1 ABORIGINAL HEAD START APPLICATION FORMaboriginalheadstart.com/uploads/Application...
Transcript of 1 ABORIGINAL HEAD START APPLICATION FORMaboriginalheadstart.com/uploads/Application...
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CHILD AND FAMILY INFORMATION
Program Site: _________________ Child’s ID Number: ________________
Class: AM PM Start Date: ______________________
New Returning
Intake Date: ______________________
(For office use only)
Child’s Legal Name:
_________________ _____________________ ____________________ (First) (Middle) (Last)
Other known name(s): _____________________________________________________
DOB: ________________________ Gender: Male Female (Month / Day / Year) Address: ______________________Suite #:___________ Postal Code: ______________
Home Phone: _______________ Work: _________________ Cell: __________________
Email Address: __________________________________________________________________
Name of Primary caregiver: ________________________ _______________________
(First) (Last) Relationship to child:
Mother (bio) Step-Mother Father (bio) Step-Father Grandmother
Grandfather Aunt Uncle Foster parent Other _________________________________
Address: Same as child? Yes No
Name of Additional caregiver (if any): ____________________ ____________________
(First) (Last) Relationship to child:
Mother (bio) Step-Mother Father (bio) Step-Father Grandmother Grandfather
Aunt Uncle Foster parent Other ___________________________________
Address: Same as child? Yes No
Address: ______________________Suite #:___________ Postal Code: _______________
Home Phone: _______________ Work: _________________ Cell: ___________________
ABORIGINAL HEAD START
APPLICATION FORM
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How many times have you moved in the last year? ___________________________
ALTERNATE PICK UP / EMERGENCY CONTACT INFORMATION
*PLEASE NOTE – A PARENT LIVING IN THE HOME IS NOT CONSIDERED AN
ALTERNATE PICK UP, AND THE EMERGENCY CONTACTS MUST LIVE WITHIN THE
EDMONTON CITY LIMITS AND HAVE A WORKING LOCAL PHONE NUMBER
Contact #1: __________________ _______________________________
(First) (Last)
Home Phone Number: ___________________ Cell Phone: ___________________
Address: ________________________ Work Phone: ____________________
Relationship to the Child: ____________________________________________
Contact 2 #: ____________________ _______________________________
(First) (Last)
Home Phone Number: __________________ Cell Phone:_____________________
Address: ___________________________ Work Phone: __________________
Relationship to the child: ____________________________________________
Alternate Caregiver’s
I _________________________ (first/last name of caregiver) give my consent for the persons listed above to pick up my child from the bus or school with proof of identification and prior notification to both the bus driver and classroom teacher. Further, the persons listed above will act as my child’s emergency contacts in the event of my absence.
Parent / Caregiver
Name: _________________________
Signature: ____________________
Date: _______________________ (Month / Day / Year)
Is anyone denied access to the child? Yes No
Who is denied access to the child? #1 ________________ _________ _______ (FIRST NAME) (LAST NAME)
If applicable – Are custody documents on file? Yes No
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Is this your child’s first Head Start program? Yes No
If No, date previously attended and where child attended:
__________________________________________________________
(Month / Day / Year)
ABORIGINAL LEARNER DATA COLLECTION INITIATIVE
(Enrollment Type)
It is mandatory that this question is included on registration forms, however answering the
question is not mandatory.
