardians. |

|Yes No |I authorize OLC EHS/HS to transport my child for all program purposes. Staff will ensure that children are safely secured in their seats and |

| |assist them in buckling seat belts. |

|Yes No |I authorize the OLC EHS/HS to release my telephone number and/or address to other parents for the purpose of communicating to me about |

| |specific program activities. |

|Yes No |I authorize OLC EHS/HS to take and use pictures of my child or my family to be used by the program for newspaper articles, or for promotional |

| |use. |

|Yes No |I give permission for OLC EHS/HS Staff to use lotion, sunscreen, bath soap, and diaper ointment on my child when needed. |

| |(If answer is no, items will only be used if supplied by parent.) |

|Yes No |I give permission for OLC EHS/HS or affiliated agencies to conduct a developmental screening on my child. I understand that this screening is|

| |a tool used to determine my child’s current developmental levels. |

|Yes No |I authorize OLC EHS/HS personnel/professional and/or affiliated professionals to observe my child informally in the classroom in relation to |

| |developmental or behavioral concerns. |

|Yes No |In the event of an emergency, I give permission to OLC EHS/HS Staff to provide CPR/First Aid treatment and/or transportation to a health care |

| |facility. This may include examinations and any tests, which in the opinion of the physician or dentist is deemed necessary or advisable. |

| |(This does not include the right to perform surgical operations without my further consent unless the OLC EHS/HS has exhausted all means of |

| |contacting.) |

|Yes No |I give permission for my child to participate in all OLC EHS/HS programs and activities including but not limited to: xylitol gum, diabetes, |

| |dental, physical, hearing and vision screenings. |

Parent/Guardian Signature: ______________________________________________

Relationship to OLC EHS/HS Students: ______________________________________

Date Signed: ______ /______ /______

**This consent is valid for one year from the Date Signed, unless otherwise noted by the parent/guardian. **

Oglala Lakota College

Head Start/Early Head Start Program

Authorization for Request of Confidential Information

I _________________________________________ hereby give permission

(Printed Name of Parent/Guardian)

for the OLC Early Head Start/Head Start Program to request the following information:[pic]

• Developmental Screenings (including speech and language)

• Medical Records (including immunizations, vision, hearing, dental, physicals and lab results)

• Educational records (including Individual Family Service Plans or Individual Education Plans)

• Professional Diagnosis (including behavioral/psychological)

• Other: ____________________________________________________________________

From one or all of the following agencies:

• Shannon County Birth to Three Connections (Batesland, South Dakota)

• Oglala Sioux Tribe Early Intervention (Pine Ridge, South Dakota)

• Local Education Agencies (Including: Shannon School District, Loneman School,

Red Cloud School, Pine Ridge School, Wounded Knee School, Porcupine School,

Our Lady of Lourdes School, Little Wound School, American Horse School,

Bennett County School District, Crazy Horse School, Jackson County School District,

and Custer School District)

• Other: _______________________________________________________________________

Regarding My Child: ______________________________________________

DOB: ______ /______ /______ Gender (Circle): Male / Female

Attending OLC EHS/HS Center: ________________________________

Classroom: _________________________________

Parent/Guardian Signature: _______________________________________________

Relationship to OLC EHS/HS Student: ________________________________________

Date Signed: ______ /______ /______

**This request consent is valid for one year from the Date Signed, unless otherwise noted by the parent/guardian. **

Oglala Lakota College

Head Start/Early Head Start Program

Authorization for Release of Confidential Information

I _________________________________________ hereby give permission

(Printed Name of Parent/Guardian)

for the OLC Early Head Start/Head Start Program to release the following information:

[pic]

• Developmental Screenings (Including speech and language)

• Medical Records (Including immunizations, vision, hearing, dental and lab results)

• Educational records (Including Individual Family Service Plans or Individual Education Plans)

• Professional Diagnosis (Including behavioral/psychological)

