GSRP Preschool Application 2017-2018

These materials were developed under a grant awarded by the Michigan Department of Education

Date of Application: _______________School District: _____________________ Home School: ________________

Child’s Birthdate: ______________ (must be 4 yrs. old on or before Sept. 1, 2017) Gender (circle one): Boy - Girl

Child’s Name: ____________________________________________ Place of Birth: ____________________________

Address: __________________________________________City: _____________________Zip Code: ______________

Mother’s Name: __________________________________________ Place of Birth: ____________________________

Address (if not child’s address): ____________________________________City: _______________Zip Code: ________

Home Phone: __________________________ Cell: _________________________ Work: _________________________

E-mail address: ______________________________ Marital Status: Married Single Divorced Widowed Separated

Father’s Name: ____________________________________________ Place of Birth: ____________________________

Address (if not child’s address): ____________________________________City: ________________Zip Code: ________

Home Phone: _________________________ Cell: __________________________ Work: _________________________

E-mail address: _____________________________ Marital Status: Married Single Divorced Widowed Separated (R-7) Who has legal custody of the child? (Documentation may be required)

Both Parents Mother Father Foster Care Legal Guardian Grandparent

If guardian or foster parent (other than biological parent), please complete:

Legal Guardian’s Name(s): ___________________________________________________________________________

Address: ____________________________________________City_____________________Zip Code_______________

Home Phone: _________________________ Cell: __________________________ Work: _________________________

E-mail address: ______________________________ Marital Status: Married Single Divorced Widowed Separated

List all persons living in the household including student

Name Relationship to Child Age

Office Use Only Start Date:_____________ID:_____________________SC:________DA:________End Date:_________

% FPL ______ H.S. Elig. ________ Placement Location: __________________________ AM _____ PM _____ Full _____

Has your child attended any United States school in the last year? (Circle One): YES NO

1st Date in the U.S. School: ___________If yes, Name of school: ________________ City, State: ____________________

Date of Arrival in the United States (month/day/year): ______________ Country of Birth: _________________________

Immigration Status (Circle one): Refugee Immigrant Migrant U.S. Born Other: __________________

Country of Immigration: ________________________

Is the student’s ethnicity Hispanic or Latino? __ Yes, child is Hispanic or Latino __ No, this child is not Hispanic or Latino

Which of the following is the student’s race (If multi-racial, place a check mark for each that applies):

American Indian or Alaska Native _____ Black or African American _____ White _____

Asian American _____ Native Hawaiian or other Pacific Islander _____ Hispanic or Latino ______

(R-4) Primary language spoken in the home (Circle language used most often):

English Chaldean Arabic Albanian Spanish Other: _______________________

(R-5) Did parent(s) graduate from High School? (Circle one): Mother- YES NO Father- YES NO

(R-1) Family Income (Estimated annual income before deductions, last 12months): $________________________ (MUST include income of all family members responsible for support of child: 1040, W2, most recent pay stubs, unemployment, child support, alimony, DHS, SSI)

(R-1) Does your family receive benefits from (DHS) Department of Human Services, SSI? (Circle one): YES NO

If YES, please explain: ________________________________________________________________________

Parents Employment:

Father’s employment status (Circle one): Unemployed Part Time Seasonal Full Time

Job Description_____________________________________________________________________

Mother’s employment status (Circle one): Unemployed Part Time Seasonal Full Time

Job Description_____________________________________________________________________

Family History:

(R-2) Has your child been diagnosed with a disability or developmental delay? (Circle one): YES NO (Example: Special Ed. IEP, Speech, Early On, Chronic health issue) **Parents MUST provide the most current IEP to the GSRP office during the application process. ** If YES, please explain: __________________________________________________________________________

(R-3) Has your child been expelled from preschool or a child care center? (Circle one): YES NO

(R-6) Has someone in your home ever been a victim of abuse and/or neglect? (Circle one): YES NO

(R-7) Is there any other information you believe would qualify your child for our program?

Please explain: _________________________________________________________________________________

How did you hear of the Great Start Readiness Program? ___________________________________________________

Placement Preference (GSRP Location*): __________________________ AM _______ PM _______ Full Day _______ *Please note that the preferred GSRP location is not guaranteed for final placement. Final placement is not determined until late August.

