Multi Step Form - Community Parents, Inc.

First Form - Step 1 of 14

Please allow 15-20 minutes to completely fill out all forms and then click Submit to send them to CPI.

EMERGENCY CONTACT/PICK-UP AUTHORIZATION

Site:

CPHS
CFHS
MEHS

CHILD’S NAME:

HOME ADDRESS:

Name of Mother/Guardian:

Home Phone #

Work #

Cell Phone #

Name of Father/Guardian:

Home Phone #

Work #

Cell Phone #

IN CASE OF EMERGENCY CONTACT:

Name:

Relationship:

Address:

Phone #

ALTERNATE CONTACT:

Name:

Relationship:

Address:

Phone #

The Following People Have My Authorization to Pick Up My Child/Children

Name

Phone Number

Age

Name

Phone Number

Age

Name

Phone Number

Age

Name

Phone Number

Age

Name

Phone Number

Age

SPECIAL INSTRUCTION:

In the event an authorized person from the list above cannot pick up the child, you must contact the agency indicating the alternate person assigned. The alternate person must show identification for the child to be released.

Parent/Guardian Signature

Date

HOUSING QUESTIONNAIRE

Name of Child:

First

Middle

Last

Gender:

Male
Female

Date of Birth:

Address:

Phone

NOTE TO PARENTS:

Children who are living in temporary housing can enroll in and begin attending Head Start programs right away, even if they don’t have the documents normally needed for enrollment (such as proof of address/residency, immunization records, or birth certificate). Parents of children in temporary housing must be given reasonable time to hand in these documents. In the meantime, the children can enroll and participate in the program. Children who are living in temporary housing also get priority for enrollment.

The answer you give below will help the Head Start program determine whether your child is in temporary housing and eligible for these benefits.

The answer you giie will be kept confidential as much as possible and will only be shared with staff providing services to your child and those who have to keep track of how many children in the Head Start program are in temporary housing.

Where is your child currently living? (Please check one box.)

With another family or other person because of a loss of housing, economic hardship, or similar reason (also called temporarily living “doubled-up")
In a shelter
In a hotel or motel
In a car, park, bus or train station, or campsite
Other temporary living situation :
In permanent housing

(Please describe):

Print name of Parent or Guardian

Signature of Parent or Guardian

Date

Eligibility Determination Interview

Site:

CPHS
CFHS
MEHS

This is to certify that

(Parent/Guardian) of

(Child) attended a face to face/or *phone (circle one) Interview with

(Family Services Staff) regarding child’s eligibility for enrollment.

Parent/Guardian Signature

Date

Staff Signature

Date

Comment:

FAMILY HISTORY

SITE:

CPHS
CFHS
MEHS

CHILD’S NAME:

DOB:

Age:

MOTHER’S NAME:

OCCUPATION:

FATHER’S NAME:

OCCUPATION:

FOSTER CARE AGENCY:

CASE WORKER

TEL#

GUARDIAN’S NAME:

ADDRESS:

Apt:

HOME #

(W)

(C)

MARTIAL STATUS:

SINGLE
MARRIED
DIVORCED
WIDOWED

DO YOU HAVE A HIGH SCHOOL DIPLOMA?

IF NO, # OF YEARS COMPLETED

DO YOU HAVE A GED?

ARE YOU A COLLEGE STUDENT?

ARE YOU IN A TRAINING/TRADE SCHOOL?

NAME OF SCHOOL:

EMPLOYMENT STATUS:

EMPLOYED
UNEMPLOYED

INCOME STATUS:

ARE YOU RECEIVING TANF?

ARE YOU RECEIVING SSI?

ARE YOU RECEIVING MEDICAID?

IF YES, CASE NAME:

CASE#

ETHNICITY: (CHECK ONLY ONE)

A. HISPANIC or LATINO ORIGIN
B. NON-HISPANIC or NON-LATINO ORIGIN

RACE: (CHECK ONLY ONE)

A. WHITE
B. BLACK/AFRICAN AMERICAN
C. ASIAN
D. NATIVE HAWAIIAN OR PACIFIC ISLANDER
E. AMERICAN INDIAN AND ALASKA NATIVE
F. BIRACIAL/MULTI-RACIAL
G. OTHER

PLEASE EXPALIN:

MILITARY:

IF YES, MILITARY STATUS:

FAMILY TYPE:

IN PERMANENT HOUSING (ONE PARENT HOUSEHOLD)
IN PERMANENT HOUSING (TWO PARENTS HOUSEHOLD)
ANOTHER FAMILY OR OTHER PERSON (DOUBLED UP)
IN A SHELTER
IN A HOTEL/MOTEL
IN A CAR, PARK, BUS, TRAIN, OR CAMPSITE
OTHER: TEMPORARY LIVING SITUATION:

(PLEASE DESCRIBE)

PRINT NAME OF SIBLING (S):

TOTAL AMOUNT OF DEPENDENTS:

I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT INFORMATION I HAVE SUPPLIED ON THIS FORM IS TRUE AND CORRECT.

