Elk Grove Unified School District PreK Education

Preschool Eligibility Determination

Thank you for your interest in preschool. Please review the Family Income Guidelines below to determine if your

family size and income meet the income eligibility requirement for one of the PreK programs in EGUSD. If so, please complete the Eligibility Determination below the income guidelines. Please note that completing this form does

NOT guarantee placement into the PreK program. Placement is not based on a first come, first served basis and is not solely determined by income. The PreK programs in Elk Grove Unified School District are funded by Head Start, the State of California, and by Title I. Each of these funding sources has specific requirements that your family must meet in order to qualify. Staff will review the information you provide to determine if you qualify. After a determination is made they will contact you to set up an appointment to register, or if you do not qualify for one of these programs, refer you to other preschool programs within the school district.

State-CSPP Family Income Guidelines (effective 07/01/2011) Head Start (effective 02/01/2017) Title I

Size of Family Monthly Income Annual Income

Monthly Income Annual Income

Live within the boundaries of a Title I school

1 $3,283 $39,396 $1,005.00 $12,060 Income is not

2 $3,283 $39,396 $1,353.33 $16,240 considered.

3 $3,518 $42,216 $1,701.67 $20,420 To qualify a

4 $3,908 $46,896 $2,050.00 $24,600 family must

5 $4,534 $54,408 $2,398.33 $28,780 live within

6 $5,159 $61,908 $2,746.67 $32,960 the boundaries

7 $5,276 $63,312 $3,095.00 $37,140 of a Title I

8 $5,394 $64,728 $3,443.33 $41,320

9 $5,511 $66,132 HEAD START ONLY For family units with more than 8 members, add $4,180 a year for each additional family member.

school.

10 $5,628 $67,536

11 $5,745 $68,940

12 or more $5,863 $70,356

PreK ELIGIBILITY DETERMINATION

Date Site requesting Program

Child’s Name: Birth Date Gender Boy Girl

Parent’s Name Address

Phone City/Zip

Email Home School

Approximate Monthly Income (before taxes) Family Size

FOR OFFICE USE ONLY: Program Eligibility: Title 1 Head Start State (CSPP) Staff Initial _____

TANF SSI Homeless Foster/CPS Referred Guardianship Transfer SETA (HSHS) Within EGUSD PreK

1st

Choice 2nd

Choice 3rd

Choice ANY SITE

Site OAIII or Program Educator contacted Family Date Contacted Priority Rank______

Family information was inputted into recruitment list in G-drive. Packet picked up appointment for completion scheduled YES NO Notes:

STUDENT REGISTRATION TODAY’S DATE ____/____/____ PLEASE PRINT *Has the student ever been enrolled in an Elk Grove Unified School District school? Y / N *Is this student currently expelled or pending an expulsion hearing in EGUSD or any other district? Y / N ________________________________________ __________________________ _______________ ________SSN ______-______-______ *Student’s Legal Last Name *First Name Middle Name (Suffix: Jr. Sr.) ______________________ _____________________ _____________ _______________________________ ___________ (Nick Name) AKA First Name AKA Middle Name AKA Last Name AKA Suffix *Student’s Home Telephone ______ - ______ - ________ Phone Unlisted? Y / N *Grade Level: ________ *Gender: Male / Female (Area Code)

*Birth Date _____/______/_______ *Birthplace ____________________________ _______ ______________________________ MM / DD / YYYY (City) (State) (Country) Foreign Born United States Citizen? Y / N If Foreign Born, does student have three years of cumulative enrollment in the United States? Y / N *What special services has your child received? Check all that apply: Special Ed. Program? GATE? 504? ESL/Bilingual? *What is your child’s Ethnicity? (Please check one) Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) Not Hispanic or Latino *What is your child’s Race? (Please show one or more) The question above is about ethnicity, not race. No matter what you selected above, please select a race that best represents your heritage for group data by selecting one or more of the races located in the Race Codes chart on page 4. Race codes #_______,#______, #______, #______, #______ HOME LANGUAGE SURVEY (Questions for “new” student registration only) *Which language did your son or daughter learn when he or she first began to talk? __________________________________ *What language does your son or daughter most frequently use at home? ___________________________________________ *What language do you use most frequently to speak to your son or daughter? _______________________________________ *Name the language most often spoken by the adults in the home: _________________________________________________ *Residence _____________ ______________________________________________ ________ _______________________ ______ ___________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code) Address Unlisted? Y / N *Mailing Same as residence? Y / N If no ___________ ___________________________ ______ _______________________ ______ __________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code) *Is student currently: Foster Youth? Homeless? If Foster Youth, where is your child/family currently living? If Homeless, where is your child/family currently living? (Please check only one of the following) (Please check only one of the following) Foster Family Home or Kinship Placement (210) Temporary Shelter (100) Licensed Children’s Institution (Group Home) (220) Hotels/Motel (110) Temporarily Doubled Up (120)

Temporarily Unsheltered (130) **FOR OFFICE USE ONLY** EGUSD Student Number____________________ Birth Date Verified Enrollment Permit Code_____________________

School Enrollment Date____/____/______ Birthplace Verified Enrollment Permit Reason____________________________________

School Name______________________________ Legal Name Verified Immunizations Complete? Y / N

