PARENTS IN COMMUNITY ACTION NC HEAD … App Spanish 2018v2.pdfcheque u otro comprobante de ingresos. ü Plan de Cuidado Infantil Individual Si su hijo tiene una condición de salud

PARENTS IN COMMUNITY ACTION, INC. HEAD START Y HEAD START TEMPRANO

www.picaheadstart.org

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© 2019 Parents In Community Action, Inc.-skc

Línea de Información

de PICA 612-377-4444

ALGUNOS DE LOS SERVICIOS DISPONIBLES EN PICA HEAD START

SERVICIOS PARA FAMILIAS APOYO

ü Transporte de puerta a puerta ü Banco de alimentos mensual ü Servicios dentales en las escuelas ü Evento “Conexión Familiar” ü Preparación escolar ü Terapia lingüística y psicoterapia

ü Superación de la farmacodependencia ü Apoyo para discapacitados en ingles y

español ü Apoyo para la alfabetización ü Salud mental ü Nuevo Contrato de Vida (para gente sin

hogar) ü Apoyo prenatal

OPORTUNIDADES PARA PARTICIPACIÓN DE PADRES

ü Comités consultivos ü Comité del Centro ü Clases de ciudadanía ü Inglés como segunda lengua (ESL) ü Clases de primeros auxilios y de RCP ü Clases de equivalencia de preparatoria (GED) ü Apoyo a los abuelos ü Involucramiento masculino ü Actividades en la Sala de Padres ü Tiempo de Padres y Niños (PAC) ü Consejo de Políticas

ü Valorando el Involucramiento de los Padres (VIP)

OPORTUNIDADES PARA CAPACITACIÓN DE PADRES

ü Ayudante de autobús ü Desarrollo infantil ü Habilidades secretariales ü Bienestar familiar ü Servicio de alimentos ü Transporte

REQUISITOS DE ELEGIBILIDAD: ¿CÓMO VOY A SABER SI MI NIÑO ES ELEGIBLE?

HEAD START/HEAD START TEMPRANO Opción de media semana (El niño asiste 2-3 días por semana) • El niño tiene de 6 semanas a 5 años. • El niño vive en el condado de Hennepin. • La familia recibe dinero del programa MFIP, Ingresos de

Seguridad Suplementarios (SSI), o no rebasa los límites de ingresos (véase abajo).

• Los niños con discapacidades diagnosticadas (y un plan de educación individual, cuyas siglas en inglés son IEP) son elegibles sin importar los ingresos. Los niños con necesidades especiales o que están en adopción temporal, que tienen de 6 semanas a 5 años y que viven en el condado de Hennepin, también son elegibles.

HEAD START: Opción de Tiempo Completo (El niño asiste 5 días por semana) • El niño tiene de 3 a 5 años. • El niño vive en el condado de Hennepin. • La familia es elegible para un subsidio de guardería

porque los padres/tutores trabajan o van a la escuela, o porque el niño tiene discapacidades diagnosticadas o necesidades especiales.

HEAD START TEMPRANO: Opción de Tiempo Completo (El niño asiste 5 días por semana)

• El niño tiene de 6 semanas a 3 años. • El niño vive en el condado de Hennepin. • La familia es elegible para un subsidio de

guardería porque los padres/tutores trabajan o van a la escuela, o porque el niño tiene discapacidades diagnosticadas o necesidades especiales.

FEDERAL INCOME GUIDELINES 2019 FAMILY SIZE MAX YEARLY INCOME 1 $12,490 2 $16,910 3 $21,330 4 $25,750 5 $30,170 6 $34,590 7 $39,010 8 $43,430 FOR EACH ADDITIONAL PERSON ADD $4,420.

CÓMO INSCRIBIR A SU NIÑO Por favor traiga los siguientes documentos:

ü Examen Físico e Historial de Vacunación Actuales. Llene la primera parte de los formularios adjuntos para el examen físico y e historial de vacunación. Pídale a su doctor que los llene y los firme..

ü Examen Dental. Si su niño tiene dentista, pídale que llene y firme el reporte dental adjunto. ü Tarjeta de Seguro. Traiga las tarjetas de Seguro medico y/o dental de su niño. ü Información de Emergencia. Venga preparado para proporcionar os

nombres, las direcciones y los numeros de teléfono de dos contactos de emergencia.