• Other _____________________________________________________________________

To one or all of the following agencies:

• Shannon County Birth to Three Connections (Batesland, South Dakota)

• Oglala Sioux Tribe Early Intervention (Pine Ridge, South Dakota)

• Local Education Agencies (Including Shannon School District, Loneman School,

Red Cloud School, Pine Ridge School, Wounded Knee School, Porcupine School,

Our Lady of Lourdes School, Little Wound School, American Horse School,

Bennett County School District, Crazy Horse School, Jackson County School District,

and Custer School District)

• Other ________________________________________________________________________

Regarding My Child: ______________________________________________

DOB: ______ /______ /______ Gender (Circle): Male / Female

Attending OLC EHS/HS Center: ________________________________

Classroom: _________________________________

Parent/Guardian Signature: __________________________________________

Relationship to OLC EHS/HS Student: ___________________________________

Date Signed: ______ /______ /______

**This release consent is valid for one year from the Date Signed, unless otherwise noted by the parent/guardian. **

(Give To Parent)

SD Department of Health – WIC Program

WIC is a supplemental nutrition program for eligible women, infants and children, funded by the U.S. Department of Agriculture and administered by the South Dakota Department of Health. WIC’s goal is to promote and maintain the health and well being of nutritionally at-risk women, infants and young children. WIC is available for all counties in the state and is an equal opportunity program. WIC provides nutrition education and counseling, breast-feeding support (information & breast pumps), healthy foods, referral to doctors, nurses, health and social service agencies, and immunizations, if needed.

WIC serves eligible women and teens (who are pregnant or have been pregnant in the last six months, are breast-feeding up to 12 months after delivery, or have had a baby in the last six months), infants and children up to age five. To be eligible, an applicant must meet income guidelines, residency requirements and have a nutrition or health risk.

For the number of the local WIC office, call toll free 1-800-738-2301 (in South Dakota only). At the WIC appointment you will be asked to provide family income information, identity and residency information, information about foods eaten, answer questions about past and current health, have height and weight taken, have a finger blood test taken, visit with health professional about nutrition education and health needs, and if eligible, get food “checks” to buy foods at authorized grocery store. Benefits will be received monthly. Come to the local WIC office to receive nutrition education and food “checks.” WIC food can be purchased at any grocery store that has signed an agreement with the WIC Program to comply with program policies. These stores are referred to as “authorized” WIC retailers. A list of “authorized” stores in your area is provided when you are determined eligible for WIC.

(Give To Parent)

Building For the Future

This Head Start facility participates in the Child and Adult Care Food Program (CACFP), a Federal program that provides healthy meals and snacks to children.

Each day more than 2.6 million children participate in CACFP Head Start centers across the country. Centers are reimbursed for serving nutritious meals which meet USDA requirements. The program plays a vital role in improving the quality of Head Start and making affordable for low-income families.

Meals CACFP centers follow meal requirements established by USDA.

|Breakfast |Lunch |Snacks |

| | |(Two of the four groups :) |

|Milk |Milk |Milk |

|Fruit or Vegetable |Meat or meat alternate |Meat or meat alternate |

|Grains or Bread |Grains or bread |Grains or bread |

| |Two different servings of fruits |Fruit or vegetable |

| |or vegetables | |

Participating

Facilities Many different homes and Head Start centers operate CACFP and share the common goal of bringing nutritious meals and snacks to participants. Participating facilities include:

• Child Care Centers: Licensed or approved public or private nonprofit child care centers, Head Start programs, and some for-profit centers.

• Family Day Care Homes: Licensed or approved private homes.

• After school Care Programs: Centers in low-income areas provide free snacks to school-age children and youth.

• Homeless Shelters: Emergency shelters provide food services to homeless children.

Eligibility State agencies reimburse facilities that offer non-residential day care to the following children:

• Children age 12 and under.

• Migrant children age 15 and younger.

• Youth through age 18 in after school care programs in needy areas.