Address Verification Method_________________ Date Birth Info Verified____/____/______ Parent Highest Ed Level (see pg 2 & 3) __________________

Date Address Verified____/____/______ Birth Place Verification Method________________

Track Restrictions? Y / N Primary Language (see pg 4 chart)

Enrolled by_______________________________ Date entered_____/_____/______

PAGE 2 STUDENT ENROLLMENT INFORMATION continued DAY CARE INFORMATION (Applies to Elementary/Middle School Students Only)

Day Care ______________________________Cell Phone ______ - ______ - _______ Home Phone ______ - ______ - _______ Work Phone ______ - ______ - _______ Provider Name (Area Code) (Area Code) (Area Code)

Day Care ____________ _________________________________________ ______ _______________________ ______ _________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code) *LAST SCHOOL ATTENDED _______________________________________________________________ Phone#_______ - _______ - _______ (School Name) (Area Code)

School Address __________ _________________________________________________ ____________________________ ______ __________ (Street Number) (Street Name) (City) (State) (Zip Code) STUDENT MISC INFORMATION (Questions for “new” student registration only)

*What month, day and year did your child first enroll in the U. S. school system not including Preschool? _____/_____/________ MM / DD / YYYY *What month, day and year did your child enter (or enroll) in a California Public School? _____/_____/_______ MM / DD / YYYY Did your child attend preschool (for at least 6 months) immediately prior to enrolling in Kindergarten? Yes / No If yes, please check the type of Preschool Program: Elk Grove Unified School District-Preschool Program (Head Start, Title 1, State Preschool) Other public Preschool outside EGUSD – Name of Program ___________________________________________ Partners Preschool through EGUSD Adult Education Private Preschool DOES YOUR STUDENT HAVE ACCESS TO THE INTERNET FROM HOME? Yes / No LEGAL PARENT/GUARDIAN INFORMATION (1) *Legal Guardian Relationship to student _________________________ *Live with student? Y / N Do you wish to receive school mailings? Y / N Do you wish to participate in EGUSD Portal in lieu of certain mailings? Y / N

______________________________ _____________________ _____________ ___________ *Guardian’s Last Name *First Name Middle Initial (Suffix: Jr. Sr.)

* Guardian ____________ _________________________________________ ______ _______________________ ______ _________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code) * Guardian’s Home Phone#_______ - _______ - _______ Cell Phone#_______ - _______ - _______ Pager/Cell#_______ - _______ - _______ (Area Code) (Area Code) (Area Code)

Email Address _____________________________________________________________________________________________ PARENT/GUARDIAN MISC INFO (1) Primary Language ________________(see page 4 chart) Language assistance needed? Y/N Driver’s License # __________________State ______

Name of Employer __________________________________________ Employer Phone#_______ - _______ - _______ _______ (Area Code) (Ext) * PARENT/GUARDIAN EDUCATIONAL LEVEL (Check the response that describes parent/guardian (1) education level)

College Graduate Graduate Degree or Higher High School Graduate Not a High School Graduate Some College or Associate’s Degree

PAGE 3 STUDENT ENROLLMENT INFORMATION continued LEGAL PARENT/GUARDIAN INFORMATION (2) *Legal Guardian Relationship to student _________________________ *Live with student? Y / N Do you wish to receive school mailings? Y / N Do you wish to participate in EGUSD Portal in lieu of certain mailings? Y / N ______________________________ _____________________ _____________ ___________ *Guardian’s Last Name *First Name Middle Initial (Suffix: Jr. Sr.) * Guardian ____________ _________________________________________ ______ _______________________ ______ _________ Address (Street Number) (Street Name) (Apt#) (City) (State) (Zip Code) * Guardian’s Home Phone#_______ - _______ - _______ Cell Phone#_______ - _______ - _______ Pager/Cell#_______ - _______ - _______ (Area Code) (Area Code) (Area Code)

Email Address _____________________________________________________________________________________________ PARENT/GUARDIAN MISC INFO (2) Primary Language ________________(see page 4 chart) Language assistance needed? Y/N Driver’s License # __________________State ______

Name of Employer __________________________________________ Employer Phone#_______ - _______ - _______ _______ (Area Code) (Ext) * PARENT/GUARDIAN EDUCATIONAL LEVEL (Check the response that describes parent/guardian (2) education level)

College Graduate Graduate Degree or Higher High School Graduate Not a High School Graduate Some College or Associate’s Degree

*EMERGENCY CONTACT (Other than Legal Parent/Guardian to child) If I cannot be reached, I authorize the school to call, release my child to, or take my child to the following individual(s). This consent is effective until revoked in writing. *Initial here ______ 1. Relationship to Child _____________________________ ________________________ ____________________ _____________ __________ *Last Name *First Name Middle Initial (Suffix: Jr. Sr.)

