Fill - Free fillable GSRP Application031116 PDF form

26524 John R Road ∙ Madison Heights, MI 48071 ∙ (248) 399-7800 ∙ Fax (248) 399-2229

Enrollment Check List

__ Child’s Birth Certificate

__ Child’s Shot Record

__ Child’s Health Insurance Card

__ Parent/Guardian I.D. Card

__ Proof of Residency (i.e. I.D. Card, Utility Bill, Lease Agreement, etc…)

__ Proof of Income (i.e. Tax Return, Check Pay Stub, Proof of State Aid)

__ Child’s Physical

__ Child’s TB Test

__ CACFP Participant Enrollment Form

__ Application for Free and Reduced Price School Meals

Application for Great Start Readiness Program

FOR OFFICE USE ONLY

STUDENT ID#: ____________________

PARENT COMPLETES THIS PAGE

Ethnic Codes: 1 = Native American 2a = Asian or 2b = Pacific Islander 3 = Black, Not Hispanic 4a = Hispanic White or 4b = Hispanic Black 5 = White, Not Hispanic

Great Start Readiness Program DATE: _________________________

CHILD APPLICATION FORM

SCHOOL/CENTER: ___________________________________________________________________________________

CHILD’S NAME: ______________________________________________ BIRTHDATE: ____________ SEX: F ( ) M ( )

CHILD’S ADDRESS: ________________________________________ ZIP: ________ HOME TELEPHONE: ______________

BIRTH CERTIFICATE#: _________________________________________ BIRTHPLACE: ____________________________

BIRTH WEIGHT: ______ LBS. ______ OZS. PREMATURE BIRTH: YES ( ) NO ( )

Special Needs/Disabling Condition: ____________________________________________ Diagnosed: YES ( ) NO ( )

If Special Needs has been diagnosed by an Agency/Physician, complete Release of Information Form.

Parent/Guardian Name: _______________________________________ Relationship to Child: _____________________

Mother’s Age at 1

st

Pregnancy: ______ Marital Status: Single ______ Married ______ Separated ______

Total # in Family: ______ Ethnic Group: ______

Are You Employed? YES ( ) NO ( ) Are You in School or Training? YES ( ) NO ( )

IF Yes, Part-Time ( ) Full-Time ( ) Seasonal ( ) IF Yes, Part-Time ( ) Full-Time ( )

Is Your Spouse Employed? YES ( ) NO ( ) NA ( ) Is Your Spouse in School or Training? YES ( ) NO ( )

IF Yes, Part-Time ( ) Full-Time ( ) IF Yes, Part-Time ( ) Full-Time ( )

Are You Enrolled in Work First? YES ( ) NO ( ) NA ( )

Source(s) of Income: 1

st

____________________________________ 2

nd

____________________________________

W, BM, M, 2XM

(Weekley, Bi-Weekley, Monthly, Twice Per Month)

W, BM, M, 2XM

(Weekley, Bi-Weekley, Monthly, Twice Per Month)

Do you receive: WIC ( ) Focus: HOPE ( ) NA ( ) Is Child: Anemic ( ) Lead Poisoned ( ) NA ( )

Do you receive: Food Stamps ( ) Medicaid ( ) SSI ( ) Child Care Assistance ( ) NA ( )

Do you need full year: YES ( ) NO ( ) and/or full day child-care? YES ( ) NO ( )

PARENT COMPLETES THIS SECTION

STAFF COMPLETES THIS SECTION

IF NOT PARENT, PROOF OF GUARDIANSHIP CASE#: (m) ________________________________________________

Mother

Father

Foster Parent(s) / Stepparent(s)

Or Guardian(s) / Relationship

Number of Other Dependent

Children In Your Household

Name:

Name(s)

Age

Birthdate:

Birthplace: (City, State or Nation)

Home Language:

Date Naturalized:

Educational Status:

Occupation:

Home Address: (if different)

Home Phone: (if different)

Cell Phone or Pager Number:

Business Address:

(Street Address, City, Zip Code)

Business Phone:

Employer:

Work / School Schedule:

(days & times)

Type of MEDICAID Insurance: _______________________________________ Case#: ________________ Child’s Recipient ID#: ________________

OTHER Medical Insurance: (Type): ______________________________________________________________ Claim Number: _________________

The above information is true and correct to the best of my knowledge. I understand that if any of this information changes, or is found to be incorrect, I am obligated to immediately notify

this program. I understand that the above information and all information contained in the child’s foster will remain CONFIDENTIAL. I hereby make application for my child and myself to be

enrolled in a Detroit Public School Preschool Program based on all the information in the Child’s Registration Form.