Contact Information If you have questions about CACFP, please contact one of the following:

Sponsoring Organization/Center: State Agency:

Child and Nutrition Services

Department of Education and Cultural Affairs

800 Governors Drive

Or Pierre, SD 57501

Phone: (605)773-3413

Oglala Lakota College

Head Start/Early Head Start Program

Administration for Children

Fluoride Varnish Consent Form

PARENT or GUARDIAN: Please complete and sign the Parental Permission for fluoride varnish (Paint to Prevent) Program treatment below.

Parental Permission

I give my son or daughter, _____________________________________, permission to have fluoride varnish placed on his or her teeth at least 4 times in a year by a trained staff or provider with prescription or standing orders. I have read the participation flyers and understand the procedure. The staff may refer to the medical history and contact list if any problems arise. I understand the Paint to Prevent program is a preventive program and the product is safe and effective.

Preventive Dental Treatment Authorization

I hereby authorize trained staff or providers to apply the varnish product to prevent dental caries and arrest incipient decay. I understand that the consent and authorization herein granted do not include major procedures. I also read the flyers and information on the product and consider it safe. This is considered a high risk area for oral diseases and participation in this preventive program will help reduce the rampant caries rate in the area. Please list any physical conditions that the school should be aware of (allergies, recurring illnesses, disabilities, chronic illnesses, etc.): ______________________________________________________________________________________

In the event that an illness or injury would require more extensive evaluation, I understand that every reasonable attempt will be made to contact me.

I have read the general information and hereby agree to all policies of the Head Start/ Early Head Start center concerning medical/dental and preventive treatment including the above authorization for the dental preventive program.

I DO ___________ give my consent to have fluoride varnish applied.

I DO NOT _____________ give my consent to have fluoride varnish applied.

Parent or guardian’s name (please print): ___________________________________________________

Parent or guardian’s signature: ___________________________________________ Date: __________

Dentist Name and phone number: ____________________________________________________________

Oglala Lakota College

Head Start/Early Head Start Program

Lead/ Hemoglobin Screening Consent Form

PARENT or GUARDIAN: Please complete and sign the Parental Permission for lead/ hemoglobin screening.

Parental Permission

I give my son or daughter, _____________________________________, permission to participate with a lead/ hemoglobin screening. The Office of Head Start (OHS) issued an Information Memorandum regarding the "Childhood Lead Poisoning Prevention Collaboration" (ACYF-IM-HS-00-13).

“Lead Toxicity Screening - All children are considered at risk and must be screened for lead poisoning. Centers for Medicare and Medicaid Services (CMS) requires that all children receive a screening blood lead test at 12 months and 24 months of age. Children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. A blood lead test must be used when screening children. A blood lead test result equal to or greater than 10 ug/dl obtained by capillary specimen (finger stick) must be confirmed using a venous blood sample.”

How is a lead/hemoglobin screening done?

The Health Coordinator will be going around to the centers and children that have consent from their parent will receive a lead/hemoglobin screening. The screening will consist of filling out the child’s information sheet; perform a simple finger stick by placing three drops of blood on the filter paper test card. The Health coordinator will mail the information sheet and test card to the Medtox Company where the lab will fax the results to the Health Coordinator and copy will go to the parent / guardian.

[pic]

I DO _________ give my consent for my child to receive a lead/ hemoglobin screening.

I DO NOT ________ give my consent to participate.

I understand that my signature will be valid for up to three (3) years upon signature and date on this consent form unless written notice has been received by the program.

Student’s Name: _______________________________________________________________

Center: ______________________________________________________________________

Classroom & Teacher: ___________________________________________________________

Parent or guardian’s signature: ___________________________________________ Date: __________

Consent for Cavity Prevention with Tooth Sealants

The goal of the Head Start Center and the Dental Clinic is to have our children be cavity free when they enter kindergarten. In addition to the present activities of; 1) brushing the child’s teeth at school and home 2) fluoride at school or at your dental office. We would like to begin one more cavity prevention activity that is proven to reduce the number of cavities in teeth.