Cell Phone#_______ - _______ - _______ Home Phone#_______ - _______ - _______ Work Phone#_______ - _______ - _______ _______ (Area Code) (Area Code) (Area Code) (Ext) 2. Relationship to Child ___________________________ _________________________ _____________________ _____________ ___________ *Last Name *First Name Middle Initial (Suffix: Jr. Sr. Cell Phone#_______ - _______ - _______ Home Phone#_______ - _______ - _______ Work Phone#_______ - _______ - _______ _______ (Area Code) (Area Code) (Area Code) (Ext) OTHER CONTACT

_______________________________________ Phone#_______ - _______ - _______ ____________________________________ Phone#_______ - _______ - _______ Social Worker/Case Worker Name (Area Code) Probation Officer Name (Area Code) MEDICAL INFORMATION Name of Insured ______________________________ _____________________ _____________ ___________ Last Name First Name Middle Initial (Suffix: Jr. Sr.) Name of Health Insurance ____________________________ Medical ID#/Policy# ________________________ Phone#_______ - _______ - _______ (Area Code)

___________________________________ Phone#_____ - _____ - _______ _________________________________ Phone#_____ - _____ - _______ Doctor’s Name (Area Code) Hospital’s Name (Area Code) SPECIAL HEALTH ISSUES

________________________________________ ____________________________________________ _________________________________________________ Allergies Medical Problems/Chronic Illness Other Comments/Information In an emergency, when I cannot be reached, I authorize the school authorities to take my student, at my expense, to my family doctor, licensed physician, nearest hospital or emergency first-aid station for treatment. This consent is effective until revoked in writing. *Initial here ______Yes, I do give permission for treatment OR *Initial here ______No, I do not give permission for treatment

PAGE 4 SIBLING INFORMATION, PRIMARY RACE CODES & PRIMARY LANGUAGE CODE CHARTS SIBLING INFORMATION

I affirm, to the best of my knowledge, that the above information is correct and that I will notify the school each time there is a change in any of this information. ______________________________________________________________________Date____/____/____ *Signature *Race Codes

American Indian or Alaskan Native(100) (Persons having origins in any of the original peoples of North, Central or South America )

Chinese (201) Japanese (202) Korean (203) Vietnamese (204) Asian Indian (205)

Laotian (206) Cambodian (207) Hmong (208) Other Asian (299) Hawaiian (301) Guamanian (302) Samoan (303)

Tahitian (304) Other Pacific Islander (399) Filipino/Filipino American (400) African American or Black (600) White (700) (Persons having origins in any of the

original peoples of Europe, North Africa, or the Middle East)

Primary Language Codes Language Code Language Code Language Code Language Code

Albanian 56 French 17 Kurdish 51 Somali 60 American Sign Language

37 German 18 Lahu 47 Spanish 01

Arabic 11 Greek 19 Lao 10 Taiwanese 46 Armenian 12 Gujarati 43 Mandarin

(Putonghua) 07 Tamil 63

Assyrian 42 Hebrew 21 Marathi 64 Telugu 62 Bengali 61 Hindi 22 Marshallese 48 Thai 32 Burmese 13 Hmong 23 Mien(Yao) 44 Tigrinya 57 Cantonese 03 Hungarian 24 Mixtexo 49 Toishanese 53 Cebuano (Visayan) 36 Ilocano 25 Pashto 40 Tongan 34 Chaldean 54 Indonesian 26 Polish 41 Turkish 33 Chamorro (Guamanian)

20 Italian 27 Portuguese 06 Ukrainian 38

Chaozhou (Chaochow)

39 Japanese 08 Punjabi 28 Urdu 35

Dutch 15 Kannada 65 Rumanian 45 Vietnamese 02 English 00 Khmer

(Cambodian) 09 Russian 29 All Other Non-

English 99

Farsi (Persian) 16 Khmu 50 Samoan 30 Filipino (Tagalog) 05 Korean 04 Serbo-Croatian

(Bosnian) 52

Last Name First Name Birthday ( MO/ DAY/ YR)

Gender ( M / F)

Track School Grade Level

PAGE 5 PRIMARY RESIDENCE CODE CHART

*Primary Residence Codes (Federally mandated by NCLB) Temporary Shelters 100 A temporary residence provided for homeless individuals who would otherwise sleep on the

street or a temporary residence provided to individuals in emergency situations. This is also applicable to children who are in temporary residences awaiting permanent placement in foster care.

Hotels/Motels 110 A temporary residence for homeless individuals usually requiring payment or vouchers for lodging and services on a daily, weekly, or monthly basis.

Temporarily Doubled Up 120 A temporary residence where a homeless family is sharing the housing of other persons due to the loss of housing, economic hardship, or other similar reasons.

Temporarily Unsheltered 130 A type of residence for homeless individuals that is not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings, campgrounds, trailer parks, bus and train stations, or persons abandoned in the hospital (on the street). A rule of thumb would be to see the dwelling as comparable to an automobile in that it shelters but is not adequate housing.

Permanent Housing 200 A type of fixed and regular residence that is owned, rented, or sublet. Foster Family Home or Kinship Placement

210 A family residence that is licensed by the state, or other public agency having delegated authority by contract with the state to license, to provide 24-hour non-medical care and supervision for not more than six foster children, including, but not limited to, individuals with exceptional needs. This also includes “Small Family Homes” as described in Health and Safety Code Section 1502(c) (6) (Education Code Section 56155.5[b]), or an “Approved Home” of a relative. An “Approved Home” means the home of a relative or non-relative extended family member that is exempt from licensure and is approved as meeting the same standards as those set forth in CCR Title 22, Div.6, Article 3. This is not the same as a Licensed Children’s Home.