PRINT PARENT/GUARDIAN NAME:

SIGNATURE:

DATE:

SIGNATURE OF INTERVIEWER:

DATE:

*NOTE: IF THE CHILD’S RESIDENCE CHANGES DURING THE YEAR, THIS FORM MUST BE UPDATED WITH NEW RESIDENCE, PRINTED NAME, SIGNATURE OF PARENT AND DATED.

Adult Education Survey

Name

Address

Apt. #

Zip

Home Phone #

Cell #

Child’s Name

Child’s Class

What Language is spoken at home?

Do you speak any other languages?

Where were you born?

If not in the USA, how long have you been in this country?

Ethnicity:

Race:

What is the highest level of school completed?

Are you interested in getting your G.E.D?

Are you enrolled in School or Job Training?

School’s Name:

When would you be available to attend workshops?

Parent Code of Conduct

Courteous and respectful behavior between and among all program participants is essential for Community Parents, Inc. (CPI) to achieve its mission, help assure a positive environment and promote the safety and security of children and families and staff. Like employees, parents, volunteers, participants and everyone else involved with the program must follow the Code of Conduct as outlined below.

Respect and promote the unique identity of each child and family and refrain from stereotyping on the basis of gender, race, ethnicity, culture, religion or disability;
Follow program confidentiality policies concerning information about children, families and other staff members;
Leave no child alone or unsupervised while under their care;
All children must be escorted by an adult upon entering and leaving the building to and from the classroom.
All children must be signed in and out of the classroom daily.
Hand to hand from parent to staff must be used at arrival and departure.
Use positive methods of child guidance and not engage in corporal punishment, emotional or physical abuse, or humiliation; not employ methods of discipline that involve isolation, the use of food as punishment or reward, to the denial of basic needs.
Conduct themselves personally and professionally in a manner that reflects positively upon the program’s reputation and upon the children and families the program serves; and,
Not solicit or accept personal gratuities, favors or anything of significant monetary value from contractors or potential contractors if they are engaged in the award and administration of contracts or other financial awards.

Community Parents, Inc. will not tolerate behavior by employees, parents, volunteers, authorized caretakers, consultants or anyone else involved with the program that violates the Code of Conduct. Examples of violations could include but are not limited to the following:

Threats to staff, parents or children, o Physical or verbal punishment of a child o Swearing or cursing o Smoking
Quarreling, verbal fighting, loud shouting or displays of anger
Bringing drugs, alcohol or weapons to program sites or events
Physical violence
Inappropriate or excessive displays of physical affection between adults and any lewd acts performed in the presence of others.
Inappropriate dress, for example, a low-cut top, bare midriff, sagging pants below the buttocks or clothes with words or pictures inappropriate for young children while volunteering on the premises or on a trip.
The use of cell phones or videos for pictures except of your child on the premises is prohibited except for special events (Moving On, holiday birthday or cultural celebration, etc.)

If a parent violates the Code of Conduct, CPI reserves the right to:

Restrict access to the program, children, classrooms and activities,
Restrict the parent/guardian/escort’s access to the premises
Remove the child’s name from the waiting list,
Contact the police, (911)
Report to ACS Child Protective Services, Child and Family Well Being
Take civil or criminal action.

PROCEDURES:

The staff person who witnesses the violation will speak directly with the parent in private when possible, practical and if safety is not an issue.
When the safety is threatened, staff will call the police. This could be but is not limited to when parents continue to quarrel, fight or threaten children, staff, or other parents or adults. Staff will notify the Center Manager as soon as practical and as immediately as possible.
Staff should report violations to the Center Manager promptly. In the Center Manager’s absence, the most senior management staff person at the central office should be notified.
The Center Manager will notify the Executive Director who will determine the program response to the violation and will notify the person(s) involved.
The Personnel Policies Manual of CPI governs employee violations of this policy.