ü Comprobante de Ingresos. Traiga documentación official de ingresos, Por ejemplo: Plan de Inversión Familiar de Minnesota (MFIP), Ingresos de Seguridad Suplementarios SSI), Ingresos por Discapacidad del Seguro Social (SSDI), o compensación por adopción temporal o desempleo. Si usted tiene empleo, traiga el formulario W-2, su declaración de impuestos, un talon de cheque u otro comprobante de ingresos.

ü Plan de Cuidado Infantil Individual Si su hijo tiene una condición de salud como: asma, alergia a los alimentos, alergia ambiental, convulsions o cualquier otra condición de salud.

ü Si usted no trae toda esta información, no podremos inscribir a su niño.

FAVOR DE PRESENTAR PERSONALMENTE SU SOLICITUD EN CUALQUIERA DE ESTOS CENTROS EDUCATIVOS.

Se aceptan solicitudes de las 9:00 a.m. a las 5:00 p.m. Usted puede llamar para hacer una cita si no puede venir durante este horario.

CIUDADES AL OESTE Helen H. Taylor Center

4901 Olson Memorial Highway Golden Valley, MN 55422 Teléfono: (763) 541-7422

EL NORTE DE MINNEAPOLIS Donald M. Fraser Center

700 Humboldt Avenue North Minneapolis, MN 55411

Teléfono: (612) 377-7422 EL SUR DE MINNEAPOLIS

McKnight Center 4225 Third Avenue South Minneapolis, MN 55409

Teléfono: (612) 825-7422

Park Place Center 2745 Park Avenue South Minneapolis, MN 55407

Teléfono: (612) 870-7422

Portland Village Center 1829 Portland Avenue South

Minneapolis, MN 55404 Teléfono: (612) 871-7422

PICA Training Center

4255 Third Avenue South Minneapolis, MN 55409

Teléfono: (612) 822-7422

CIUDADES AL SUR South Branch Center 7145 Harriet Avenue Richfield, MN 55423

Teléfono: (612) 871-7422

Pond Center 9600 Third Avenue South Bloomington, MN 55420 Teléfono: (612) 871-7422

EL NORESTE DE MINNEAPOLIS

Northeast Center 342 Thirteenth Avenue N.E.

Minneapolis, MN 55413 Teléfono: (612) 379-7422

CIUDADES AL NOROESTE Town Hall Center

8500 Zane Avenue North Brooklyn Park, MN 55443 Teléfono: (763) 425-7422

Aubrey Della Center

6415 Brooklyn Boulevard Brooklyn Center, MN 55429

Teléfono: (763) 535-7422

EL SURESTE DE MINNEAPOLIS

Glendale Center 96 St. Mary’s Avenue S.E. Minneapolis, MN 55414

Teléfono: (612) 874-7422

REQUISITOS DE SALUD PARA HEAD START Su niño necesita un examen físico llamado un Chequeo para Niños y Adolescentes

ü Los resultados de una prueba de plomo en sangre ü Un chequeo de todo el cuerpo ü Los resultados de una prueba de hierro (hemoglobina)

en sangre ü Una lectura de presión arterial ü Un chequeo de los ojos y los oídos ü Un historial de vacunación actualizado

El compromiso de Head Start al bienestar abarca una vision integral de salud para los niños y las familias. Se requiere un examen físico completo para que nos podamos asegurar de que, si se identifican en los niños problemas de salud y desarrollo, los niños y las familias sean conectados con una fuente de cuidado continuo y accesible (un hogar medico) para satisfacer sus necesidades básicas de salud. El enfoque de los servicios de salud de Head Start son la prevención y la intervención temprana.

Pidele a mi doctor que me

haga un Examen para Niños y Adolescentes (Child & Teen

Checkup).

Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 612-377-7422

CHILD PHYSICAL Please complete the attached Individual

Child Care Plan for Chronic Health Issues

Child’s Last Name First Name Middle Initial Birth Date

Parent/Guardian Names Address Present Age Telephone Number:

Early and Periodic Screening Diagnosis and Treatment (EPSDT) exam required. Starred items (*) are required by Federal Head Start and Early Head Start regulations.

Enter date if date of test is other than “exam date” recorded below.

FINDINGS, TREATMENTS, AND RECOMMENDATIONS.