If you wish to declare that your child is an Aboriginal person, please specify:
331 Status Indian / First Nations 334 Inuit
332 Non-Status Indian / First Nations 333 Métis
CHILD’S CITIZENSHIP STATUS
CANADIAN CHILD OF A CANADIAN CITIZEN
PERMANENT RESIDENT/LANDED IMMIGRANT STUDENT AUTHORIZATION-VISA
CHILD OF AN INDIVIDUAL LAWFULLY ADMITTED TO TEMPORARY RESIDENTS
CANADA FOR PERMANENT CITIZENSHIP
INCOME DECLARATION
ANNUAL FAMILY INCOME:
LESS THAN $12,000 $12,000 - $15,000 $15,001 - $18,000 $18,001 - $21,000
$21,001 - $24,000 $24,001 - $27,000 $27,001 - $30,000 $30,001 - $33,000
$33,001 – 36,000 $36,001 - $39,000 $39,001 - $42,000 OVER $42,000
SOURCE OF INCOME A:
EMPLOYMENT SOCIAL SERVICES/SFI STUDENT FINANCE
EMPLOYMENT INSURANCE CHILD SUPPORT IMMIGRATION CANADA
AISH/DISABILITY CANADA PENSION PLAN WCB
SOURCE OF INCOME B:
EMPLOYMENT SOCIAL SERVICES/SFI STUDENT FINANCE
EMPLOYMENT INSURANCE CHILD SUPPORT IMMIGRATION CANADA
WCB AISH/DISABILITY CANADA PENSION PLAN
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Does your current income meet the financial needs of your family? YES NO
Which needs are not being met?
_______________________________________________________________
_______________________________________________________________
How is this affecting your family?
_______________________________________________________________
_______________________________________________________________
What is the education level of the primary caregiver of the child?
Grade ________
Technical training: Area of study: _____________________________
College or university: Area of study:_____________________________
Other ________________________________________________________
Age of the primary Parent/Caregiver?
Under 20 years old 30-40 years old
20-30 years old Over 40 years old
Type of family?
Single parent Two parent Foster parent Other_______
Grandparents Kinship care Group home
Residents in the home?
Mother (bio) Step-Mother Father (bio) Step-Father Child’s grandmother
Child’s grandfather Child’s Uncle Child’s Aunt
Child’s siblings & number of siblings______________ Child’s Cousin(s) Family Friend(s) Other________
Names and Ages of Siblings:
Name: __________________________________ Age: ____________
Name: __________________________________ Age: ____________
Name: __________________________________ Age: ____________
Name: __________________________________ Age: ____________
Name: __________________________________ Age: ____________
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HEALTH INFORMATION
Does your child have any special needs that we should know about? (Special diet,
language problems, particular fears etc.) Yes No
_________________________________________________________________
_________________________________________________________________
Has your child had previous assessments (speech& language, OT…) Yes No
_________________________________________________________________
_________________________________________________________________
What family issues should we be aware of that have been occurring in the home
and affecting your child?
_________________________________________________________________
_________________________________________________________________
Does your child have a family doctor? Yes No, we go to a Medicentre
Child’s Doctor: ___________________ Type: Family Pediatrician
Specialist (ears, nose, throat…) ___________________
Doctor’s Address: _____________________ Phone: ____________________
Medicentre: ___________________________ Phone: ____________________
Alberta Health Care Number: _______________________________________ Birth Certificate Number: __________________________________________
Treaty Number: __________________________________________________
Is child’s immunization up to date? Yes No Don’t know Attached
If immunized out of Edmonton, where? _______________________________
_______________________________________________________________
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CHILD’S PHYSICAL HEALTH Does your child have allergies? Yes No
ALLERGY REACTION MEDICINE/TREATMENT
Does your child need an Epi pen? Yes No
Does your child have asthma? Yes No
What is the treatment?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Does the child require asthma treatment at school? Yes No
Is this child on regular medication? Yes No
What medications?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
How is the medication administered?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
How often?
__________________________________________________________
Are there any side effects? Yes No
Description:________________________________________________________
_________________________________________________________________
_________________________________________________________________
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COMMUNITY RESOURCES AND SERVICES Do you presently have involvement with another agency? Yes No
Do you need to know about more resources and services in your community for
your child and family?