Approved by CPI Policy Council:
REVISED 2/14/2020

I have received a copy of the Parent Code of Conduct:

Parent’s Signature

Date

Child’s Name

Class

Parent/Guardian Consent

Desplácese hacia abajo para ver la versión en español

Date

parent/guardian

(parent/guardian)

(please print legibly) parent/guardian of

child

(child)

give consent for the following:

Brigance Screenings
Case Conferences
Evacuation Drills
Neighborhood Walks
Teacher/Coach Observations
Mental Health Consultant Observations
Anecdotal Records
Photographs/Videos
Email sharing with any parent groups within the program

Parent/Guardian’s Signature:

Consentimiento del Padre/Guardian

Fecha:

Yo,

padre/guardian

(padre/guardian)

(por favor escribe legible) padre/guardian de

niño

(niño)

dando consentimiento para lo siguiente:

*Proyecciones (“Brigance”)
*Casos Conferencias
*Evacuación de Alarma
*Caminatas en el Vecindario
*Observaciones de los Maestros y Encargados
*Observaciones de Consulta Salud Mental
*Archivos de las observaciones
*Fotografias/Videos
*Compartir correo electronico con grupos de padres del programa

Firma de Padre/Guardian:

Bus Safety

Dear Parents/Guardian,
CPI doesn’t provide transportation to children to and from school but you may authorize a private bus company to transport your child. We would like to take this time to suggest a few safety tips when you’re making that decision.

Bus Safety Tips

Does the driver have a valid drivers license?
Does the company have insurance?
Is there a matron on the bus to assist with the children daily?
Are there seat-belts/car-seats for every child?
Is there a seat belt cutter on the bus?
What is the capacity of the bus?
How many years of experience do you have?
Do you have references from other parents?

Parent’s Signature:

Date:

Transportation Bus Memo

Dear Parents:
As you are aware, Head Start’s funding does not allow us to provide daily transportation for your children to and from school. Transportation is therefore strictly the responsibility of each parent and is not included in our services. I would like to remind you that children are received and discharged from the classroom hand to hand. It has been brought to our attention that parents have contracted jointly with private bus carriers to provide transportation for their children to and from school. You should be aware that Head Start is not a party to this arrangement and is not liable for any claim or damages resulting in injury in connection with this private agreement. In addition, you should be aware that once you have place a child on a bus or van, they are not in our custody. The bus or van carrier as well as the parents, are solely responsible for the safety of your child until placed in the hand of a teacher or staff member.
In order to assured that we have your permission to receive your child from a bus or van each day, the driver must escort the child/children to and from the classroom and sign them in and out. The escort must be listed on the emergency contact pick-up authorization form. To ensure that each parent understands that this is a private arrangement and that Community Parents, Inc. can bear no liability for the bus carrier’s failure to provide safe transportation, your acknowledgement of receipt and understanding of this Memorandum must be indicated with your signature below. Thank you for your cooperation in this matter.

Sincerely,

Cynthia Cummings Executive Director

Name of Parent (please print)

Name of Child

Signature of Parent/Guardian

Date

CACFP Program

This is to certify that my child

Attends

Community Parents Head Start
Community & Family Head Start
Medgar Evers Head Start

Monday-Friday from the hours of 8:00am-4:00pm and receives the following meals:

Breakfast
Lunch
Snack

Parent/Guardian’s Signature

Date

Verified by Staff-Signature

Date

OFFICE USE ONLY

Transferred to Classroom:

Date of Transfer:

Verified by Staff-Signature

Date

EMERGENCY MEDICAL TREATMENT/AUTHORIZATION

Site:

CPHS
CFHS
MEHS

Child’s Name:

Classroom/Teacher:

In the event I cannot be contacted, I hereby give my consent for Emergency Medical Treatment of the child listed above, while under the care of Head Start Staff. This Emergency Medical Care may include PHYSICAL EXAMINATIONS and any NECESSARY TESTS which, in the opinion of the attending Physician are deemed NECESSARY OR ADVISABLE. This DOES NOT INCLUDE THE RIGHT TO PERFORM SURGICAL OPERATIONS without any further consent, except in the CASE OF EMERGENCY AND ADVISED BY PHYSICIAN TO BE VITAL to my child’s recovery, and after every effort has been made to locate me, I AM FOUND TO BE UNAVAILABLE.

MEDICAL AND ALLERGIES INFORMATION

Child’s DOB:

Allergies:

Primary Dr:

Address:

Apt.

Clinic:

Telephone Number:

PARENT/LEGAL GUARDIAN INFORMATION

Parent/Guardian Name:

Telephone #:

Address:

Apt:

Cell #:

Emergency #:

INSURANCE/H.M.O INFORMATION

Medicaid #:

HMO #:

Child’s Health Plus/Family Health Plus #:

Private Insurance Name & #:

Special Approval Phone #:

Parent/Guardian Signature

Date

Authorization to Release Health Care Information

(Parent/Guardian)

authorize the release of medical information regarding

my Child

(Child’s Name)

Community Parent, Inc.