• Dental sealants are placed on permanent teeth routinely; we would like to begin placing sealants on the cavity free baby teeth molars for your child.

• With preventive sealants there will be no shots or drilling.

• The soft white paste is placed on the teeth and dries in 60 seconds.

• The sealant may taste bitter and may feel different to the teeth before it dries. After a glass of water and a snack the child should not experience any discomfort with the sealed molars.

• Pine Ridge Dental Team is able to place the sealants on cavity free molars at the Head Start center or in the Dental Clinic.

• Sealants are not perfect protection against cavities. It takes all three to be cavity free.

o Brush teeth at school and home

o Limit the amount of sugary snacks at school and home

o Have fluoride and sealants applied on as many teeth as possible.

I understand that my signature is consent for sealants and will be valid for up to

three (3) years upon signing and dating this form.

Student’s Name: _______________________________________________________________

Center: ______________________________________________________________________

Classroom & Teacher: ___________________________________________________________

Signature of Parent or Guardian & Date

CACFP Enrollment Form

Please complete and/or update and sign this form and return it to the designated HS/EHS Center no later than five (5) working days.

Our agency participates in the Child and Adult Care Food Program (CACFP) and receives Federal reimbursement for the meals served to your child(ren). The Federal regulations for the CACFP require us to collect and update this information on an annual basis for all of our enrolled children. This information is used to confirm your child(ren)’s current enrollment in the center and thus in the CACFP. All information is confidential and will be shared with appropriate personnel and state/federal staff as needed. Note: The indication of racial and ethnic background is optional and will not affect eligibility for the Program. This information is used for reporting purposes only. By providing this information you will assist us in assuring that this program is administered in a nondiscriminatory manner. If racial / ethnic background is not reported, a visual identification of the child’s race and ethnicity will be made.

* Race: Hispanic or Latino Ethnicity: American Indian or Alaskan Native / Asian / Black or African American / Native Hawaiian or other Pacific Islander / White

** B = Breakfast AM = AM Snack L = Lunch PM = PM Snack Su = Supper Ev = Evening Snack

| |(Select one or | |(Please circle all that apply) |

| |more) | | |

|Full Name(s) of Enrolled |* Race/ |Date of Birth |Normal Hours In Care |Normal Days of Care |Meals Normally Eaten While at the |

|Child(ren) |Ethnicity | | | |Facility ** |

| | |

| |CHILD'S NAME: ____________________________________________________ | | BIRTHDATE_____________________ |

| | | | |

|PART I TO |Medical Care Provider: _______________________________________________ | | |

|BE | | | |

|COMPLETED | | | |

|BY HEALTH | | | |

|CARE | | | |

|PROVIDER | | | |

|BEFORE/ | | | |

|AFTER | | | |

|PHYSICAL | | | |

|EXAMINATIO| | | |

|N/ASSESSME| | | |

|NT | | | |

| | |

| |1. Please complete the following screening items which are recommended by the American Academy of Pediatrics for children 0-6 years. |