TEST DATE RESULTS TEST DATE RESULTS A. HEIGHT (CM)* H. Vision (Type of Test)* B. WEIGHT (KG)* I. ACUITY, R/L C. BMI J. CORNEAL REFLEX D. BLOOD PRESSURE K. COVER TEST E. HEMATOCRIT or

HEMOGLOBIN* Result L. COMMENTS

M. OTHER TESTS Complete or send past results)

F. LEAD* (1) TB (2) Sickle Cell (3) Ova & Parasites (4) Urinalysis (5) Other

G. HEARING (Type of Test)* Pure Tone at 20dB

1000 Hz 2000 Hz RIGHT EAR q Pass q Fa

il q

q Fail q Pass q Fail

LEFT EAR q Pass q Fail

q q Fail q Pass q Fail

PHYSICAL EXAMINATION/ASSESSMENT Normal for Age Abnormal Not

Evaluated Note to physician: Please fill out all items in Health Record.

A. GENERAL APPEARANCE q NL q AB q NE Specify any condition that may result in an emergency situation:

How is child’s overall physical status?

B. POSTURE, GAIT q NL q AB q NE C. SPEECH q NL q AB q NE D. HEAD q NL q AB q NE E. SKIN q NL q AB q NE F. EYES: q NL q AB q NE Specify type and dose of any current medication or therapies:

(1) External Aspects q NL q AB q NE (2) Optic Fundoscopy q NL q AB q NE

G. EARS q NL q AB q NE Environmental Allergies:

(1) External & Canals q NL q AB q NE (2) Tymanic Membranes q NL q AB q NE

H. NOSE, MOUTH, PHARYNX q NL q AB q NE I. DENTAL q NL q AB q NE

(1) Examine Teeth q NL q AB q NE Food Allergies Describe any dietary substitutions

(2) Examine Gums q NL q AB q NE (3) Referral to Dentist? q NL q AB q NE

J. HEART q NL q AB q NE K. LUNGS q NL q AB q NE L. ABDOMEN (Include hernia) q NL q AB q NE M. GENITALIA q NL q AB q NE Describe any diagnosed disabilities:

N. BONES, JOINTS, MUSCLES q NL q AB q NE O. NEUROLOGICAL/SOCIAL q NL q AB q NE

(1) Gross Motor q NL q AB q NE (2) Fine Motor q NL q AB q NE Please print or type physician or nurse practitioner’s name and telephone number.

(3) Communication Skills q NL q AB q NE (4) Cognitive q NL q AB q NE Print MD/NP Name (5) Self-Help Skills q NL q AB q NE First Last (6) Social Skills q NL q AB q NE

P. GLANDS (Lymphatic/Thyroid) q NL q AB q NE MD/NP Signature Q. DEVELOPMENTAL ASSESSMENT q NL q AB q NE

Phone Exam Date Abnormal Findings/Diagnoses Treatment Plan and Recommended Follow-Up or Results Date

Rev:4/26/18skc

Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 (612) 377-7422

INDIVIDUAL CHILD CARE PLAN

Please send the Asthma Action Plan or Anaphylaxis Plan, if applicable.

First Name Last Name Birthdate

HEALTH CARE PROVIDER TREATING THE CHILD’S CONDITION: Site Class Session

Name/Title Clinic

Address City Zip

Telephone Fax

1. Diagnosed Medical Condition:

a) When was your child first diagnosed? Is it an ongoing health issue? ☐ Yes ☐ No

b) If yes, describe how often it occurs:

c) What symptoms and behaviors does your child experience?

d) List any restrictions at day care:

2. Treatment and Medications (Complete MEDICATION PERMISSION form)

a) Routine treatment(s) and medication(s):

b) As needed (PRN) treatment(s) and medication(s):

3. Emergency Care: If your child does not respond to medication and treatment, the emergency plan is:

4. Additional Information and/or Health Care Provider Recommendations:

5. Child’s Knowledge (to be completed by parent):

a) What is your child’s understanding of the medical condition?

b) Does your child understand about any restrictions at day care?

c) Can your child tell the teacher when treatment or medication is needed? ☐ Yes ☐ No

d) Does your child cooperate with treatment and medication? ☐ Yes ☐ No

Parent or Guardian Signature and Date Health Care Provider Signature and Date (not needed for eczema)

© 2018 Parents In Community Action, Inc. – skc

Child Care Immunization Form Must be on file before a child attends child care

Name Birthdate Minnesota law requires children enrolled in child care to be immunized against certain diseases or have a legal medical exemption or conscientious exemption on file.

Parent/Guardian: You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease or laboratory evidence of immunity, and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs.

Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status, section 2A to document medical exemptions (including a history of varicella disease), and 2B to document a conscientious exemption.

For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970.