Licensed Children’s Institution 220 A residential facility that is licensed by the state, or other public agency having delegated authority by contract with the state to license, to provide non-medical care to children, including, but not limited to, individuals with exceptional needs. Licensed children’s institution includes a group home as defined by subdivision (g) of Section 80001 of Title 22 of the California Code of Regulations. As used in this article and Article 3 (commencing with Section 56836.16) of Chapter 7.2, a “licensed children’s institution” does not include any of the following: (1)A juvenile court school, juvenile hall, juvenile home, day center, juvenile ranch, or juvenile camp administered pursuant to Article 2.5 (commencing with Section 48645) of Chapter 4 of Part 27. (2)A county community school program provided pursuant to Section 1981. (3)Any special education programs provided pursuant to Section 56150. (4)Any other public agency.

Residential School/Dormitory 230 A nonsectarian school where a student with exceptional needs resides on a 24-hour basis and receives special education and related services at the school. This includes both public and private facilities. This is not the same as an Incarceration Institution or a Licensed Children’s Institution.

Health Institution 240 A public hospital, state licensed children’s hospital, psychiatric hospital, proprietary hospital, or a health facility for medical purposes. (E.C 56167(a)). It does not state hospitals operated by the California Department of Developmental Services.

Incarceration Institution 250 Individuals who have been adjudicated by the juvenile court, for placement in a juvenile hall or juvenile home, day center, ranch, or camp, or for individuals placed in a county community school (E. C. 56150); includes placement in the Department of Corrections – Division of Juvenile Justice (formerly California Education Authority or California Youth Authority), and other public correctional institutions.

Development Center 260 A residential facility providing services to individuals who have been determined by the Department of Developmental Services (DDS) regional centers to require programs, training, care, treatment and supervision in a structured health facility setting on a 24-hour basis. This is not the same as Residential School/Dormitory, Health Institution, or State Hospital.

State Hospital 270 A state hospital is a residential facility operated by the California Department of Mental Health (DMH). This is not the same as Residential School/Dormitory, Health Institution, or Development Center.

Other 300 Any other type of residence not referenced in any other Primary Residence Category.

Unknown 310 The primary residence of an individual cannot be determined. For example, the information is unavailable or was erroneously reported and is indecipherable.

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CALIFORNIA DEPARTMENT OF EDUCATION Form CD 9600A, (Rev. 01/04)

Child Care Data Collection Privacy Notice and Consent Form

The United States Department of Health and Human Services (HHS) is gathering information about

families who receive child care assistance. The information will be reported to the California

Department of Education (CDE) and then to HHS. The information will be used for research on the

status of child care in the United States and will provide valuable data to persons developing child care

programs and policies at the state, local, and national levels.

All the information HHS receives about your family and other families will be summed up and reported

to Congress every two years. No person or family will be individually identified in reports made to

Congress, the Legislature, other governmental agencies, or the public.

To ensure that children and families receiving child care services are counted only once, HHS and

CDE are requesting the Social Security Number of the head of the family unit receiving child care

assistance. If you do not wish to give your Social Security Number for this purpose, you may still

receive child care assistance. Social Security Numbers will help CDE meet HHS reporting requests

and state requirements for program statistics. Authority to ask for your Social Security Number for this

purpose is stated in Section 98.71(a)(13) of Title 45 of the Code of Federal Regulations, Education

Code Section 8261.5, and Section 18070 of Title 5 of the California Code of Regulations. Your

decision to provide your Social Security Number is voluntary. I have been informed of the way my Social Security Number will be used. I understand that if I do not wish to give my number, I can still receive child care assistance.

YES, my Social Security Number may be used: _______-_____-_______

NO, I do not wish to give my Social Security Number for this purpose. ______________________________________ ____________________ Signature of the Head of Household Date ______________________________________ Type or Print Name You have the right to access records containing your personal information. For information about this system of records, contact the California Department of Education, Child Development Division, 1430 N Street, Sacramento, CA 95814; telephone (916) 445-1907.

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ELK GROVE UNIFIED SCHOOL DISTRICT

Pre-K6 Education

Family Income Declaration Form Child’s Name___________________________________

“Family” means the parents and the children for whom the parents are responsible. Who comprise the household in which the child receiving services is living. For purposes of income eligibility and family fee determination, when a child and his or her siblings are living in a family that does not include their biological or adoptive parents, “family” shall be considered the child and related siblings (Title 5 18078 f).

Birth certificates required for all siblings. Date Verified _______________ Staff Initial_______________

“Total Countable Income” means all income of the individuals counted in the family size that includes, but is not limited to the following (Title 5 18078) gross wages or salary, advances, commissions, overtime, tips, bonuses, gambling or lottery winnings; wages for migrant, agricultural, or seasonal work; public cash assistance; gross income for self-employment less business expenses with the exception of wage draws; disability or unemployment compensation; workers compensation; spousal support, child support , or financial assistance for housing costs or car payments paid as part of or in additional to spousal or child support; survivor and retirements benefits; dividends, interest on bonds, income from estate or trusts, net rental income or royalties; rent for room within the family’s residence, foster care grants, payments or clothing allowance for children placed through child welfare services; financial assistance received for the care of child living with an adult who is not the child’s biological or adoptive parent; veterans pensions; pensions or annuities; inheritance; allowances for housing or automobiles provided as part of compensation; portion of student grants or scholarships not identified for educational purposes as tuition, books, or supplies; insurance or court settlements for lost wages of punitive damages; net proceeds from the sale of real property, stocks, or inherited property; or other enterprise for gain.