Parent/Guardian Signature: ___________________________________________ Date: _________________ By signing this application, you certify that the information given is true and accurate to the best of your knowledge.

Nondiscrimination in Education

In compliance with Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of

1975, Title II of the Americans with Disabilities Act of 1990, the Elliot-Larsen Civil Rights Act and the Persons with Disabilities Civil Rights Act, it is the policy of Utica Community Schools

that no person shall, on the basis of race, color, religion, national origin or ancestry, sex, age, disability, height, weight, or marital status be excluded from participation in , be denied the

benefits of , or be subjected to discrimination during any instructional opportunities, programs, services, job placement assistance, employment or in policies governing student conduct and

attendance. Any person suspecting a discriminatory practice should contact the Executive Director of Human Resources at Utica Community Schools, 11303 Greendale, Sterling Heights, MI

48312 or call (586-) 797-1000.

CHILD INFORMATION RECORDState 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 116COMPLETION: RequiredPENALTY: 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.

Parent Notice of Program Measurement*

____________________________ is required to work with the Michigan Department of Education (MDE) to measure the effect of the state-wide Great Start Readiness Program (GSRP). Information is sometimes collected about GSRP staff, enrolled children, and their families. Program staff or a representative from MDE might:

Ask parents questions about their child and family.

Observe children in the classroom.

Measure what children know about letters, words, and numbers.

Ask teachers how children are learning and growing. Information from you and about your child will not be shared with others in any way that you or your child could be identified. It is protected by law. Questions? Contact: mde-gsrp@michigan.gov or 517-373-8483 Or MDE, Office of Early Childhood Education and Family Services, 608 W. Allegan, P.O. Box 30008, Lansing, MI 48909 *Provided to parents upon enrollment. ____________________________ __________ Parent Signature Date ____________________________ ________________________ _________ GSRP Staff Signature Position/Title Date

Macomb Intermediate School District Macomb Intermediate School District

P:\Office\CommEdCommon\GSRP\Back to School Packet\Assessment Info

Screening Consent Form

The first 5 years of life set the stage for success in school and for a life time.

The Ages & Stages Questionnaire-3 (ASQ-3) and the Ages & Stages-Social Emotional (ASQ-SE2) are screening tools that ask questions about your child’s overall and social emotional development, looking at how children are doing in the important areas of communication, physical ability, social skills and problem-solving skills. These screens can help identify your child’s strengths, as well as, any areas where your child may need support. The screening should take about 10-20 minutes to answer questions about your child. Your individual information is protected to ensure confidentiality. Information is entered on a web based database that is secure and password protected. Identifying information from the screen will be seen only by the developmental screening specialist, who scores your screening and provides the results to you. General information about the ages and results of children’s screening scores are compiled at the Macomb Intermediate School District in order to better understand the strengths and challenges of the children living in Macomb County. I have read the above description and give Great Start Macomb and Utica Community Schools consent to screen my child(ren).

Yes, I do wish to participate No, I do NOT wish to participate

____________________________________ ____________________________________ Parent/Guardian Signature Date ____________________________________ ____________________________________ Child’s name & birth date Child’s name & birth date ____________________________________ ____________________________________ Child’s name & birth date Child’s name & birth date

RESIDENCY INFORMATION FORM

This questionnaire is in compliance with the McKinney-Vento Act, U.S.C. 42 § 11431 et seq. Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act. Student ______________________________ Parent/Guardian ___________________________ School _______________________________ Phone ___________________________________ Age __________ Grade _____________ Date of Birth ___________________________ Address __________________________________________ City _________________________ Zip Code ___________________ Is this address Temporary or Permanent? (circle one) Please choose which of the following situations the student currently resides in (you can choose more than one): _____ House or apartment with parent or guardian _____ Motel, car or campsite _____ Shelter or other temporary housing _____ With friends or family members (other than or in addition to parent/guardian) _____ Foster Care placement If you are living in shared housing, please check all of the following reasons that apply: _____ Loss of housing _____ Economic situation _____ Temporarily waiting for house or apartment _____ Provide care for a family member _____ Living with boyfriend/girlfriend _____ Loss of employment _____ Parent/Guardian is deployed _____ Other (Please explain) Are you a student under the age of 18 and living apart from your parents or guardians? Yes No

Residency and Educational Rights Students without fixed, regular and adequate living situations have the following rights:

1. Immediate enrollment in the school they last attended or the local school where they are currently staying even if they do not have all of the documents normally required at the time of enrollment without fear of being separated or treated differently due to their housing situations;

2. Transportation to the school of origin for the regular school day;

RESIDENCY INFORMATION FORM

3. Access to free meals, Title I and other educational programs and transportation to extra-curricular activities to the same extent that it is offered to other students.