| | |

| | |

| |TEST |DATE |RESULTS | |YES |NO |

| | |  | |E. Medical History Completed |  |  |

| |A. HEIGHT |  | | Family History Completed |  |  |

| | | | | | | |

| | | | | | | |

| |B. Weight | | | Neonatal History Completed |  |  |

| |C. HEMOGLOBIN |  |  | Physical, Mental Health and |  |  |

| | | | |Developmental History Completed | | |

| | | | | |

| |D. LEAD REQUIRED: |  |  | | | |

| |12 months & 24 months, Children | | | | | |

| |between ages 36 to 72 months must have| | | | | |

| |a screening blood test if a lead | | | | | |

| |toxicity screening has not been | | | | | |

| |previously conducted. | | | | | |

| | | | | | | |

| | | | |F. Anticipatory Guidance Completed | | |

| | | | | Injury Prevention Guidance | | |

| | | | | Violence Prevention Guidance | | |

| | | | | Sleep Positioning Counseling | | |

| | | | | Nutrition Counseling | | |

| | | | | | | |

| |12 Months |  |  | |  |  |

| |24 Months |  |  | |  | |

| |3-6 Years of Age |  |  | | |  |

| | | | | | | |

|PART II TO|2. PHYSICAL EXAMINATION/ASSESSTMENT |

|BE | |

|COMPLETED | |

|BY HEALTH | |

|CARE | |

|PROVIDER | |

|AFTER | |

|PHYSICAL | |

|EXAMINATIO| |

|N/ASSESSME| |

|NT | |

| |  |NORMAL FOR |ABNORMAL |NOT EVALUATED |COMMENTS |

| | |AGE | | | |

| | | | | | |

| |a. GENERAL APPEARANCE |  |  |  |  |

| |b. POSTURE GAIT |  |  |  | |

| |c. SPEECH |  |  |  | |

| |d. HEAD |  |  |  | |

| |e. SKIN |  |  |  | |

| |f. EYES: (1) External Aspects |  |  |  | |

| | (2) Optic Fundiscopic |  |  |  | |

| | (3) Cover Test |  |  |  | |

| |g. EARS: (1) External & Canals |  |  |  | |

| | (2) Tympanic Membranes |  |  |  | |

| |h. NOSE, MOUTH, PHARYNX |  |  |  | |

| |i. TEETH |  |  |  | |

| |j. HEART |  |  |  | |

| |k. LUNGS |  |  |  | |

| |l. ABDOMEN |  |  |  | |

| |m. GENITALIA |  |  |  | |

| |n. BONES, JOINTS, MUSCLES |  |  |  | |

| |o. NEUROLOGICAL/SOCIAL |  |  |  | |

| | (1) Gross Motor |  |  |  | |

| | (2) Fine Motor |  |  |  | |

| | (3) Communication Skills |  |  |  | |

| | (4) Cognitive |  |  |  | |

| | (5) Self-Help Skills |  |  |  | |

| | (6) Social Skills |  |  |  | |

| |p. GLANDS (Lymphatic/Thyroid) |  |  |  | |

| |q. MUSCULAR COORDINATION |  |  |  | |

| |s. GENERAL STATEMENT ON CHILD'S PHYSICAL STATUS: |

| | |

| |Signature _____________________________ Date: _______________ |

| |4. FINDINGS, TREATMENTS, AND RECOMMENDATIONS |

| |ABNORMAL FINDINGS/DIAGNOSIS |TREATMENT PLAN |RECOMMENDED FOLLOW-UP OR RESULTS |DATE |

| | | |(initial when complete) | |

| |  |  |  |  |

|CHILD HEALTH RECORD |FORM 5, DENTAL HEALTH |

| | | |

|CHILD'S NAME: __________________________________________________________ | |BIRTHDATE: _________________ |

| | | |

|Dental Provider: __________________________________________________________ | | |

| | |

| |

|Type: ο Screening ο Examination ο Treatment |# of times per day child flosses: ____________ |

|1. Teeth Condition | | |

| |Brushing Frequency |Oral Condition |

|[pic] | | |

|Key |ο N/A |ο Normal |

|Missing (X) Crown (#) | | |

|Decayed (=) Sealants (S) |ο Never |ο Gingivitis |

|Filled (+) | | |

| |ο Daily |ο Plaque |

| | | |

| |ο Weekly |ο Dental abscess |

| | | |

| |ο Occasionally | |

| |Referral for: ____________________ |Follow Up for: ________________________ |

| | | |

| |Date |Date |

| | | |

| |MM DD YYYY |MM DD YYYY |

| | | |

| |Clinic Name |Clinic Name |

| | | |

| | | |

| |

|Comments: ______________________________________________________________________________________________ |