Please provide documentation of each source of income listed. Family Member Receiving

Income Source of Income Gross Amount Per Month Document Attached Verified by Office Staff

1

2

3

4

I certify under penalty of perjury that any other adults living in the home whose income is not listed above are not taking responsibility for the child. I realize that failure to report this information constitutes fraud and may result in repayment of child care funds and/or termination of subsidized child care services. Two signatures are required if child has two adults responsible for his/her care. Signature________________________________________Date____________ Signature____________________________________Date______________

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISION

CHILD CARE CENTERNOTIFICATION OF PARENTS’ RIGHTS

PARENTS’ RIGHTSAs a Parent/Authorized Representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care.

2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years.

4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: _________________________________________________

Licensing Office Address: _________________________________________________

Licensing Office Telephone #: _________________________________________________

7. Be informed by the licensee, upon request, of the name and type of association to the child carecenter for any adult who has been granted a criminal record exemption, and that the name of theperson may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO APARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVEPOSES A RISK TO CHILDREN IN CARE.

LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)

AC K N OW L E D G E M E N T O F N OT I F I C AT I O N O F PA R E N T S ’ R I G H T S(Parent/Authorized Representative Signature Required)

I, the parent/authorized representative of ________________________________________________, havereceived a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and theCAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

_____________________________________Name of Child Care Center

______________________________________________ __________________Signature (Parent/Authorized Representative) Date

NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given toparent/authorized representative.

LIC 995 (9/08)

For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov

For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

Department of Social Services Childcare Licensing

2525 Natomas Park Drive, Suite 250

(916) 263-5744

EGUSD, Pre K-6 Education

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTSChild Care Centers

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are

not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/herneeds.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with dailyliving functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids tophysical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of theprovisions of law regarding complaints including, but not limited to, the address and telephone number of thecomplaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisorof his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completelyvoluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits fromspiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night.

(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensingagency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATELICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

NAME

(PRINT THE NAME OF THE FACILITY)

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)

LIC 613A (8/08)

(PRINT THE ADDRESS OF THE FACILITY)

ADDRESS

CITY ZIP CODE AREA CODE/TELEPHONE NUMBER

DETACH HERE

TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in theCalifornia Code of Regulations, Title 22, at the time of admission to:

Department of Social Services Childcare Licensing

2525 Natomas Park Dr. Suite #250

Sacramento 95833 (916) 263-5744

EGUSD, Pre K-6 Education 9510 Elk Grove-Florin Rd. 95624

ELK GROVE UNIFIED SCHOOL DISTRICT PreK-6 Education

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Student’s Name Birthdate _________________________________ ____________________

PHOTO RELEASE FORM I hereby consent for my child to be photographed and/or video taped for use in the preschool classroom. I understand the photographs/slides/video tapes of my child will be used to demonstrate best practice instructional techniques and strategies in early childhood education settings. The visual materials created will be presented to early childhood educators, administrators and family representatives participating in the preschool program. I understand that no photograph, slide or video tape will be released to persons, agencies, or publications without additional written permission. INSPECTION AUTHORITY OF THE DEPARTMENT OF SOCIAL SERVICES – Title 22, Division 12, Chapter 1, Article 4, Section 101200 (b) and (c) I understand that: (b) The Department has the authority to interview children or staff, and to inspect and audit child

or child care center records, without prior consent. (1) The licensee shall make provisions for private interviews with any child(ren), or

staff member; and for the examination of all records relating to the operation of the child care center.

(c) The Department has the authority to observe the physical condition of the child(ren),

including conditions that could indicate abuse, neglect or inappropriate placement. ________________________________ Print Parent/Guardian Name ________________________________ Parent/Guardian Signature _________________ Date ______________ 2nd Year Initial Parent _______________ Date

_____ Initials

_____ Initials

FOSTER oChild's Name: _____________________________ Birth date: ______________ Male o Female o Insurance: Medi-Cal o Private Pay o None oParent/Guardian: ___________________________ W.I.C. Services: Yes o No o Medical Plan: ________________________________2nd Year Parent Initial ________ Date _________ W.I.C. Number: _________________________ Dental Plan: _________________________________

1. INFANT/CHILDHOOD HEALTH 4. Has the child had any of 6. NUTRITION HISTORY: Yes NoChild's birth weight lbs. oz. the following: Yes NoCheck Yes or No Yes No Vision problemsPremature birth Wears glasses Is child allergic to any foods?Feeding problems/poor weight gain More than 3 ear infections/yearBreathing difficulty Tubes in earsDid child walk by 14 months?

More than 3 colds/yearPneumoniaEczema Does child drink from a baby bottle?Cerebral Palsy How many times a day does child have?Fractures Meals: Snacks:Teeth/gums/mouth problems Would you describe child's diet as

Good o7. How many times a day does child eat the following?

Is child currently taking: Yes NoFluoride Meat, fish, poultry, eggsVitamins 5. Toilet Training Yes No Dried beans, lentils, peanut butterIron FruitsPrescribed medication(s)-please list: Vegetables

MilkCheese, yogurtBread, rice, grits, cereal, tortillas

3. Check the "Family" column if there is a history Child wears a diaper or pull-up. Sodas/sweetened fruit drinksCake, cookies, candy, chips

the "Child" column if it applies to your child. FOR STAFF TO COMPLETE ONLY: Yes NoFamily Child 6. DENTAL CARE HISTORY Does child need medication at school?

