2017-18 Big Five Head Start Applicant & Family Member Information Applicant

First Middle Last Suffix Nickname Birthday Gender SSN

Race Asian Black White

Other:

American Indian/Alaska Native Hawaiian/Pacific Islander Multi-Racial

Hispanic Yes No

Primary Health Coverage Sooner Care

Private Insurance

Adult 1First

Other Health Coverage CDIB

Military

Insurance# Other None

Middle Last

English Proficiency None Little Moderate Proficient Medicaid Not Eligible On Medicaid

Potentially Eligible

Other Language Other Language Proficiency Poor Moderate Proficient

Medicaid # Doctor Dentist

Suffix Nickname Birthday Gender SSN

Race Asian Black White

Other:

American Indian/Alaska Native Hawaiian/Pacific Islander Multi-Racial

Hispanic Yes No

English Proficiency None Little Moderate Proficient

Other Language

Highest Grade Completed Employment Status Child's Relationship Custody Associate's Grade 10 Full Time Full Time & Training Natural/Adopted/Step Yes Bachelor's Grade 11 Part Time Part Time & Training Grandchild No Col Deg/Train Grade 12 Seasonal Training or School Niece/Nephew Col or Adv Train Grade 9 Unemployed Retired or Disabled Foster GED HS Graduate

Master's Other

E-mail Address:

Adult 2First Middle Last Suffix Nickname Birthday

Other Language Proficiency Poor Moderate Proficient

Check all that apply: Lives with Family Provides Financial Support Teen Parent

If teen parent, subsidized? Yes No

Gender SSN

Race Asian Black White Other:

American Indian/Alaska Native Hawaiian/Pacific Islander Multi-Racial

Hispanic Yes

No

English Proficiency None Little Moderate Proficient

Other Language Other Language Proficiency Poor Moderate

Proficient

Highest Grade Completed Employment Status Child's Relationship Custody Check all that apply: Associate's Grade 10 Full Time Full Time & Training Natural/Adopted/Step Yes Lives with Family Bachelor's Grade 11 Part Time Part Time & Training Grandchild No Provides Financial Support Col Deg/Train Grade 12 Seasonal Training or School Niece/Nephew Teen Parent Col or Adv Train Grade 9 Unemployed Retired or Disabled Foster GED HS Graduate

Master's Other If teen parent, subsidized?

Yes No

E-mail Address:

TransportationHave transportation?

Yes

No

If yes. what type? If no, does child need to be transported by bus?

HousingType of housing Housing payment

Personal Yes House Own Public No Apartment Rent Family/Friend Mobile home/trailer Exchange for services

Community shelter No payment Homeless Subsidized Other Other

* If family has more than one child applying for services. please complete a separate copy of this form for each applicant

Copyright © 2013 Management Information Technology USA, Inc, CENTER/CLASSROOM ______________________________________________________________________________________________________________________________________

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2017-2018 Big Five Head Start Applicant & Family Additional Child (Non-Applicant) * First Middle Last Suffix Nickname

Member Information (continued)

Birthday Gender SSN

Race Asian American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi-Racial Other:

Hispanic Yes No

English Proficiency None Little Moderate Proficient

Other Language Other Language Proficiency Poor Moderate Proficient

Additional Child (Non-Applicant) * First Middle Last Suffix Nickname Birthday Gender SSN

Race Asian American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi-Racial Other

Hispanic Yes No

English Proficiency None Little Moderate Proficient

Other Language Other Language Proficiency Poor Moderate Proficient

Additional Child (Non-Applicant)* First Middle Last Suffix Nickname Birthday Gender SSN

Race Asian American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi-Racial Other:

Hispanic Yes No

English Proficiency None

Little Moderate Proficient

Other Language Other Language Proficiency Poor Moderate Proficient

Additional Child (Non-Applicant) * First Middle Last Suffix Nickname Birthday Gender SSN

Race Asian American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi-Racial Other:

Hispanic Yes No

English Proficiency None Little Moderate Proficient

Other Language Other Language Proficiency Poor Moderate Proficient

Additional Child (Non-Applicant) * First Middle Last Suffix Nickname Birthday Gender SSN