Any questions about these rights can be directed to the local McKinney-Vento Liaison at 586-797-1120 or the County Coordinator at 586-228-3490 By signing below, I acknowledge that I have received and understand the above rights. ______________________________________________________________________________ Signature of Parent/Guardian/Unaccompanied Youth Date ______________________________________________________________________________ Signature of McKinney-Vento Liaison Date

P:\Human Resources\Forms\STUDENT-FAMILY\Volunteer Criminal History Check Form.doc 2/6/2014

PLEASE RETURN COMPLETED FORM TO YOUR CHILD’S SCHOOL

As a prospective volunteer of the Utica Community Schools, I understand that it is the school district’s policy to secure Conviction Criminal History information as part of their screening process using the information provided below:

School Year PLEASE PRINT CLEARLY

(All requested information must be completed) __________

NAME: _______________________________________________________________________ LAST (as shown on your license) FIRST(as shown on your license) Middle Initial Maiden Name/Names Previously Used: ______________________________________________ Daytime Phone: _________________________ Other Phone: ___________________________ Birthdate: ___________________________________ Race: ____________ Sex: ___________ MICHIGAN Driver’s License No: ________________________________ (State ID not accepted) School Name: __________________________________________________________________ Student(s) Name: ___________________________________Student(s) Grade: ______________ Volunteer For: _________________________________________________________________ (List teacher, activity, specific fieldtrip and date attending) Please submit 2 weeks prior to activity

I understand that the above information is required by the Central Record Division of the Michigan State Police in Lansing, Michigan. I authorize Utica Community Schools to utilize the above information for the sole purpose of obtaining a conviction only criminal history file search. Signature ___ Date ________________

Please be advised that if you have been convicted of a FELONY, volunteer activity will be prohibited.

Have you ever been convicted of a felony? _______ Yes _______ No Are there any felony charges currently pending against you? _______ Yes _______ No If yes, please explain the nature of conviction and date of conviction:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

_______

HEALTH APPRAISAL

Dear Parent or Guardian: The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD’S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL CHILD’S NAME (Last, First, Middle) DATE OF BIRTH (mm/dd/yy)

/ /

ADDRESS (Number & Street) (City) (ZIP Code) TODAY’S DATE (mm/dd/yy)

MI / /

PARENT/GUARDIAN (Last, First, Middle) HOME TELEPHONE NUMBER

( )

ADDRESS (Number & Street) (City) (ZIP Code) WORK TELEPHONE NUMBER

MI ( )

SECTION I - HEALTH HISTORY

# Is your child having any of the problems listed below? Birth History:

h h h 1 Allergies or Reactions (for example, food, medication or other)

h h h 2 Hay Fever, Asthma, or Wheezing

h h h 3 Eczema or Frequent Skin Rashes

h h h 4 Convulsions/Seizures

h h h 5 Heart Trouble

h h h 6 Diabetes

h h h 7 Frequent Colds, Sore Throats, Earaches (4 or more per year) Are there any current or past diagnosis(es) h Yes h No

h h h 8 Trouble with Passing Urine or Bowel Movements If yes, please describe:

h h h 9 Shortness of Breath

h h h 10 Speech Problems

h h h 11 Menstrual Problems

h h h 12 Dental Problems: Date of Last Exam / /

h h h Other (please describe):

h h Does your child take any medication(s) regularly? If yes, list medications:

Reason for Medication [

/ / Was the health history reviewed by a health professional?

