Fillable Gunalchesh/Hawaa for your interest in Head Start! (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Gunalchesh/Hawaa for your interest in Head Start! (Central Council Tlingit and Haida Indian Tribes of Alaska)

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U.S.A. forms for Central Council Tlingit and Haida Indian Tribes of Alaska

BROWSE CENTRAL COUNCIL TLINGIT AND HAIDA INDIAN TRIBES OF ALASKA (AK) FORMS

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This institution is an equal opportunity provider.
Revised 02.2021
Gunalchéesh/Haw’aa for your interest in Head Start!
Head Start Application 2021/22
INSTRUCTIONS
1. To Apply—there are 2 options
a. By Paper. Print/Save, fill out, & email to headstartenrollment@ccthita-nsn.gov
b. Online. Fill out the following pages, digitally sign, & click submit
2. Send Income Verification—with your paper application or separately if you submitted your application
online.
a. At least one of the following documents are required per working adult(s) in the home:
i. Income Documentation—for last 30-days, i.e. check stubs, or
ii. Latest Income Tax Form—i.e. W-2 or 1040, or
iii. Proof of Unemployment Insurance, or
iv. Proof of Public Assistance—i.e. TANF/ATAP, SSI, or
v. Homeless Documentation-i.e. written statement from homeless service provider,
documentation from pubic or private agency, a declaration, information gathered on
application, notes from an interview, or
vi. Send Foster Care Verification-court order, or other legal or govenment-issued
document, or foster care payment.
3. Send Immunization Records
4. Send Child's TB Risk Assessments Questionnaire
5. Send IEP/IFSP document(s), if applicable
INSTRUCTIONS TO SUBMIT
(4) different ways
In-Person. 9095 Glacier Highway, Juneau, AK 99801, or
By Mail. 9097 Glacier Highway, Juneau, AK 99801, or
Phone. 1.800.344.1432, or
Fax. 1.877.389.7796, or
Email. headstartenrollment@ccthita-nsn.gov
Tlingit & Haida Head Start
Physical Address:
9095 Glacier Highway
Juneau, AK 99801
Phone: (907)463-7127
Mailing Address:
9097Glacier Highway
Juneau, AK 99801
Fax: (877) 389-7796
SECTION A
CHILD INFORMATION
FULL FIRST NAME:
FULL MIDDLE NAME:
FULL LAST NAME:
SUFFIX:
NICKNAME:
DOB:
MALE
FEMALE
RACE: (Choose all that apply)
Alaska Native
American Indian
African American/Black
Caucasian/White
Asian
Pacific Islander/Native Hawaiian
CHILD PRIMARY LANGUAGE:
Little
Moderate
Proficient
CHILD SECONDARY LANGUAGE:
Little
Moderate
Proficient
SECTION B
PRIMARY ADULT
FIRST NAME:
LAST NAME:
DOB:
MALE
FEMALE
PRIMARY LANGUAGE:
Translation or Interpretation Services Needed Yes No
RACE: (Choose all that apply)
Alaska Native
American Indian
African American/Black
Caucasian/White
Asian
Pacific Islander/Native Hawaiian
ETHNICITY: (Choose one) Hispanic Non-Hispanic
MILITARY STATUS:
Active
Veteran
PRIMARY PHONE: □ Home □ Cell □ Work
Able to receive text messages? □ Yes □ No
ALTERNATE PHONE: □ Home □ Cell □ Work
Able to receive text messages? □ Yes □ No
E-MAIL:
RELATIONSHIP TO CHILD: (Check one)
Parent/Legal Guardian
Grandparent
Legal Foster Parent (Attach letter)
Other:
HIGHEST EDUCATION LEVEL: (Check one)
EMPLOYMENT STATUS: (Check one)
Highest Grade:
High School Graduate
GED
COL
AA
BA
MA or Higher
FT only
PT only
Seasonal
Training/School
FT and School
PT and School
Retired or Disabled
Unemployed
SECTION C
SECONDARY ADULT
FIRST NAME:
LAST NAME:
DOB:
MALE
FEMALE
PRIMARY LANGUAGE:
Translation or Interpretation Services Needed Yes No
RACE: (Choose all that apply)
Alaska Native
American Indian
African American/Black
Caucasian/White
Asian
Pacific Islander/Native Hawaiian
ETHNICITY: (Choose one) Hispanic Non-Hispanic
MILITARY STATUS:
Active
Veteran
PRIMARY PHONE: □ Home □ Cell □ Work
Able to receive text messages? □ Yes □ No
ALTERNATE PHONE: □ Home □ Cell □ Work
Able to receive text messages? □ Yes □ No
E-MAIL:
RELATIONSHIP TO CHILD: (Check one)
Parent/Legal Guardian
Grandparent
Legal Foster Parent (Attach letter)
Other:
HIGHEST EDUCATION LEVEL: (Check one)
EMPLOYMENT STATUS: (Check one)
Highest Grade:
High School Graduate
GED
COL
AA
BA
MA or Higher
FT only
PT only
Seasonal
Training/School
FT and School
PT and School
Retired or Disabled
Unemployed
Secondary Adult Lives with Primary Parent:
Yes
No*
*If NO, is there a Custody Agreement?