Allergies Are child's teeth: Yes No Medication Form provided.Anemia Brushed daily by parent Does child need an emergency health plan?Asthma Brushed daily by child School nurse to be notified at enrollment.Seizures / Epilepsy Flossed daily by parentDiabetes Seen by dentist within past year Drug reactions Food/Nutrition ServicesOverweight/Obesity Medical Statement Form provided.Alcohol / Substance abuseAutism / PDD / Asperger'sDevelopmental or intellectual delays Alternate Meal Form provided.Sickle Cell disease ANY "YES" ANSWER MUST BE ADDRESSED:

Parent/Guardian Signature: Date:

Staff Signature: Date:

Is family requesting an alternate meal plan for religious/personal reasons?

Is there any health information or concern you would like us to know about your child?

Is child on a special diet for medical reasons?

Is there any food child should not eat for religious/personal reasons?

Does child eat/chew things that are not food?Do you have any concerns about child's eating habits?

Does child require a special diet for medical reasons?

Child is able to walk to toilet, pull down clothing, get on & off toilet without assistance.

Did child speak single words by 15 months?Was child exposed to drugs/alcohol/tobacco smoke during Is child exposed to secondhand smoke now?Has child had serious illness/injury, been hospitalized overnight or had surgery?

Frequent constipation/diarrhea/stomach

Child expresses the need to go and can ask to use the toilet.

CHILD HEALTH HISTORY** CONFIDENTIAL **

of the following conditions in your family. Check

#Foods

Fair o Poor o

2. MEDICATIONS

Can you understand most of what your child says?Are you concerned your child's ability to talk or understand is very delayed?

Child has 2 or more toileting accidents each day.

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Elk Grove Unified School District PreK-6 Education

HEALTH SERVICES CONSENT

Child’s Name__________________________ Site: __________________________ We want your child to have the best chance for positive growth and development during his/her time with us in Head Start Preschool. Healthy children learn better. Head Start Preschool has health requirements and provides health screenings at school to help identify any medical or dental concerns that may require further education and/or treatment. We encourage you to be actively involved in your child’s health care. At school your child may be screened for vision, hearing, height/weight, blood pressure, dental, speech/language and development. These are required health screenings. The results of the screenings will be shared with you. We want you to understand that the required medical, dental and other health screenings will help determine if your child needs a referral to a doctor, dentist, or another health specialist to address health concerns or learning needs. The information will also help us provide an education program suited to your child’s needs. All the information will be kept confidential. Please check one box and sign below. I am aware of the health services and screenings required for Head Start Preschool.

Yes, I agree to have my child participate in any of the health screenings that are provided at school. Parent/Guardian Signature Date Staff Signature Date No, I do not want my child to participate in the health screenings that are provided at school and will have them done by my child’s doctor. Parent/Guardian Signature Date Staff Signature Date

2nd Year Parent’s initial ________________

Date________________________________

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FACING THE FACTS: A Parent’s Guide to the Understanding of

CHILD ABUSE

Definition of Child Abuse As used in the article, “child abuse” means a physical injury, which is inflicted by other than accidental means on a child by another person. “Child abuse” also means the sexual abuse of a child or any act or omission prescribed by Section 273a (willful cruelty or unjustifiable punishment of a child) or 273d (unlawful corporal punishment or injury). “Child abuse” also means the neglect of a child or abuse in out-of-home care, as defined in this article. “Child abuse” does not mean a mutual affray between minors.

Penal Code section 11165.6

Definition of Sexual Abuse As used in this article “sexual abuse” means sexual assault or sexual exploitation as defined by the following: (a) “sexual assault” means conduct in violation of one or more of the following sections: section 261 (rape), 264.1 (rape in concert), 285 (incest), 286 (sodomy), subdivision (a) or (b) of section 288 (lewd or lascivious acts upon a child under 14 years of age), 288a (oral copulation), 289 (penetration of a genital or anal opening by a foreign object), or 647a (child molestation).

Penal Code section 11165.1

Definition of Neglect As used in this article, “neglect” means the negligent treatment or the maltreatment of a child by a person responsible for the child’s welfare under circumstances indicating harm or threatened harm to the child’s health or welfare. The term includes both acts and omissions on the part of the responsible person.

Penal Code section 11165.2

Contacts and Services For your information, the following chart shows what agencies may assist you in specific areas as listed below:

Police or Sheriff

County Dept. of Children’s Social Services

State or local Division of Community Care Licensing

*If you believe a child is being (or has been) abused by an individual (relative, friend)… X X

*If you believe a child has been assaulted by a stranger…. X

*If you believe a child is being (or has been) abused in a licensed day care setting (child care center, school, recreational facility, family day care home)….