Parent/Guardian Signature Date h Yes h No Examiner’s Initials:

Yes

No Reso

lved

SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTSRequired for Child Care and Head Start / Early Head Start

Tests and Measurements

No Yes

Was child tested for: Test results: Norm

al

Refe

rred

Unde

r Car

e

Visual Acuity

Muscle Imbalance

Other:

Audiometer

Other:

Sugar

Albumin

Microscopic

Level ug/dl [

VISION

Date: / /

HEARING

Date: / /

URINALYSIS

Date: / /

BLOOD LEAD LEVEL

Date: / /

h h

h h

h h

h h

No Yes

Was child tested for: Test results: Norm

al

Refe

rred

Unde

r Car

eHeight

Weight

Other

]Reading:

Type:

Neg.: h Pos.: h mm

HEIGHT & WEIGHT

Other:

HEMOGLOBIN / HEMATOCRIT

BLOOD PRESSURE

TUBERCULIN

Date: / /

h h

h h

h h

h h

NOTE: Blood lead level required for all children enrolled in Medicaid must be tested at one and two years of age, or once between three and six years of age if not previously tested. All children under age six living in high-risk areas should be tested at the same intervals as listed above.

h h

Examinations and/or Inspections Essential Findings Deviating from Normal:

Exam Date: / /MDCH/BCAL-3305 (formerly OCAL 3305/BRS-3305) Page 1 of 2 Rev. August 2013

SECTION III - IMMUNIZATIONSStatements such as “UP-TO-DATE” or “COMPLETE” will not be accepted. Admission to school may be denied on the basis of this information.*

VACCINES (Circle Type)

Hepatitis B

(HepB)

DTaP/DTP/DT/Td

Tdap

Haemophilus Influenzae

type b (HIB)

Polio

(IPV/OPV)

Pneumococcal Conjugate

(PCV7/PCV13)

Rotavirus (RV1/RV5)

Measles,Mumps, Rubella (MMR)

Varicella (Chickenpox)

1 3

2

1 4

2 5

3 6

1

1 3

2 4

1 3

2 4

1 3

2 4

1 3

2

1 2

1 2

History of Chickenpox Disease? h Yes h No If yes, date:

I certify that the immunization dates are true to the best of my knowledge

/ /

Health Professional’s Signature Title Date

DATE ADMINISTEREDMM/DD/YYYY VACCINES (Circle Type)

Hepatitis A (HepA)

Influenza (IIV/LAIV)

Meningococcal (MCV4 / MPSV4)

Human Papillomavirus

(HPV4/HPV2)

OTHER Vaccines

Specify Date & Type

1 2

1 3

2 4

1 2

1 3

2

Type of Vaccine(s) Date of Vaccine(s)

1

2

3

DATE ADMINISTEREDMM/DD/YYYY

Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable

*NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for the first time must be adequately immunized, vision tested and hearing tested. Exemptions to these requirements are granted for medical, religious and other objections, provided that the waiver forms are properly prepared, signed and delivered to school administrators. Forms for these exemptions are available at your child’s school or local health department.

Parent/Guardian refused immunizations: h

SECTION IV - RECOMMENDATIONS(Required for Child Care and Head Start/Early Head Start)No Ye

s

h h

h h

Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:

Should the child’s activity be restricted because of any physical defect or illness?If yes, check and explain degree of restriction(s): h Classroom h Playground h Gymnasium h Swimming Pool h Competitive Sports h Other

Other Recommendations

SECTION V - DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL)

I have examined ’s teeth. As a result of this examination, my recommendation for treatment is: child’s name

/ / Dentist’s Signature Date

PHYSICIAN’S SIGNATURE

/ / Examiner’s Signature Date Examiner’s Name (Print or Type) Degree or License

MI ( ) Number & Street City ZIP Code Telephone

Information required for:

Early On - Hearing and Vision Status; Diagnosis; Health Status

Child Care Licensing - Physical Exam, Restrictions, Immunizations

Head Start/Early Head Start - Determination that child is up-to-date on a schedule of age-appropriate preventive and primary health care, including medical, dental, and mental health. The schedule must incorporate the well-child care visit required by EPSDT and the latest immunizations schedule recommended by the Centers for Disease Control and Prevention, State, tribal, and local authorities. An EPSDT well-child exam includes height, weight, and blood tests for anemia at regular intervals based on age.**************Developed in Cooperation with the Departments of Human Services, Education, Community Health, Michigan American Association of Pediatrics, Early Childhood Investment Corporation, Child Care Licensing, Head Start, Michigan State Medical Society, Michigan Association of Osteopathic Physicians and Surgeons.

MDCH/BCAL 3305 (formerly OCAL 3305/BRS-3305) Page 2 of 2 Rev. August 2013