Yes No Not sure
Have your children experienced any form of trauma or abuse? Yes No
If Yes, Please explain: ____________________________________________
Do you currently have or had Children Services involvement? Yes No
Children Services Worker: _________________________________________ (First & Last Name)
Phone: ______________________ Email: _______________________
Social Worker: _________________________________________ (First & Last Name)
Phone: ______________________ Email: _______________________
Family Support Worker: _________________________________________ (First & Last Name)
Phone: ______________________ Email: _______________________
PERSONAL AND SOCIAL DEVELOPMENT
Is the mother tongue of either parent/caregiver an Aboriginal Language? YES NO
Does either parent/caregiver speak an Aboriginal Language Fluently? YES NO
Does your child speak an Aboriginal Language Fluently? YES NO
What is the primary language spoken in the home? ___________________________
What is the primary language your child speaks?
English Other: ____________________________
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How would you describe your child’ ability to speak? (√) All that apply.
Is your child?
Yes
No
Sometimes
Easy to understand
Difficult to understand
Talkative
Stutters
Speaks in sentences
longer than three (3)
words
Shy/quiet
Other: ____________________________________________________ ____________________________________________________ Please indicate how you deal with your 3-4 year old child’s behavior? Do you do
the following… usually, sometimes or never?
Usually Sometimes Never
Time out
Move child away
Ignore the behavior
Spank
Distract the child onto something else
Speak Louder
Other
_____________________________________________________________
Do you practice traditional Aboriginal culture at home? Yes No
What are you hoping that your child will gain from Head Start? (Choose as many
as you wish)
To learn some of his or her Aboriginal language
To learn about his or her culture
To get ready for kindergarten (ECS)
To learn to play with others his or her own age
To improve his or her behavior social skills
To improve his or her language or communications skills
Another reason- please explain _________________________________
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What do you hope that Head Start will offer you as a parent or caregiver? (Choose
as many as you wish)
To meet other parents
To learn better parenting strategies
To learn about Aboriginal culture
To learn some of the local Aboriginal language
To learn how to help my child learn
Another reason- please explain _________________________________
How did you hear about Aboriginal Head Start? (Choose as many as you wish)
Word of Mouth: Through Friends
Through past participants
Head Start Flyer
What business/location did you find our flyer at?
_______________________________________________________
Facebook Advertisement
Newspaper Advertisement
Other… ___________________________________________________
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Consent to ordinary medical and dental care:
This authority includes treatment for minor illnesses and injuries and other procedures that
are performed routinely and do not require hospitalization.
The Head Start staff have the authority to admit the child to hospital but not to authorize any
treatment or tests except according to the following clause:
Consent to emergency treatment or surgical procedures. This authority includes immediate
measures necessary to preserve the child’s life, health and physical wellbeing. The authority
must be used only if contacting the parents or caregivers will delay treatment enough to
endanger the child’s life. After giving treatment, the staff must immediately notify the parents
or caregivers.
Delegation of Powers in Case of Emergency Name of Child:
____________________ ____________________ ______________________
(First) (Middle) (Last)
Date of Birth: ______________________________________________________
(Month / Day / Year)
Band/First Nation: _________________________________________________
Treaty Number: ___________________________________________________
Alberta Health Care number: _________________________________________
I, the Parent/Primary Caregiver, delegate the Powers and Duties set out above in this
delegation to the staff of the Aboriginal Head Start Program regarding my child.
Parent / Caregiver
Name: _________________________
Signature: ____________________
Date: ________________________ (Month / Day / Year)
Parent/Caregiver Delegation of Power and Duty
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I _______________________ (first/last name of caregiver) hereby authorize the following
agencies to observe my child _______________________ (first/last name) in the Head Start program and provide necessary documentation and consultation to Aboriginal Head Start staff in order to enhance my child’s learning in the classroom.
• Alberta Health Services
• Child Adolescent and Family Mental Health (CASA)
• Glenrose Hospital (Assessment Facility)
• Edmonton Student Health Initiative Program (ESHIP) ______ Initials
I understand that as part of the services provided by Head Start, these services and screenings may be completed with and/or provided for my child.