__________________________________________ ________ __________________________________________ ________

Signature of Parent / Guardian Date Signature of Staff Verifying and Auditing Form Date

Child Risk Factor

1. Extremely Low

2. Low family income

3. Diagnosed disability or identified development delay

4. Severe or challenging behavior

5. Primary home language other than English

6. Parent/guardian with low educational attainment

7. Abuse/neglect of child or parent

8. Environmental Risk

Risk Factors Accrued: ____________________________________

Is child Head Start income eligible: Yes _____ No _____

Date enrolled:

INCOME VERIFICATION

Parent / Guardian Name

Wages / Salary

W, BW, M, 2XM

Amount of

TANF (2XM)

Amount of Monthly

SSI / Social Security

Foster Care/Other

Date & Type of

Verification/Proof

Annual Total

T O T A L

* Date enrolled is the first actual day of attendance.

CHILD INFORMATION RECORD

State of Michigan Department of Human Services - Bureau of Children and Adult Licensing

Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply,

“unknown” or “none” is the required response. A blank ﬁ eld, a line through a ﬁ eld or “N/A” are not acceptable responses.

For Provider

Use Only:

Date of Admission Date of Discharge

Name of Child (Last, First, Middle Initial) Child’s Date of Birth

Address (Number and Street, Building/Apartment Number) City State Zip Code

Father/Legal Guardian’s Name Home Phone

( )

Mother/Legal Guardian’s Name Home Phone

( )

Home Address (if not child’s address) Cell Phone

( )

Home Address (if not child’s address) Cell Phone

( )

City State Zip Code City State Zip Code

Email Address (optional) Email Address (optional)

Employer Name Work Phone

( )

Employer Name Work Phone

( )

Name of Child’s Physician or Health Clinic Physician’s or Health Clinic’s Phone Number

( )

Hospital Preferred for Emergency Treatment (optional)

Allergies, Special Needs and Special Instructions (Attach additional sheets, if necessary.)

BCAL-3731 (Rev. 7-12) Previous editions 9-09, 3-08, 10-07, & 1-06 may be used until 12/31/13. See Reverse Side

Emergency Contact & Release of Child: List all individuals,including parents/legal guardians, in order of preference, to be contacted in an

emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child

can be released. The second phone number column can be left blank. (If more individuals, attach additional sheets.)

1. ( ) ( )

2. ( ) ( )

3. ( ) ( )

Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)

1. ( ) 2. ( )

3. ( ) 4. ( )

I give permission to , licensed by the Department of Human Services

(Provider’s Name)

to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care.

Signature of Parent or Guardian

Date Signed

Date Card

Reviewed

Parent or Legal

Guardian Initials

Date Card

Reviewed

Parent or Legal

Guardian Initials

Date Card

Reviewed

Parent or Legal

Guardian Initials

Date Card

Reviewed

Parent or Legal

Guardian Initials

Department of Human Services (DHS) will not discriminate against any individual or group because of race,

religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or

expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans

with Disabilities Act, you are invited to make your needs known to a DHS ofﬁ ce in your area.

AUTHORITY: 1973 PA 116

COMPLETION: Required

PENALTY: Rule Violation Citation.

BCAL-3731 (Rev. 7-12) Previous editions 9-09,3-08, 10-07, & 1-06 may be used until 12/31/13.

Dear Parents/Guardian,

Your child will receive a breakfast or snack each day in the Great Start Program. The district participates in the United

States Department of Agriculture Child and Adult Care Food Program. Meal and snacks served must meet the

Department requirements. Food substitutions may be made only when supported by a physician’s statement indicating

an allergy or other medical reason for the substitution. Please ask your physician to complete and sign this form if child

requires a substitution and must avoid certain foods. Return the form to Valerie Martin before school begins in

September. If you have any questions please call Valerie Martin at (248) 399-7800, ext 3404.