X X

*If you have any questions or complaints concerning the licensing organization, staffing, or programs of a licensed child care setting…

X

Mandated Reporters While everyone should report suspected child abuse and neglect, the California Penal Code provides that certain professionals and lay persons must report suspected abuse to the proper authorities. The mandated reporters include:

*Any child care custodian (teachers, licensed day care workers, foster parents, social workers) *Medical Practitioners (physicians, dentists, psychologists, nurses) *Nonmedical Practitioners (public health employees, counselors, religious practitioners who treat children) *Employees of a child protective agency (sheriff, probation officers, county welfare department employees)

If abuse is suspected, a phone report to Police or CPS must be made immediately. Failure to submit the written report of suspected abuse by a mandated reporter (listed above) within 36 hours is a misdemeanor punishable by 6 months in jail and/or a $1,000 fine. Remember, you have the primary responsibility for your child’s well being. With a little time, effort, and understanding you may prevent your child from being abused or assist your child when abuse has occurred.

CHILD ABUSE PREVENTION INFORMATION RECEIPT This will acknowledge that I/We; the parent(s) of _________________________________have received a copy of (Name of Child)

“FACING THE FACTS: A PARENT’S GUIDE TO THE UNDERSTANDING OF CHILD ABUSE” from the licensee or authorized representative of the Elk Grove Unified School District, PreK-6 Education. (Name of Facility)

Signature of Parent(s)/Guardian(s) _______________________________ Date: _____________________

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2nd Year Parent Initial _______________ Date: _________________

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LEAD RISK ASSESSMENT Child’s Name ___________________________________

Parents, your answers will help us find out your child’s risk for lead exposure.

1. Does your child live in, or spend a lot of time in, a place built before 1978 that has peeling or chipping paint or that has been recently remodeled? Yes No

2. Does your child eat candies that were made in another country? (Such as Bolorindo, Chaca Chaca, Pelon Pelo Rico, Lucas Acidito, Tama Roca, Limon 7, or others) Yes No

3. Do you use imported, old, or homemade dishes or containers to serve, prepare or store food or drinks such as bean pots, clay pots, lead-soldered pots or cans, ceramic ware? Yes No

4. Does your family use items from foreign countries, such as crayons, cockroach chalk, dried fruit/herbs, teas, candles, dried grasshoppers or other items? Yes No

5. Do you or anyone else who lives with or cares for your child use home remedies such as Greta, Azarcon, Pay-loo-ah, or cosmetics such as Kohl or Surma? Yes No

6. Does your child have a parent, brother, sister, housemate or a playmate who is being followed for lead poisoning or has an elevated blood lead level? Yes No

9. Has your child lived in the United States for less than one year? Yes No

10. Does your child visit other countries frequently? Yes No

11. Does your child live near an active lead smelter or battery recycling plant or other industry that could release lead into the environment? Yes No

12. Does your child live or play next to a freeway, such as at a babysitter’s house? Yes No

Note: 2 or more “Yes” answers indicate an immediate referral, as well as any questions in the above box. Staff Parent Signature Signature Date Date 2nd year Parent’s initial_______________ Date

The questions inside this square indicate an immediate referral.

7. Does your child live with or visit someone who may use lead in his/her work or hobbies? (For example, painting, soldering, automobile battery manufacturing or recycling, vehicle radiator repair, auto painting, demolition or stained glass work?) Yes No

8. Does your child eat dirt, clay, or other non food items, chew on windowsills or pick at chipped paint? Yes No Resources Provide on: ______________________

(Date)

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Members of the Board Beth Albiani Nancy Chaires Espinoza Carmine S. Forcina Chet Madison, Sr. Dr. Crystal Martinez-Alire Anthony “Tony” Perez Bobbie Singh-Allen

Claudia Charter

Program Specialist, PreK Education

(916) 686-7595

FAX: (916) 686-7718 Email: ccharter@egusd.net

Robert L. Trigg Education Center

9510 Elk Grove-Florin Rd., Elk Grove, CA 95624

Parents, your answers will help us find out your child’s risk for TB exposure. Child’s Name Date _ ___ Center ______________ One “Yes” response to questions below indicates an automatic referral.

1. Has the child come in close contact with a person infected with TB? Yes No

2. Is the child infected with or at risk of infection of HIV? Yes No

3. Is the child foreign born, a refugee or a migrant? Yes No

4. Has the child had contact with an incarcerated person or a person who has been incarcerated within the last 5 years? Yes No

5. Has the child been exposed to any of the following: nursing homes, institutionalized adolescents or adults, users of illicit drugs, migrant farm workers and/or those who have recently visited outside of the U.S.?

Yes No

6. Does the child live in a community in which it has been established at high risk for TB? Yes No

7. Has the child traveled outside of the U.S. since his/her last medical visit? Yes No

1st Year Parent Signature: __________________________________________ Date:__________

1st Year Staff Signature: ____________________________________________ Date:__________

2nd Year Parent Signature: __________________________________________ Date:__________

2nd Year Staff Signature: ____________________________________________ Date:__________

TB Risk Assessment

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ELK GROVE UNIFIED SCHOOL DISTRICT

PreK-6 Education

PARENTAL CONSENT FOR ASSESSMENTS Progress monitoring is an important component of our preschool program. Observations, screenings and assessments are conducted throughout the year to provide teachers with information on student progress. Screening/testing results will be utilized by teachers to design instructional strategies to enhance students’ learning. Results are confidential and are used only by the Elk Grove Unified School District PreK-6 Education staff. The following screenings/assessments may be administered: Screening / Observations

ASQ-3 Fluharty Preschool Speech and Language Screening ASQ-SE School Readiness Screening Preschool Language Scale -5 (PLS-5) Observations

Assessment

Desired Results Developmental Profiles 2015

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * __________________________________ ______________________________ Child’s Name Site

Yes, my child may participate in the above screenings and assessments. Yes, the results of my child’s assessments may be forwarded to his/her next

year’s teacher.