| |

|________________________________________________________________________________________________________ |

| |

|________________________________________________________________________________________________________ |

|2. DENTAL NEEDS (Check one or more) |

| | |ο B. CLEANING |ο C. FLUORIDE VARNISH |

|ο A. TREATMENT (extraction, pulp| | | |

|therapy, restoration) | | | |

| | |ο E. DENTAL SEALANTS |

|ο D. ORAL HYGIENE INSTRUCTION | | |

| | | |

| | |ο G. OTHER_______________________ | |

|ο F. NO NEEDS | | | |

| | |

|3. DENTAL ENCOUNTER: ο Received Dental Encounter Treatment DATE: ______________________________________ |

| |

|Services Received: |

|ο Fluoride Varnish ο Cleaning ο Oral Hygiene Instructions ο Dental Sealants ο Other: ___________________ |

|4. TREATMENT: ο Received Treatment DATE: ______________________________________ |

| |

|Services Received: |

|ο Pulp Therapy ο Extraction ο Restoration ο Other: __________________ |

|5. CHILD ORAL HEALTH SUMMARY |

| All planned treatment (_____ is, _____ is not) complete. |

| If not, check the following items |

|ο a. Routine recall visits |  |ο c. Dietary problem(s) | ο e. Harmful oral habits |

|ο b. Special home | |ο d. Developmental problems | ο f. Needs fluoride supplement |

| emphasis oral hygiene | | |

| |

| |

|Signature ______________________________________________ Date _________________ |

Circle of Smiles

Registration

Please PRINT to fill out this form completely. If you have questions, please ask a Circle of Smiles staff member. Thank You!

Patient’s Legal Name

(Last Name) (First Name)

Sex (circle) M F Birth Date (mm/dd/yyyy) Age

Patient’s Social Security Number Medicaid ID

Parent/Guardian Name ___________________________________ Home (_____)

Work (_____) Cell (_____)

Home Address_____________________________________________________________________________

Street/ P.O. Box City State Zip

School Attending Grade Level

Emergency Contact: Person to contact in case of an emergency

Name __________________________________ Relation to patient _____________ Phone (___)

|Medical History |Yes |No |Please explain “yes” answers |

|Does the patient have a current medical condition? | | | |

|Is the patient taking any medications? | | | |

|Has the patient ever been hospitalized or had surgery? | | | |

|Does the patient have any allergies? | | | |

|Has patient had a history of OR had difficulty with the following? Check any the apply (√) |

| Latex Allergy | Anemia | Diabetes | Mono | AIDS / HIV |

| Asthma | Fainting | Mumps | Epilepsy / Seizures | Rheumatic Fever |

| Birth Defects | Heart Problems | Cancer | Hepatitis | Tuberculosis |

| Kidney Disease | Tobacco Use | Could Patient Be Pregnant | Other |

|Please explain “Other” and “yes” answers: |

|Dental History |Dentist Name / Location |

|Date of last dental visit: | |

|Insurance: Please circle any that apply. Must provide a copy of your Medicaid or dental insurance card. |

| |

|Medicaid/SCHIP # ___________________ Private dental insurance #___________________ IHS None |

Dental Ins. Name: __________________________________ policy #_____________ group #_____________

Employer Name: _______________________________________________________

** Parent/ Legal Guardian signature ________________________________________ Date_____________

Circle of Smiles

Treatment Consent and Agreement Form

I authorize and request the performance of dental services for my child __________________________.

(child’s name)

This treatment may consist of topical fluoride application, sealants, and other preventive measures as recommended by the Circle of Smiles Program staff. I understand that the Circle of Smiles staff will use treatment and behavior management that is reasonable and necessary.

I, _________________________________, as a legally responsible guardian of __________________________

(print parent/legal guardian name) (print child’s name)

give my consent for the use of fluoride, sealants and dental cleanings as deemed appropriate by the Circle of Smiles staff in performing the recommended treatment(s) with the exception of________________________________ (write NONE in this blank if you give permission for all dental procedures suggested).