Yes (Attach documentation)
No
USDA and this institution are equal opportunity providers and employers. Parent/Guardians have the right to receive translation or interpretation services in their
primary language as well as reasonable accommodations to participate in the program.
Program Year 2021/22
SECTION D
FAMILY INFORMATION
LIVING ADDRESS:
Address:
City: , AK Zip
MAILING ADDRESS:
Address:
City: , AK Zip
HOUSING: (Check one)
Own
Rent
Neither
PARENTAL STATUS:
(Check one)
One Parent
Two Parent
Teen Parent (age 19 or
under at time of birth)
Do you live in a shelter,
transitional housing,
motel, vehicle or move
frequently between
homes of relatives or
friends?
(Attach housing verification)
Yes No
Was your family referred
for services by a child
welfare agency? (Office of
Children’s Services, Child in
Transition, ICWA, etc.)
Yes No
SERVICES YOUR FAMILY RECEIVES: (Check all that
apply)
None
Child Care Assistance
SNAP/Food Stamps
WIC
Indian Health Services (IHS)
TANF/ATAP
Supplemental
Security
Income
Number of individuals related by blood, marriage or adoption, living in the home, supported by the parent/guardian's income:
NUMBER OF ADULTS:
NUMBER OF CHILDREN:
TOTAL NUMBER: _
Please list all members of the household. If more than one child is applying for HS, an application is needed for each child.
First
Middle
Initial
Last
Relation to HS
Applicant
Birthday
Gender
Race
Hispanic/
Latino
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
SECTION E
CHILD HEALTH INFORMATION
PRIMARY HEALTH
COVERAGE/INSURANCE:
Denali KidCare/Medicaid
Private
Other:
None
DOCTOR/MEDICAL CLINIC NAME:
PHONE:
DENTIST/DENTAL CLINIC NAME:
PHONE:
Does your child have any diagnosed food or medical allergies?
Yes* No If YES, please explain:
*If your child has a food allergy, a completed “Medical Statement for Food
Substitution" or other documentation MUST be provided before food
substitutions can be made.
Does your child take any medications that have to be
administered during class time? (Head Start Only) Yes* No
*If YES, parent/guardian will be required to fill out a separate medication
authorization form prior to the first day of attendance.
Do you have any health concerns about your child?
Yes No If YES, please explain:
Do you have any developmental concerns about your child?
Yes No If YES, please explain:
SECTION F
CHILD INDIVIDUALIZED EDUCATION PLAN (IEP)/ INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP)
Is your child currently being evaluated for an IEP or IFSP?
Yes No
□ Suspected
Does your child have a current or expired IEP or IFSP?
Yes No If YES, please attach copies of the:
IEP or IFSP or Signed Release of Information Form
AGREEMENT
PLEASE READ, SIGN, AND DATE YOUR APPLICATION
I certify that this information is true and correct. I agree to promptly update my child and family’s information during my child’s enrollment with
Tlingit & Haida Head Start. I agree to review this information every year. All information is kept strictly confidential and I may access it during
normal business hours.