Community Parents Head Start

Community & Family Head Start

Medgar Ever Head Start

I understand that the information may be accessed via telephone, fax or mail.

Signature

Relation to child (eg. parent, legal guardian, etc.)

Office Use Only

Information requested:

Release of Information Form

Parent/Guardian

(Parent/Guardian)

authorize the release of information regarding my child

child

Signature of Parent/Guardian

Signature of Head Start Representative

Date

Brief Respiratory Questionnaire (BRQ)

Desplácese hacia abajo para ver la versión en español

Interview:

Date of interview:

Center:

Child:

First

Last

D.O.B

Gender

Class

Ethnicity:

Black
Latino
Asian
White
Mixed
Other

Specify

Parent/caregiver:

First

Last

Relationship to child:

Mother
Father
Other family member
Non-family member

Specify

1. In the past 12 months, has your child experienced wheezing or whistling in the chest, or a cough that lasted more than a week?

2. In the past 12 months, how many times did your child experience wheezing or whistling in the chest, or a cough that lasted more than a week?

3. In the past 12 months, how many nights did your child have trouble sleeping because of wheezing or whistling in the chest, or a cough that lasted more than a week?

4. For each health condition, please answer whether a doctor, medical care provider, or clinic ever used that name to describe your child’s condition.

Asthma

RAD (Reactive Airway Disease)

Bronchitis or bronchiolitis (bron-kee-oh-lite-iss)

Asthmatic or Wheezy Bronchitis

Wheezing

5. In the past 12 months, has a doctor, medical provider or clinic prescribed any medicine, inhaler, nebulizer, or breathing machine treatments for any of these conditions, that is for asthma, reactive airway disease, bronchitis or bronchiolitis, asthmatic or wheezy bronchitis, or wheezing?

6. In the past 12 months, how many times did your child have an emergency visit to a doctor, clinic or an emergency room for asthma, wheezing, cough, chest tightness, or shortness of breath?

7. In the past 12 months, how many times did your child have to stay overnight in the hospital for asthma, wheezing, cough, chest tightness, or shortness of breath?

8. Is your child currently under the care of a doctor, nurse, or clinic for asthma, wheezing, cough, chest tightness, or shortness of breath?

9. Does anyone in your household smoke?

SIGN

DATE

Cuestionario Respiratorio Breve

Nombre de entrevistador:

Fecha de entrevista:

Centro:

Niño:

First

Last

Fecha de nacimiento

Sexo

Clase

Grupo Étnico:

Negro
Hispánico
Asiático
Blanco
Mezcla
Otro

especifique

Padre/Guardián

First

Last

Relación con el niño/a:

Madre
Padre
Otro familia
Otro que no sea familia

especifique

1. ¿En los últimos 12 meses, ha tenido su niño/a un pito o silbido en el pecho o una tos que le duró más de una semana?

2. ¿En los últimos 12 meses, cuántas veces su niño/a tuvo un pito o silbido en el pecho o una tos que le duró más de una semana?

3. ¿En los últimos 12 meses, cuántas noches su niño/a tuvo problemas durmiendo debido a un pito o silbido en el pecho, una tos, u otros problemas respiratorios?

4. Para cada condición de salud, responda si un médico, proveedor de atención médica o clínica alguna vez usó ese nombre para describir la condición de su hijo.

Asma

Enfermedad en las vías respiratorias

Bronquitis o bronquiolitis

Bronquitis asmático o pito en los bronquios

Pito o silbido en el pecho

5. ¿En los últimos 12 meses, un doctor, proveedor de asistencia médica o una clínica le recetó alguna medicina, inhalador, nebulizador, o tratamientos de máquinas de respiración por alguna de esas condiciones: asma/ fatiga, enfermedad de las vías respiratorias, bronquitis o bronquiolitis, asma o silbido en los bronquios, o un pito o silbido en el pecho?

6. ¿En los últimos 12 meses, cuántas veces Ud. hizo una cita urgente con el doctor o la sala de emergencia para su niño/a por asma, un pito o silbido en el pecho, una tos, bronquitis, u otros problemas respiratorios?

7. ¿En los últimos 12 meses, cuántas veces su niño/a tuvo que pasar la noche en el hospital por asma, un pito o silbido en el pecho, una tos, bronquitis, u otros problemas respiratorios?

8. ¿Actualmente está su niño/a bajo el cuidado médico de un doctor, proveedor de asistencia médica o la clínica por el asma/ fatiga, un pito o silbido en el pecho, tos, u otros problemas respiratorios?

9. ¿Hay alguien que fuma en su casa/departamento?

FIRMA

FECHA