Race Asian American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi-Racial Other:

Hispanic Yes No

English Proficiency None Little Moderate Proficient

Other Language Other Language Proficiency Poor Moderate Proficient

Additional Child (Non-Applicant) * First Middle Last Suffix Nickname Birthday Gender SSN

Race Asian American Indian/Alaska Native Black Hawaiian/Pacific Islander White Multi-Racial Other:

Hispanic Yes No

English Proficiency None Little Moderate Proficient

Other Language Other Language Proficiency Poor Moderate Proficient

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2017-2018 Big Five Head Start Family Information, Income & Contacts

Applicant Name: Birthday,

Family Information Living Address Address Line 2 Zip City State County

Mailing Address (if different) Address Line 2 Zip City State County

Phone Numbers Type (check one) Note (for example, an extension or best time to calf)

Cell Home Work Other

Cell Home Work Other

Cell Home Work Other Parental Status (check one) Primary Language at Home Homeless Family Active Duty Military One Parent Two Parent Yes No Yes No

Family Income TANF Supplemental Security Income WIC SNAP/Food Stamps Yes No Formerly Yes No Yes No Yes No

InterviewDate Verified (agency use only) Verified by (agency use only)

Family Member

Amount Per (for example: week, month, year)

Annual Amount Verification (for example: W2, check stub)

Description (for example: SSI, Job. Child Support)

Income Notes

Emergency Contacts & Individuals with Pick-Up Permission Name Relationship Emergency Contact Release To

Yes No Yes No

Cont

act 1

Address

Phone # 1

Cell Home Work

Zip

Phone# 2

Cell Home Work

City

Phone #3

State

Cell Home Work

Name Relationship Emergency Contact Release To

Yes No

Address Zip Yes No

City State

Cont

act 2

Phone #1

Cell Home Work

Phone # 2

Cell Home Work

Phone # 3

Cell Home Work

Cont

act 3

Name Relationship Emergency Contact Release To

Yes No Yes NoAddress Zip City State

Phone #1 Cell Home Work

Phone# 2 Cell Home Work

Phone #3 Cell Home Work

Certification: / certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.

Parent/Guardian Signature ______________________________________________________________ Date ______________________________

$ $

$ $

$ $

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1. Child Health History; Has the child ever had any of these conditions? Please give explanation to any “ Yes” answers. (Use space provided below to explain.)

Condition Yes No Condition Yes No Condition Yes No Allergies Anemia (low iron) Asthma Boils Bleeding conditions Broken bones Cancer Chicken pox Diabetes Eczema Hives Heart conditions High Blood Pressure High Blood Lead Mumps Measles Immune System Disease Inherited Disease Liver Disease Seizures Emotional Disturbance Down Syndrome Overweight Pneumonia Sickle Ceil Disease Sickle Cell Trait Tubes In Ears Tonsils Removed Rheumatic Fever Scarlet Fever Please explain “Yes” answers: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Is child receiving treatment for any of the following health conditions? Condition Yes No Condition Yes No

Anemia (low iron) Asthma Overweight Hearing Difficulties Vision Problems High Lead Levels Diabetes Other

3. a. Is the child currently taking medication? Yes No If “Yes”, explain: Name of Medication: _______________________

Dose: ___________________________________ How often? ______________________________

b. Will Head Start staff need to administer this medication? Yes No (If “Yes“ a special consent form must be completed entirety before the child can receive medication while attending the Head Start program.)

4. Does this child have a diagnosed health problem? Yes No If “Yes” Name of Physician ______________________

Address _____________________ Phone# _____________________

5. Has this child ever had surgery? Yes No If “Yes” please explain: ____________________________

6. Has this child ever had a seizure? Yes No If “Yes” please explain: Cause if known. ________________________

How often: _______________________________ Date of last seizure: ________________________

7. Has the child ever been diagnosed with asthma? Yes No If “Yes” please explain: Cause if known: _______________________

How often: _______________________________ Date of last asthma attack: ___________________

8. Has the child ever had an allergic reaction? Yes No If “Yes”, please explain the reaction: ___________________________ ______________________________________________________