• Measurement of Height and Weight
• Dental Screening • Hearing Screening
• Vision Screening
• Brigance Inventory of Early Childhood Development II (IED-II) • Safe Preschoolers Education & Awareness Kit (S.P.E.A.K.) • Speech and Language Referral/Assessment, if required
• Occupational Therapist Referral/Assessment, if required
• Physical Therapist Referral/Assessment, if required ______ Initials
I also give permission for the information collected to be used by Head Start and the above agencies for educational, research and statistical purposes. I understand that the information will be coded in such a way that the identities of individual children and parents will be kept confidential for research and statistical purposes. ______
Initials I hereby give my consent and agree to the above screening(s) and services indicated with my initials.
Parent / Caregiver
Name: _________________________
Signature: ____________________
Date: ________________________ (Month / Day / Year)
Health Promotion and Assessment
Permission Form
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I understand that the Head Start may release the following information on my child to Early
Education Programs and/or institutions and may collect the following information from
previous Early Education Programs and/or institutions that will support my child’s educational
programming:
Individual Program Plan (IPP)
Speech and Language Report, if applicable
Occupational Therapist Report, if applicable
Physical Therapist Report, if applicable
______ Initials
I understand that the Head Start may collect the following information from previous Early
Education Programs and/or institutions that will support my child’s educational programming:
Individual Program Plan (IPP)
Speech and Language Report, if applicable
Occupational Therapist Report, if applicable
Physical Therapist Report, if applicable
______
Initials
I understand that the information collected by Head Start will be kept confidential.
Parent / Caregiver
Name: ___________________________
Signature: _____________________
Date: ________________________ (Month / Day / Year)
Collection and Release of Information
Form
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TRANSPORTATION
Does your child require transportation: Yes No, caregiver will provide
transportation
Yes, program transportation Pickup/Drop Off: Home – Home Daycare – Daycare
Home – DaycareDaycare – Home
Number of Siblings on Bus: ___________
Daycare Name: ____________________________________________________
Daycare Address: ___________________ Phone Number: __________________
Transportation Procedures The amiskwaciy Cultural Society provides the Aboriginal Head Start Program with four 24 passenger school busses and access to the program’s spare bus if needed. These vehicles are used to transport those children who are registered in our program and who live within the designated boundaries set forth by the Aboriginal Head Start Program. Estimated hours for pick up. 7:30 – 8:15 a.m. or 11:30 – 12:45 p.m. Estimated hours for drop off. 11:30 – 12:30 p.m. or 4:00 – 5:00 p.m. The bus will pick up/drop off your child at home or/at the designated child care facility. Parents/Guardians are required to bring the child to the bus upon pick up and meet the bus upon drop
off. The bus drivers are not allowed to leave the bus at any time. The bus will stop at each home for exactly 3 minutes. Please have your child dressed and ready for the bus. If your child is not ready to go or no one attempts to signal the driver, she/he will carry
on with the route and there will be no reattempt at any later time. Drop off – If no one is home at time of drop off, the driver will attempt to call parent/guardian. The bus driver will then make a second attempt at the end of the route. If
still no one is available to receive the child, the bus driver will attempt to contact emergency phone numbers and if still no one is available, they will then contact the Children’s Services Crisis Line. A transportation permission form must be signed for all children who ride the bus. If a parent/guardian has an alternate caregiver receiving their child upon drop off or pick up from school, teachers must be informed verbally and in written form. Individuals will be required to show proper
identification. If your child will not be riding the bus on any given day, the bus driver MUST be notified the night before or at least half an hour before s/he arrives at your residence. If your child is sick or away from school and will not be riding the bus for any number of days, the drivers MUST be contacted in order to resume bus riding for his/her child.
Parents/guardians are required to read, agree and abide by these procedures.
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I, _________________________ (first/last name of caregiver) understand the
transportation procedures and hereby give consent for my child
_________________________(first/last name of child) to
be transported by the Aboriginal Head Start Program from
September 2017 to June 2018.