I consent that _________________________, who is under the age of eighteen years, may participate in the dental

(print child’s name)

services provided by the Circle of Smiles program, and consent that their dentists and other agents and employees may furnish to Circle of Smiles employees and/or authorized organizations all information concerning the child’s case history, dental examinations, written reports (and any accompanying photographs) with respect to the dental examination and the exam results. An authorized organization is one approved by the Circle of Smiles Program and the Delta Dental Philanthropic Fund.

I consent and authorize the Circle of Smiles Program to file and collect South Dakota Medicaid/SCHIP reimbursement for dental services performed. I also certify that I understand and agree to the conditions described above.

*Are you currently the legal guardian for this child? YES NO

*Can you sign for medical treatment? YES NO

*I have been informed of the risks involved with dental treatment YES NO

Parent/guardian name _______________________________________________________________________

(please print)

Relationship to child_________________________________________________________________________________

Signature_____________________________________________________Date_________________________________

HIPPA

Acknowledgement of Receipt of Notice of Privacy Practices

Patient name_______________________________________________________________________

I, ________________________________________________________________________________

(parent/legal guardian name)

have received a copy of the Circle of Smiles Program’s Notice of Privacy Practices.

**Parent/legal guardian signature _________________________________________Date____________

Note: This authorization is valid for six years from date of signature unless revoked in writing prior to that date. This authorization may be revoked by writing to: Circle of Smiles Program, 804 N Euclid – Suite 101, Pierre, SD 57501.

Circle of Smiles

Authorization of Release of Protected Health Information

By signing this document, you are allowing the Circle of Smiles staff to give or receive your child’s health care records to other health care providers, SDIIS or child agencies to provide the best care for your child. The records may be sent to another dentist, dental specialist or other health care provider that the Circle of Smiles staff recommends further treat your child. The information may also be shared with an agency that your child is affiliated with (such as school, Head Start, SDIIS, etc.) for record keeping purposes.

Patient’s Name ______________________________________ Social Security Number ______-_____-_______

(please print)

I hereby authorize:

Circle of Smiles Program

804 N Euclid – Suite 101

Pierre, SD 57501

605-224-7345

to receive from or release to the appropriate health care provider or agency, my child’s records to facilitate his or her health care needs and/or treatments.

Name of parent/legal guardian____________________________________________________________

(please print)

**Parent/legal guardian signature_________________________________________Date_______________

If there are providers or agencies that you do NOT want your child’s records released to or received from please list here:

__________________________________________ ___________________________________________

__________________________________________ ___________________________________________

Photo Consent and Release

I consent to the use of pictures, video or audio recordings of myself or my child for program promotion, including print, audio, video and web promotion. I also agree that any writing or other material in connection with the Circle of Smiles may be used in promotional materials.

**Signature of parent/legal guardian ___________________________________________Date____________

-----------------------

What is Head Start/Early Head Start?

What is Oglala Lakota College Head Start Program?

How to apply for Head Start/Early Head Start?

What Happens Next?

Eligibility Application

Oglala Lakota College

Head Start/Early Head Start Program

Date Intake/Application Completed: ___________________

(Office Use Only)

Who is age eligible to participate in the pre-school head start services (3-5 year olds)?

# of Adults in Family? (Check) – [pic] 1 / [pic] 2 / [pic] 3 / [pic] 4 / [pic] 5 / [pic] 5+

# of Adults Contributing to the Income? (Check) – [pic] 1 / [pic] 2 / [pic] 2+

# of Children in Family? (Check) – [pic] 1 / [pic] 2 / [pic] 3 / [pic] 4 / [pic] 5 / [pic] 5+

Office use Only: Enrollment Date: ____ /____ /____ Update Date: ____ /____ /____ Dismissal Date: ____ /____ ____

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