Type of Vaccine DO NOT USE (✓)or(*) 1st Dose Mo/Day/Yr

2nd Dose Mo/Day/Yr

3rd Dose Mo/Day/Yr

4th Dose Mo/Day/Yr

5th Dose Mo/Day/Yr

Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP) • 3 doses during 1st year (at 2-month intervals) • 4th dose at 12-18 months • 5th dose at 4-6 years

Indicate vaccine type: DTaP or DTP

5th dose not required if 4th dose was given on or after the 4th birthday

Polio (IPV, OPV) • 2 doses in the first year • 3rd dose by 18 months • 4th dose at 4-6 years

4th dose not required if 3rd dose was given on or after the 4th birthday

Measles, Mumps, and Rubella (MMR) • Required for children 15 months and older • 1st dose on or after 1st birthday • 2nd dose at 4-6 years

Haemophilius influenza type b (Hib) • 2-3 doses in the first year • 1 dose required at 12 months or older • For unvaccinated children 15-59 months, 1 dose is

required • Not required for children 5 years or older

Varicella (chickenpox) • Required for children 15 months or older • 1st dose on or after 1st birthday • 2nd dose at 4-6 years

Pneumococcal Conjugate Vaccine (PCV) • Required for children age 2-24 months • 3 doses in the first year • 4th dose after 12 months • At least 1 dose is recommended for children 24-59

months in child care

Hepatitis B (hep B) • 2-3 doses in the first year • 3rd dose (final dose) by 18 months

Hepatitis A (hep A) • 2 doses separated by 6 months for children 12 months

and older

Recommended Rotavirus (2-3 doses between 2 and 6 months)

Influenza (annually for children 6 months or older) © 2018 Parents In Community Action, Inc.-skc

Name

Instructions, please complete: Box 1 to certify the child’s immunization status Box 2 to file an exemption (medical or conscientious)

1. Certify Immunization Status. Complete A or B to indicate child’s immunization status. A. Children who are 15 months or older: B. Children who are younger than 15 months:

For children who are 15 months or older and who have received all the immunizations required by law for child care. I certify that the above-named child is at least 15 months of age and has completed the immunizations which are required by law for child care.

Signature of Parent/Guardian OR Physician/Nurse Practitioner/Physician Assistant/Public Clinic _____________________________Date

For children who are younger than 15 months OR have not received all required immunizations. I certify that the above-named child has received the immunizations indicated. In order to remain enrolled, this child must receive all required vaccines within 18 months of the initial enrollment date. The dates on which the remaining doses are to be given are: Signature of Physician/Nurse Practitioner/ Physician Assistant/Public Clinic _____________________________Date

2. Exemptions to Immunization Law. Complete A and/or B to indicate type of exemption. A. Medical exemption: B. Conscientious exemption:

No child is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a child to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement: I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below). List exempted immunization(s): Signature of physician/nurse practitioner/physician assistant _____________________________Date * History of varicella disease only. In the case of

varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in __________(year)

Signature of physician/nurse practitioner/physician assistant (If disease occurred before September 2010, a parent can sign.)

No child is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the child or others they come in contact with. In a disease outbreak, children who are not vaccinated may be excluded in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s). ¨ I am opposed to all vaccines. ¨ I am opposed only to vaccines indicated below. ___________________ __________________ ___________________ __________________ Signature of parent or legal guardian

______________________________Date Subscribed and sworn to before me this: ________day of _______________________20___ Signature of notary (A copy of the notarized statement will be forwarded to the commissioner of health.)


ASTHMA ACTION PLAN

SITE: ROOM:

Patient Name: Weight: # DOB: Peak Flow:

Doctor or Nurse Practitioner Name: Asthma Severity:

Clinic Name: Phone: Symptom Triggers:

Green Zone The Green Zone means take the following medicine(s) every day:

“Go All Clear!” Controller Medicine(s): Dose:

- Breathing is easy - Can play, work, and sleep without

asthma symptoms

Peak Flow Range Spacer Used: (80%-100% of personal best)

to Take the following medicine if needed 10-20 minutes before sports, exercise, or any other strenuous activity:

Yellow Zone

The Yellow Zone means keep taking your Green Zone controller medicine(s) every day and add the following medicine(s) to help keep the asthma symptoms from getting worse.

“Caution…” Reliever Medicine(s): Dose:

- Wakes up at night - Coughs or wheezes - Chest is tight

Use Quick Reliever 2-4 puffs, every 20 minutes for up to 1 hour or use nebulizer once.

If your symptoms are not better or you do not return to the GREEN ZONE after 1 hour, follow RED ZONE instructions. If you are in the Yellow Zone for more than 12-24 hours, call your provider. If your breathing symptoms get worse, call your provider.