Parent / Caregiver
Name: ___________________________
Signature: _____________________
Date: ________________________ (Month / Day / Year)
Field Trip Blanket Permission Form The following form is a Blanket Permission Form which will allow your child to attend and be transported by the Aboriginal Head Start bus to ANY and ALL field trips in and around the Edmonton City limits. Regularly scheduled field trips and activities will be listed on your child’s monthly classroom calendar
that is handed out at the beginning of each month, and this form will grant permission for your child to attend.
I do understand the above and hereby give my permission for my child to attend ANY and ALL
program planned field trips and activities during the 2017-2018 Academic School Year. I do give permission for my child to be transported by the Aboriginal Head Start bus to and from
ANY and ALL program planned field trips and activities during the 2017-2018 Academic School Year.
I do authorize the Aboriginal Head Start program staff to obtain emergency medical treatment
for my child in cases of emergency.
I also understand that I WILL NOT hold the Aboriginal Head Start program liable for injury to my child during ANY or ALL of these planned field trips and activities without just cause.
Name of child Name of parent
_________________________ _________________________ (Please Print) (Please Print) Signature of Parent Date
_________________________ _________________________ (Please Sign) (Month / Day / Year)
Transportation Permission Form
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Audio/Visual Recording Consent
No consent given
I _________________________(first/last name of caregiver) the parent/caregiver of
_________________________(first/last name of child) do hereby acknowledge that the
Aboriginal Head Start , and the amiskwaciy Cultural Society may use, reproduce or distribute
any photographs, slides, video or other similar material associated with the program and
related events and activities for promotional and archival purposes. There is no time limit to
this consent; however, the consent can be revoked at any time with written notice to the
Program Manager. Audio and visual recordings will be securely stored at the amiskwaciy
Cultural Society office.
Parent / Caregiver
Name: ___________________________
Signature: _____________________
Date: ________________________ (Month / Day / Year)
Waiver
As Guardian / Caregiver I hereby understand that the Aboriginal Head Start Program, and
The amiskwaciy Cultural Society will not be responsible for the following:
Lost or stolen and/or Damage of personal items.
Any occurrence, after program hours where a child has been dropped off at specified
childcare location. (i.e.: Home, daycare, babysitter)
Restricting contact without legal documentation on file. (Both office and school files)
To inform the Aboriginal Head Start program of any changes to parent/caregiver or
emergency contact information as soon as they occur.
Parent / Caregiver
Name: ___________________________
Signature: _____________________
Date: ________________________ (Month / Day / Year)
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Parent participation plays a major role for the success of the Aboriginal Head Start
Program. Your participation as a parent/primary caregiver will benefit the Program
as well as yourself and your child. The parent/primary caregiver portion of the
Program requires you to become involved. We attempt to be flexible in order to
accommodate your hours available. Parent participation is crucial for the continued
success of our Head Start program.
I (caregiver) do agree to fulfill my parental/primary caregiver obligation to the Aboriginal Head
Start Program. I understand that my participation in the Program will benefit my child and
myself as a parent/primary caregiver. I will become involved in the following ways:
1. I will attend parent/primary caregiver gatherings/functions. 2. I will ensure my child attends Head Start on a regular basis. 3. I will contact the bus driver when my child will not be taking the
Head Start Bus. 4. I will permit home-visits by Head Start staff regarding my child to access
community services. 5. I will volunteer a minimum of 9 hours in the Head Start Program. This could
include, classroom participation, fieldtrips, making play-dough, material
preparation or any of the listed below.
6. I am willing to contribute to the program by sharing my skills, talents, and
knowledge in (check as many as apply to you) :
□ Traditional Foods □ Story Telling
□ Drumming □ Crafts
□ Singing □ Personal Career
□ Other: ________________________________
Parent/Primary Caregiver
Name: ___________________________
Signature: ________________________
Date: ___________________________ (Month / Day / Year)
Parent/Primary Caregiver Participation Agreement
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Parent/Primary Caregiver Consent Form Brigance Head Start Screen Evaluation
The Aboriginal Head Start in Urban and Northern Communities (AHSUNC) Program is a
national program funded by the Public Health Agency of Canada (PHAC). AHSUNC is an
early learning program that serves more than 4,000 First Nations, Inuit and Metis children
and their family in 126 communities. It is a comprehensive program designed to support
the spiritual, emotional, intellectual and physical needs of participating children.