Cause if known: _____________________________ Date of last reaction:__________________________

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9. Has this child ever had problems with the following conditions? Condition Yes No Condition Yes No Condition Yes No

Frequent Ear Infections Frequent sore throats Frequent bed wetting Frequent chest pains Frequent coughing Frequent stomach aches Problems with bowels Problems eating Problems with urinating Hearing problems Vision problems Problems with eyes Frequent trouble sleeping Speech problems Temper Tantrums Other _______________ Other ______________ Other _______________ Explain any "Yes" answers:

10. Has this child ever been involved in a child abuse &/or neglect incident or case? Yes No If “Yes”, please explain: _____________________________________________________

11. Does child have a regular doctor? Yes No If “Yes”, please explain. When did you obtain doctor for child? _____________

Where does child receive medical care? Doctor office Clinic Date of last physical exam: __________

Name of Doctor _________________________________________________ Address _______________________________________________________ Phone Number _____________________________________________________________

12. Does child have a regular dentist? Yes No If “Yes”, please explain: When did you obtain dentist for child? ________________

Where does child receive dental care? Dentist office Clinic Date of last dental exam: _____________

Name of Dentist _________________________________________________ Address ________________________________________________ Phone Number __________________________________________________

13. Are child's immunizations up to date? Yes No If "No", child cannot be accepted into program. Please attach copy of record.

Disability Information: Children with special needs may receive priority for Head Start enrollment..

1. Does this child have any additional condition that could interfere with his/her daily activities? Yes No If “Yes”, please explain: ___________________________________________________________________ __________________________________________________________________________________

2. Is this child's routine screenings (developmental, sensory, and behavioral) completed? Yes No

If “Yes”, does the child need follow-up assessment or format evaluation to determine if the child had a disability?

3. Does your child have a disability? Yes No (if no, please go to question #8.)

4. Type of special needs or disability? ______________________________________

5. Has the disability been professionally diagnosed? Yes No If so, by whom? ____________________

6. Is the child receiving special services for the disability? Yes No If “Yes”, type of services? ____________________________

7. Does child currently have an (IEP) Individual Education Plan? Yes No If “Yes”, which school district completed the IEP? _____________________________________________

8. In your opinion, does your child have a special need that has not yet been diagnosed? Yes No

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NUTRITION ASSESSMENT SURVEY 2017-2018

Name of Child:____________________________________________ Center Name: _______________________

Please answer the following questions regarding your child:

1. Is your child taking a vitamin supplement? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If yes, are they prescribed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

2. Does your child have any persistent/current issues? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If yes, please select: Nausea or vomiting? Diarrhea? Constipation? Trouble Swallowing?

3. Has your child experienced a dramatic weight change in the past year? . . . . . . . . . . . . . Yes No

If yes, please explain: _____________________________________________________________________

______________________________________________________________________________________

4. Is your child on a special diet? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, please list type of diet: ______________________________________________________________

5. Does your child have an allergy to food? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, please list: _________________________________________________________________________

6. Is your child enrolled in a Nutrition Program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, which program? WIC Food Stamps Other _______________

7. Does your child use spoon and fork? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 8. Does your child have a feeding tube? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

Other method? Yes No If yes, please list _____________________________

9. Do you have any concerns about your child’s size? . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If yes, please check your concern: Too Thin? Too Small? Too Heavy? Too Tall?

10. Please check which meals your child eats daily: Breakfast Lunch Dinner Snack

11. On a WEEKLY basis, how often does your child eat items from the following food groups? (Please check number)

a. Dairy ( milk, cheese, yogurt) 0* 1* 2* 3 4 5 6 7 7+

b. Meat, fish, poultry, eggs or dried beans / peas peanut butter? 0* 1* 2* 3 4 5 6 7 7+

c. Grains (rice, grits, bread, cereal, tortillas) 0* 1* 2* 3 4 5 6 7 7+

d. Vegetables (greens, carrots, broccoli, winter squash, pumpkin, sweet potatoes) 0* 1* 2* 3 4 5 6 7 7+

e. Fruit or juices (oranges, grapefruit, tomatoes, grapes) 0* 1* 2* 3 4 5 6 7 7+

f. Oil, butter, margarine, etc. 0* 1* 2* 3 4 5 6 7 7+

g. Sweets (cakes, cookies, soda/pop, fruit drinks (Kool-Aid), candy) 0* 1* 2* 3 4 5 6 7 7+