No, my child may not participate in the above screenings and assessments.

__________________________________ ______________________________ Parent/Guardian Signature Date

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Elk Grove Unified School District Early Childhood Education

Receipt of Information

I hereby acknowledge that I have received information from the Elk Grove Unified School District regarding the Elk Grove Unified School District Pre-Kindergarten

Programs including information on parents’ legal rights and the Tobacco Free Schools Board Policy 33513 (a)

Name of Student Preschool Site Signature of Parent or Guardian Date__________ Name of Parent or Guardian (Print) ______________________ Date__________

Elk Grove Unified School District PreK-6 Education

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CHILD RELEASE FORM

Child’s Name: Site: Parent’s/Guardian’s Name: Phone (Home) (Other)

In the event that I am unable to pick my child up from preschool, I, , give my permission/consent for my child, , to be released to the following adult(s) who are at least 18 years of age and are recognized by my child. If I arrange for my child to be picked up by someone not listed below, I understand that I must notify the classroom teacher by phone or in writing. Further, I understand that any adult who picks up my child must provide a photo identification card. If these requirements are not followed, I understand that my child will not be released to an adult other than myself or another custodial parent/guardian. Parent/Guardian Signature: Date: 2nd year Initial___________________________________________Date:________________ PARENT/GUARDIAN: Please provide a minimum of two adults who have permission to pick up your child from the classroom.

ADULT’S NAME Local (916) Area Code PHONE NUMBER RELATIONSHIP DESCRIPTION

1.

2.

3.

4.

Review/Update 2nd year

1st Parent Conference: 1st Parent Conference: Parent/Guardian Signature Date Parent/Guardian Signature Date 2nd Parent Conference: 2nd Parent Conference: Parent/Guardian Signature Date Parent/Guardian Signature Date

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ELK GROVE UNIFIED SCHOOL DISTRICT PreK-6 Education

PRESCHOOL ADMISSION AGREEMENT BETWEEN ELK GROVE UNIFIED SCHOOL DISTRICT AND PARENTS/GUARDIANS OF

PRESCHOOL CHILDREN

This agreement informs the parents/guardians of expectations for participation in preschool programs administered by PreK-6 Education. These expectations are applicable to Head Start, State and Title I Preschool.

1. ARRIVAL AND DEPARTURE POLICY: Arrival Time - Children are to always arrive in the classroom at the scheduled time.

Signing-In and Out - For your child’s protection and in compliance with the State of California Child Care Licensing Law, you must sign your child in when you arrive and sign out when the child leaves.

Departure Time - Children are to be picked up at the scheduled time. If your child is not picked up on time the following procedures will be used:

1) A verbal reminder will be given the first time the child is not picked up on time. 2) A parent conference will be held the second time this occurs.

3) A written reminder will be given the third time a child is not picked up on time. 4) A parent conference will be held to discuss possible termination of your child from the program.

Authorized Release of Child - Staff members will release children only to the parent or guardian (or a person explicitly authorized by the

parent or guardian, age 18 or older). 2. PARENT PARTICIPATION:

Parent participation is essential to your child’s successful school experience. You are highly encouraged to attend parent meetings and workshops and to volunteer in the classroom a minimum of three (3) hours a week.

3. ABSENCE/ILLNESS: 1) Children must attend class regularly. If your child is ill, you must notify the teacher. 2) Parents will be contacted/ notified regarding unexcused

absences or inconsistent attendance, which can result in your child being dropped from the class if attendance does not improve 3) Children who are absent ten (10) days or more without notification may be dropped from the class.

4. HOME VISITS/PARENT CONFERENCES:

Parent conferences are scheduled twice a year. For Head Start Preschool, teachers will also schedule two (2) or more home visits during the school year. Your participation is necessary to facilitate ongoing communication.

5. DISCIPLINE: Staff members are required to provide all children with a safe, healthy and comfortable learning environment. Expectations for all children

will be clearly explained to children and to parents/guardians.

6. CONFIDENTIALITY: All information pertaining to children and families is maintained in a confidential manner. Release of information to any agency or other

Party will not occur without written consent of the parent/guardian.

7. TRANSPORTATION:

No transportation is provided to or from preschool. 8. PLACEMENT: Upon completion of the student file, children will be placed based on criteria mandated by the grant funding the program.

PRESCHOOL ADMISSION AGREEMENT I understand all of the above requirements. 2nd Year

Child’s Name:

__________________________________________________________

Program:

__________________________________________________________

Initial: _____________

Parent/Guardian Signature:

_____________________________________ Date:_______________

Date:_______________

PHYSICAL/ TUBERCULOSIS RISK ASSESSMENT/ DENTAL REQUIREMENT: All children are required by Child Care Licensing (Title 22, 10122) to have completed a Physical Examination within 30 days of entry. TB Risk Assessment prior to entry/placement into the Pre-K program. Children who do not meet the 30-day Physical Exam requirement will be notified and temporarily excluded from attendance until requirements are received. An updated Dental Examination must be completed within the program year.