Purpose of the Brigance Head Start Screen Evaluation
The purpose of the Brigance Head Start Screen is to evaluate the education/school
readiness component of the program by collecting information on AHSUNC participants.
This screen is being used to evaluate the AHSUNC program, not individual children. The
results will help show if the AHSUNC program is effectively helping children improve school
readiness skills from the start to the end of the school year. The results can also be used to
adapt and enhance the activities offered by the program, according to the needs of the
children.
Description of the Brigance Head Start Screen
The screen will be given to each child twice - once at the beginning of the school year and
once at the end. The Brigance Head Start Screen is a well-tested and well-researched tool.
It is used by many school boards and child psychologists throughout North America as a
quick and reliable way of monitoring a child’s developmental progress. Each child will be
asked to show how he/she can perform certain skills: drawing, moving their bodies,
understanding directions and words and some skills that are important for school.
Administering the Brigance Screen takes about 15 to 30 minutes.
How information will be used
AHSUNC teachers will record the results of the screen onto answer sheets. Before these
sheets are sent to PHAC for analysis, the teachers will replace the child’s name with a code.
This code will make sure that the screen results remain anonymous when they are
submitted to PHAC. An external consultant will put all the data together into a report. The
information provided in this report will support national program accountability and provide
insight on where improvements to the program can be made. Complete reports will be
shared with your AHSUNC project when available.
Confidentiality
The information associated to your child’s name will never be shared without your consent
with anyone other than staff at your child’s AHSUNC site. If changes are made to the study
or new information becomes available, you will be informed.
Participation
Participating in this evaluation of the AHSUNC program is voluntary (optional). Parents
and/or guardians can choose to give their permission, or not, for their child(ren) to
participate. Also children do not have to answer any question that they do not want to
answer, and they can stop participating in the screening at any time. Choosing not to
participate in the screen will in no way affect your quality of service and that of your
child(ren). Your information will be protected according to the requirements of the Canada’s
Privacy Act. There are no known harms to participating in the Brigance Head Start Screen.
I, ____________________________________ (print name), consent for my child to
participate in the Brigance Head Start Screen Evaluation.
_____________________________________ (signature) _______________________
Date (dd/mm/yy)
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Orientation Agreement
This is to verify that I, __________________________________ (first/last name of
caregiver) have had the opportunity to go over all the information shared in the
Aboriginal Head Start program with a family support worker. I fully understand all
information shared and have asked the necessary questions for me to understand
what it takes to have my child participate in the Head Start program. I have been
informed and completed the following:
□ Overview of the Application form
Provided the program with a copy of:
□the child’s Alberta Health care card
□the child’s Birth Certificate
□the Delegation of Powers (if required)
□the child’s Treaty Status card (optional)
□Documents Pending □ Alberta Health care card □ Birth Certificate
□ Delegation of Powers
□ Signing of all Parental Consent forms
□ I understand all Program Policies and Procedures
□ I understand the 9 hours commitment for volunteering in the program
□To inform the Aboriginal Head Start program of any changes to parent/caregiver or
emergency contact information as soon as they occur.
□ I was given an opportunity to ask questions and gain clarity of my responsibilities in relation
to the Head Start program
□ I understand that the program is obligated by law to report to the appropriate authorities
should they suspect any form of abuse.
If I should have any further questions or concerns relating to my child or the program in any
way, I will contact my site family support worker to discuss the matters directly.
Parent/Caregiver Interviewer
_________________ ___________________ Name (First/Last) Name (First/Last)
_____________________ ________________________ Signature Signature
_____________________ ________________________ Date (Month/Day/Year) Date (Month/Day/Year)