PARENT/GUARDIAN SIGNATURE:
DATE:
click to sign
signature
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ERSEA ROI rev. 202043
ERSEA (Enrollment)
REQUEST TO RELEASE & EXCHANGE INFORMATION AND NOTICE OF
CONFIDENTIALITY
Dear Parent/Guardians:
In order to provide your family with quality services, it may be necessary to release and exchange information with others
that serve your family and child. For example, to review your Head Start eligibility, we need income statements from
ATAP or TANF. Other examples are to allow us to send forward immunization records to your local school when
transition to kindergarten, or requesting current immunization records, physical or dental exam from your health care
providers. We need your written consent to legally release and exchange information. This Request to Release to
Exchange information form allows us to share this information between programs/agencies.
All the information gather about your family is kept confidential and released only when you give us permission. Parents and
legal guardians of Head Start children have the right to access their own children’s files at the Head Start center as well as at
the Head Start Central Office located in Juneau, Alaska.
Child Name:
Date of Birth:
To rush your application pleases provide:
Alaska Temporary Assistance Program (ATAP) Benefits-Case worker: __________________________
Temporary Assistance for Needy Families (TANF) Case worker: ______________________________
Supplemental Security Insurance (SSI) Benefits-Case#: ______________________________________
State Disabilities Assistance Benefits-Case#: _______________________________________________
Foster Care-Health & Social Services: ____________________________________________________
Guardianship – Alaska Legal Services: ___________________________________________________
*************************************************************************************
**SEARHC requires a specific Release of Information form to release & exchange information to Head Start. If you
are a SEARHC client, please complete a Head Start & SEARHC form in addition to this ROI form. **
I request the following information for me or my child to be released and exchanged between Tlingit & Haida
Head Start…
Check the following and provide clinic names (required):
Dental Records/Name of Clinic: _______________________________________________________________
Medical Records/Name of Clinic: _____________________________________________________________
Immunization & TB test records/Name of Clinic: ________________________________________________
Check the following if you receive these services for your child and name of agency (required):
Infant Learning Program (ILP)/or other program: _______________________________________________
Developmental screening and assessment information at: _________________________________________
Individualized Education Plan (IEP or IFSP) from Local Education Agency (LEA): ____________________
Behavioral or Social/Emotional Service Agency: __________________________________________________
Individual Learning Plan (ILP) records from another Pre-K Program: _______________________________
Other (records created during Child find, Tots Clinic, etc.): ________________________________________
THIS RELEASE & EXCHANGE OF INFORMATION IS VALID FOR 12 MONTHS FROM DATE SIGNED.
_________________________________ _____________________________ ___________________
Parent/Guardian Signature Printed Name Date
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signature
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Page 1 of 2 rev. 2020-4-2 MMG/2019-03-21-FIN-REV-HIM 015
HEALTH INFORMATION MANAGEMENT
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH
INFORMATION INFORMATION
This form is for release of information requests to third parties. Please allow up to 30 days for SEARHC to process your
request. Incomplete forms will be returned. There may be a fee associated with processing the request. Staff will inform
you if the fee applies.
Printed Name of Patient:
Previous Names (if applicable):
Date of Birth (MM/DD/YYYY):
Daytime Telephone Number:
INFORMATION TO BE RELEASED FROM:
SEND INFORMATION TO:
Provider Name/Organization:
SEARHC
Name of Person/Facility/Organization:
Central Council Tlingit and Haida Indian Tribes of
Alaska- Head Start
Address:
3100 Channel Drive Ste. 300
Juneau, AK 99801
Address:
9095 Glacier Hwy
Juneau, AK 99801
Contact Number:
907-463-6630
Contact Number:
1.800.344.1432/x7153
Fax Number:
907-463-4012
Fax Number:
1.877.389.7796
Format in which you would like the recipient to receive your records: ____Mail __X__ Fax _ Pick Up ____Verbal
____ Encrypted Email ____ Unencrypted email (there is a risk that your records may be intercepted or viewed if sent
unencrypted.) Email address: _______________________________________________________________________
REQUIRED INFORMATION
PURPOSE OF DISCLOSURE:
____ Transfer of Care ____ Disability ____ Law Enforcement ____ Specialist
____ Attorney __X_ Head Start School ____ Insurance ____ Other: _______
INFORMATION TO BE DISCLOSED:
____ Medical records from the last two years ____ Complete Designated Record Set
Date(s) of Service: ____/____/____ through ____/____/____
___ Health Summary ____ Billing records ____ Emergency room records
____ Discharge summary ____ Physician progress notes ____ Nursing notes
____ Laboratory/pathology reports ____ Radiology reports ____ Radiology images
____ Medication list _X__ Immunization record ____ Accounting of disclosures
____ Dental chart note ____ Dental Pano X-ray ____ Dental X-ray
_X__ Other: _Head Start Physical Exam Form (Including: Grow measurement, Blood Pressure, Vision, Hearing, TB,
Hemoglobin/Hematocrit, Physical/Developmental Assessment, allergies and chronic illness), & Head Start Dental Exam Form
(Including: Procedures Performed, Caries Risk Status, Current Oral Health Status, Recommendations, & Treatment Plan)
__________________________________________________________________________________
Page 2 of 2 2020-4-2-HS-REV-MMG/2019-03-21-FIN-REV-HIM 015
Disclosures Requiring Special Consent:
If your records contain any of the information listed below, please initial next to that information to indicate that we are
allowed to release these type of records:
____ HIV/AIDS Virus ____ Mental Health/Psychiatric Disorders ____ Sexually Transmitted Diseases
____ Substance Use/Treatment
This form may be revoked at any time by submitting a written request to the address below, provided the information
has not already been disclosed. This authorization expires 90-days from date of signing unless an alternate expiration
date or event is indicated (not to exceed one-year.)
Alternate expiration date/event: _1 Year from date of signature___________________________________________
We will not condition or deny treatment on completion of this authorization. Please be aware that once we disclose this
information, the information is subject to re-disclosure and may no longer be protected by HIPAA.
I have read and understand this form and authorize the information to be released as indicated.
________________________________________ _________________________ _______________________
Signature of patient or personal representative* Relationship to patient Date
ID # ____________________
*legal documentation may be required to confirm the authority or the personal representative.
SEARHC HIM DEPARTMENT
3100 Channel Dr., Suite 300
Juneau, AK 99801
P: 907-463-6630 F: 907-463-4012
For Facility Use:
Date Received: Date Released: MRN #: Acct #: ROI #: Released by:
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TLINGIT & HAIDA HEAD START
Central Council Tlingit and Haida Indian Tribes of Alaska
Mailing: 9097 Glacier Hwy, Juneau, AK 99801• Physical 9095 Glacier Highway • Juneau AK 99801
Phone 907.463.7127 • Toll Free 800.344.1432 • Fax 1.877.389.7796 • www.ccthita-nsn.gov
Tuberculosis Risk Assessments Questionnaire
Date:
Dear Parent/Guardian:
Please complete this TB risk assessment regarding your Head Start student.
Child’s Name
Date of Birth
Head Start
Center
TB testing is required if any “YES” boxes are checked
Close contact to someone with infectious TB during the student’s lifetime
• Re-testing should only be done in children who previously tested negative and have had no close
contact with an infectious TB case since the last assessment.
□ Yes
Birth, travel or residence in a country with an elevated TB rate for at least 1 month
Includes any country other than the United States, Canada, Australia, New Zealand, or a country
in western or northern Europe
□ Yes
Immunosuppression, current or planned
HIV infection, organ transplant recipient, treated with TNF-alpha antagonist, steroids for more
than 2 weeks (i.e., equivalent of prednisone ≥ 2 mg/kg/day, or ≥ 15mg/day for ≥ 2 weeks), or
other immunosuppressive medication.
□ Yes
□ None of the above apply; TB testing is not required at this time.
Please note:
Do not repeat TB testing unless there are new risk factors since the last negative test.
Children with a newly positive TB test result will be referred to their healthcare provider for a medical evaluation
and parents/guardians will be notified.
Parent/Guardian
Signature
Date
This section to be filled out by Head Start Child Health & Safety Coordinator reviewing this
assessment.
Assessment
Reviewed by
Date
Follow-Up, if
needed
Due Date
Follow-Up
completed? □
Yes □ No
Mail or fax a copy of physical & screenings to Head Start:
Attention: Child Health & Safety Coordinator
N: Health\Forms\ 13.07 Tuberculosis Risk Assessment Questionnaire Form Rev. 8/212019
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GunalcheshHawaa for your interest in Head Start (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Completed 18 November 2021

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