*Starred answers may require follow-up. Explain or provide additional comments here:

12. Criteria for Referral: Suspect Dietary Problem Inadequate food intake Underweight Overweight

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Big Five Head Start / Enrollment Agreement

The Big Five Head Start Program is federally funded, thus there is no charge to attend the Head Start Program. The program complies with federal Head Start Performance Standards, the Oklahoma State Licensing Regulations, and Big Five Agency Policies.

The following is an agreement between ________________________________________________________________

(Printed Name of Parent/Guardian)

and Big Five Head Start regarding placement of ___________________________________________in Head Start.

(Printed Name of Child )

Please initial each item and sign at the bottom.

__________ I understand, I must sign my child in and out of class daily on the sheet provided by Big Five. I also understand, my child cannot arrive more than 15 minutes prior to the session and should be in class no later than 9:00 a.m.

_________ I understand, I must contact my child’s classroom in advance if my child is going to be absent including any last minute and/or unexpected absences.

_________ I understand, my child will be released to ONLY those people whom I have listed on the Emergency Contact form. I understand I can only make changes to this form in person. I also understand that person(s) picking my child up who are not familiar to staff in charge will be requested to show photo identification.

_________ I understand, if my child is transported to and/or from the classroom by Big Five’s transportation system, it is my duty to inform my child’s teacher of ANY change of location for pick up or delivery of my child ONE DAY IN ADVANCE. I also understand, if my child is not at the designated location three (3) days in succession, he/she may be dropped from the route pending contact from a designated family member.

__________ I understand, if my child is not picked up by someone previously authorized and/or someone cannot be located for more than one (1) hour from the end of the session with no contact from a family member; my child may be placed in the custody of the local police, sheriff’s department, and/or Child Protective Service Agency.

__________ I understand, I am a part of a team consisting of our family, Big Five Head Start staff, and other resources as needed. I understand I will be asked to join in a partnership with Head Start to establish trust and communication while working toward the overall health and development of my child.

__________ I understand, if my child is referred for services by a Child Development Specialist, Child Psychologist, and/or Mental Health Clinician . . . I agree to follow through with recommended referrals.

__________ I understand that inappropriate behavior that disrupts the daily operation of the Head Start program will not be tolerated.

__________ I understand that video and sound equipment will be used in my child’s classroom. I understand that only approved individuals will be viewing the video recordings for the purposes of observation and professional development trainings.

Parent/Guardian Signature: __________________________________________________ Date: ________________

Big Five Head Start Staff Signature: ____________________________________________ Date: _________________

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Big Five Head Start Consents, Authorizations, and Releases

Center Name _________________________________________Classroom#_____ Date ___________

Child’s Name ______________________________________________Date of Birth ______________

Consents, Authorizations, and Releases for Screenings/Exams: Parent please check each item and initial.

Parent/Guardian Initials

Vision Screening

Hearing Screening

Height and Weight

Lead Screening (Required)

Hematocrit and/or Hemoglobin (Required)

Blood Pressure

Dental Exam (Required) (including treatment if indicated)

Well-Child Check/Physical Exam (Required) including treatment if indicated)

Behavioral Screening

Classroom Mental Wellness Observation/Consultation

Developmental Screening and Assessment

Articulation / Speech Screening

Other Permissions / Releases: Parent please check each item and initial.

Parent/Guardian Initials

Share Health/Developmental Records with School System

Accompany Class on Field Trips

Use of Child’s Photograph (Social Media, Big Five Newsletter and/or Website)

Parent/Guardian Signature:_______________________________________Date: ___________________

PRINTED Name of Parent/Guardian:________________________________________________________

Big Five Staff Signature: _____________________________________Date: _________________

PRINTED Name of Big Five Staff:________________________________________________________

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