Peak Flow Range (50%-80% of personal best)

to

Red Zone The Red Zone means start taking your Red Zone medicine(s) and call your doctor NOW! Take these medicines until you talk with your doctor. If your symptoms do not get better and you can’t reach your doctor, go to the emergency room or call 911 immediately.

“STOP!” “Medical Alert”

- Medicine is not helping - Nose opens wide to breathe - Breathing is hard and fast - Trouble walking - Trouble talking - Ribs show

Reliever Medicine(s): Dose:

Peak Flow Range (Below 50% of personal best)

to

I give my permission for this asthma action plan to be used by the following, and for them to share information with each other about my child’s asthma for one year beginning today, so that they can work together to help my child manage his/her asthma. This plan, when signed and dated, may replace or supplement the school’s/daycare’s consent to administer medication form, and allows my child’s medicine to be administered at school/daycare.



CHILD EMERGENCY CARD

CHILD’S NAME:

☐ Female ☐ Male

(First) (Middle) (Last) Birth Date Gender

Parent or Guardian Full Name Relationship to Child Cell/Work or Home Phone Number


Home Address City Zip Code

PICK UP AND DROP OFF ADDRESS IF DIFFERENT FROM THE HOME ADDRESS:

Pick Up Address Pick Up Contact Notes

Drop Off Address Drop Off Contact Notes

IN CASE OF EMERGENCY THE FOLLOWING ADULTS ARE AUTHORIZED CONTACTS AND MY CHILD MAY BE RELEASED TO THESE PEOPLE.

In the event of an emergency, we will make every effort to contact you or one of the emergency contacts. Your child will NOT be released to anyone other than those adults listed on this form. Please allow 48 hours for changes to go into effect.

Full Name Address City & Zip Code

Relationship to Child Cell Phone Number Home Phone Number Work Phone Number





In the case of a medical or dental emergency I hereby authorize Parents In Community Action, Inc. (PICA) staff to take my child to a health facility for treatment. I also authorize any licensed medical practitioner to provide whatever treatment is deemed necessary. I accept responsibility for any costs arising from such treatment that are not covered by insurance and/or Medical Assistance.

Parent or Guardian Signature

Date



DENTAL EXAM & TREATMENT REPORT

☐ Female ☐ Male CHILD’S NAME:

(Last) (First) (Middle Initial) Birth Date Gender


Home Address City Zip Code

Child’s Dental Insurance Provider Child’s Dental Insurance Number MN Health Care Programs Number

Dear Parent or Guardian: To ensure good oral health, every child one year and older must have a dental examination within the last six months, or no later than 90 days after the child starts school. If your child does not have a regular dentist, you may choose to have your child seen at PICA through Children’s Dental Services. If your child does have a dental provider, please have them complete the section below and bring it with you to registration.

DENTAL REPORT This child received the following treatment in my office:

q Dental exam q Fillings q X-rays TAKEN q Emergency q X-rays READ q Extractions q Cleaning q Steel crowns q Topical fluoride application q Space maintainers q Sealant q Bitewing X-Rays taken

q Other, explain:

q ALL treatments ARE complete. q ALL treatments are NOT complete – the following is still needed:

q TAKE X-rays q Fillings Next Appointment q READ X-rays q Extractions Date: q Topical fluoride application q Steel crowns q Cleaning q Space maintainers q Sealant

q Other, explain: Date of Initial Exam

Date of Follow-up Exam

Dentist’s Signature ( ) -

Print Dentist’s Name Dentist’s Telephone

Parent or Guardian Signature Date


PARENTS IN COMMUNITY ACTION, INC. 700 Humboldt Avenue North Minneapolis, MN 55411

Head Start Application & Information A publication of

www.picaheadstart.org • 24-Hour Hotline: (612) 377-4444

PICA Head Start - Child Care and So Much More • Enroll Your Children In Head Start Now! ¡Inscriba a sus niños en Head Start ahora! • Hadda U Buuxi Cunugaaga Head Start-ka!

Sau Koj Tus Menyuam Npe Kawm Head Start Tam Sim No! Head Starttii Keessat Qooda Fudhadha, Ijoollee Galcha!

© 2018 Parents In Community Action, Inc. – skc

Documents

PARENTS IN COMMUNITY ACTION NC HEAD … App Spanish 2018v2.pdfcheque u otro comprobante de ingresos. ü Plan de Cuidado Infantil Individual Si su hijo tiene una condición de salud