1. Medical/special dietary restrictions (check or describe)

______ Food Allergy (explain) ___________________________________________________________________

______ Lactose Intolerance

______ Iron Intolerance ______ Obesity

______ Other (describe) _______________________________________________________________________

2. Foods to be omitted

______ Iron Fortified Infant Cereal ______ Wheat Products

______ Milk ______ Other (list) ______________________________

3. Foods to be substituted

______ Low Iron Infant Formula ______ Vita-mite

______ Rice Products ______ Other (list) ______________________________

4. Description of handicapping condition that may restrict child’s diet:

___________________________________________________________________________________________

____________________________________________________ _______________

Physician’s Signature Date

Part 1: Contract Provisions Provided by Childcare Facility

CHILD PLACEMENT CONTRACT

Note: This contract is required of all licensed child care centers as provided by R 400.5105b of the Michigan

Administrative Code.

As of _______________, the ____________________________________________________ Prekindergarten

(Date) (School)

Program agrees to provide childcare services for __________________________________________________.

(Child’s Name)

The ________________________________ Prekindergarten Program as a licensed childcare facility will

provide the following provisions of the Michigan Administrative Code as required by R 400.5105b:

R 400.5102 Licensee.

Rule 102

(2) A license shall have the following administrative responsibilities regarding staff:

(c) Develop and implement a written screening policy for all staff and volunteers, including parents,

who have contact with children.

R 400.5106 Program.

Rule 106

(1) A developmentally appropriate program shall be implemented that includes all of the following ideas:

(a) Physical Development

(b) Social Development

(c) Emotional Development

(d) Intellectual Development

(2) The following types of activities shall be provided daily:

(a) Quiet and active

(b) Individual, small groups and large groups

(c) Large and small muscle

(d) Child initiated and staff initiated

(e) Developmentally appropriate language and literacy experiences throughout the day accumulating

for not less than 30 minutes

(f) Early math and science experiences

Part 2: Additional Contract Provisions

(3) Daily activities shall be planned so that each child may do the following:

(a) Have opportunities to feel successful and feel good about himself or herself and develop

independence

(b) Use materials and take part in activities which encourage creativity

(c) Learn new ideas and skills

(d) Participate in imaginative play

(6) The program shall provide daily outdoor play unless prevented by inclement weather.

(7) The program shall provide a naptime and quiet time

(11) The program shall permit parents to visit for the purpose of observing their children during the day.

I will work with my child’s teacher and other staff to ensure that my child’s Health Appraisal, Immunizations

and other health requirements are kept updated throughout the school year.

If my child is sick or has a contagious disease, I will take my child to the doctor and/or keep my child home

until he/she is able to return to school, or I will bring a doctor’s statement verifying that my child is able to

return to school.

I understand that the staff may contact me if there are any health problems or if any additional health

information is needed.

I will also keep my phone number(s), and address current.

I have read, understand and received a copy of the Attendance Policy.

I have read, understand and received a copy of the Late Pick Up Policy.

Upon signing this agreement, the parent, legal guardian or responsible adult and the child care staff agree

to abide by all the provisions contained in this contract.

Staff Signature: _________________________________________________________

Staff Position / Title: _____________________________________________________

Parent / Legal Guardian Signature: _________________________________________

Relationship to Child: ____________________________________________________

Volunteers to our schools are vital to our success in providing the highest quality educational services to your children.

Without volunteers, many of the school, classroom, and extracurricular activities could not take place. We thank all of

those individuals who offer to help in school activities and events.

For the safety of our students a volunteer form must be filled out each year.

Please complete the information below. A background check through the Michigan State Police will be performed.

Once the report is received by the district, your name will be made available to your school to begin volunteering if you

choose to do so. We do ask volunteers to report to the school office to sign in and pick up a volunteer badge. Please

return the badge to office when you sign out.

If you have any questions, please call Sharon Kline in the Madison Board Office at (248) 399-7800. Thank you for helping

us keep your children safe at school.

Please print (one form per family)

1. Volunteer Name: __________________________________________________ Date of Birth: ______________

Volunteer Signature: ______________________________________________________

2. Volunteer Name: __________________________________________________ Date of Birth: ______________

Volunteer Signature: ______________________________________________________

Child’s Full Name: ________________________________________________________

School: _________________________________________________________________

Preschool: ______________________________________________________________

Your signature indicates your consent to a Michigan State Police background check.

Please indicate if you have had any training in the following:

CPR ______ First Aid ______ Universal Precautions ______

__________________________________________________________________________________________________

Office use only

District signature approving volunteer _______________________________________________ Date: ______________

Directions: Check any of the following conditions that you as teacher have observed that may warrant referral,

additional screening or treatment. This form needs to be completed during the enrollment process. Send original to

the instructional specialist and keep the copy in the child’s folder.

HEALTH OBSERVATION OF CHILD DEVELOPMENT FORM

Child’s Name: _________________________________________________________________ Birthdate: ____________

School: __________________________________________________________________________ Date: ____________

Assessor: __________________________________________________________________________________________

VISION

______ shows symptoms of eye fatigue or stress as indicated:

______ { } blinking; { } squinting; { } itching; { } tearing

______ shows symptoms of eye infection as indicated by:

______ { } redness; { } discharge; { } holds materials far from eyes

______ { } closes one eye or squints; { } stranismus (lazy eye)

HEARING

______ has difficulty hearing over background noise

______ turns head to one side frequently

______ misunderstands instructions

______ often asks for instructions to be repeated

SPEECH

______ is difficult to understand

______ voice quality is: { } too loud; { } too weak;

______ uses ______ number of words in a sentence

SELF-RELIANCE

______ lacks confidence

______ is careless

______ needs encouragement in order to perform

______ lacks independent toileting skills

EMOTIONAL FUNCTION

______ cries or angers easily

______ is easily frustrated

______ requires much praise

______ needs encouragement and attention

______ has difficulty cooperating

______ acts without thinking

______ avoids difficult tasks

______ has short attention span

______ shows symptoms of nervousness indicated by:

______ { } hits; { } kicks or pushes others; { } yells at others or

______ uses name calling

MOTOR SKILLS

______ performs significantly below age in large muscle skills

______ development (like walking up and down stairs; riding a bike)

______ performs significantly below age in small muscle skills

______ development (using crayons, scissors or forks/spoons)

PHYSICAL APPEARANCE

______ appears to lack good physical health and stamina-tires easily

List any significant observations that suggest a need for medical care,

such as rashes, obesity, fragility and clumsiness:

_________________________________________________________

Referral made: { } Yes { } No

Reason for referral:

_________________________________________________________

Results: __________________________________________________

Undercare: _______________________________________________

PARENT NEEDS ASSESSMENT

School: ___________________________________ Teacher: __________________ Room#: _________ Date: _________

Parent/Guardian: ____________________________________ Telephone: _________________ GSRP: _____ HS: _____

Suggested Topics: Number in the order of wants (1-first, 2-second, etc.)

Child Growth and Development

______ Self-Esteem & Your Child’s Success

______ Helping Children Develop Good Language & Thinking Skills

______ Activities to Do at Home/The Value of Play

______ Effective Discipline/Encouragement

Health and Safety Information

______ Asthma

______ Dental Health (Adult & Pediatrics)

______ Communicable Diseases & Immunizations

______ Family Planning/Teenage Pregnancy/Birth Control

______ STDs (Sexually Transmitted Diseases)

______ Cancer/Self Breast/Testicular Exam

______ Fire Safety/Home Safety

______ Lead Poisoning/Poisons

______ Car Seat Safety

______ Indoor/Outdoor Safety/First Aid Tips

Nutrition Information

______ Diet/Exercise/Weight Control/Child Obesity

______ Healthy Snacks

______ Menu Planning/Cutting Food Costs

______ Basic Cooking & Related Skills

Disability Information

______ Working with Disabled Children (mildly & severely)

______ Rights & Responsibilities of the Handicapped

______ Mainstreaming Handicapped Children

______ Networking with Resources for Disabilities

______ ADHD (Attention Disorders and Hyperactivity Deficit)

Coping Skills/Personal Enhancement

______ Stress/Time Management

______ Basic Parenting

______ Male & Female Relationships Issues

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