___________________________________

Child’s Name

Please complete the attached paperwork for Pre-K Counts and return to the

address below. In addition, please include the child’s birth certificate,

immunizations record and proof of income. If any questions, please call

(412) 664-3612.

McKeesport Area School District

3590 O’Neil Blvd.

McKeesport, PA 15132

Attn: Allison Wynn

Please indicate which Pre-K Counts class in which you want to enroll your child.

_____Half day AM – 8:30 am to 11:30 am – located at Founders’ Hall.

Best option for 3 year olds

_____Half day PM – 12:15 pm to 3:15 pm – located at Founders’ Hall.

Best option for 3 year olds

_____FULL DAY – 8:15 am to 2:15 pm – located at Founders’ Hall.

Best option for 4 year olds

Please keep in mind that parents must provide transportation to and from school.

Also, enrollment slots are limited and are on a first come first serve basis.

2016 Enrollment Review Checklist

Child’s Name _______________________________ Date of Birth ________/_______/_______

Parent’s Name _______________________________ Phone Number _______________________

Start Date _____/_____/_____ Outcomes ID# _______________________

School District of Residence __________________________________________________________________

Application Immunization Record

Proof of Residence Physical

Verification of Income Dental

Birth Certificate Other _________________________________

Income and Family Size Information

Household Size: _________ Actual Verified Gross Household Income (Annual): ____________________

If by actual income:

W-2 Check Stubs (3) Zero Income Letter County Case Message

Tax Return Employer Letter Child Support TANF Printout

Foster Care Letter SSI Other _________________________________________

2016 Federal Poverty Level Guidelines

300%

Family Size Annual Monthly Weekly

1 $35,640 $2,970 $685

2 $48,060 $4,005 $924

3 $60,480 $5,040 $1,163

4 $72,900 $6,075 $1,402

5 $85,320 $7,110 $1,641

6 $97,740 $8,145 $1,880

7 $110,190 $9,183 $2,119

8 $122,670 $10,223 $2,359

Each Add’l $12,480 $1,040 $240

All sources of income have been verified prior to enrollment. Copies of documents used to verify income prior to

enrollment have been recorded, filed and available for review.

Family income is at or below 300% of federal poverty level (required).

To the best of my knowledge, the information provided is accurate. I understand that I may be asked to verify or substantiate

information provided.

Enrollment Information Reviewed: ____________ _________________________________________ Date Reviewer Signature

MASD Pre-K Counts Application

Child’s Name: _____________________________ _____ ______________________________ First MI Last

Child’s Date of Birth: ___________________________ Gender: Male Female

Social Security #: ______________________________

Race (optional): _______________________________

Ethnicity: Hispanic Non-Hispanic

Address: __________________________________ Home phone #: _____________________

__________________________________________ Cell phone #: ________________________

Email address: ______________________________ Alternative phone #: _________________

Parents/Guardians

__________________________________________ Mother Father Grandparent Guardian Other

Name Biological Foster Adoptive Step-parent Other

If other, please list:______________________________________

Resides in home w/ child? (circle one) YES NO

Education Status of Guardian 1:

Up to 8th Grade

9th to 11th Grade

High School Diploma GED Vocational or Technical Program after High School

Some College

Associates Degree

Bachelor’s Degree

Graduate/Professional School

Unknown

Employment Status of Guardian 1:

Employed Full-Time (30 hours/week and over) Seasonal

Employed Part-Time (Fewer than 30 hours/week) Student or Job Trainee

Multiple Part-Time Unemployed

__________________________________________ Mother Father Grandparent Guardian Other

Name Biological Foster Adoptive Step-parent Other

If other, please list:______________________________________

Resides in home w/ child? (circle one) YES NO

Education Status of Guardian 2:

Up to 8th Grade

9th to 11th Grade

High School Diploma GED Vocational or Technical Program after High School

Some College

Associates Degree

Bachelor’s Degree

Graduate/Professional School

Unknown

Employment Status of Guardian 2:

Employed Full-Time (30 hours/week and over) Seasonal

Employed Part-Time (Fewer than 30 hours/week) Student or Job Trainee

Multiple Part-Time Unemployed

Marital status: _____________________________

Family type

One Parent Two Parent Foster Child living with Relative

Other; Please specify: _______________________

Including your child, how many people live within the household? __________

Of the above number, how many people are over the age of 18? ___________

Do other adults live in your home? YES NO If yes, please list: ______________________________________________________________

Number of siblings: __________ (Include all siblings related by blood or marriage)

Names of the other children in the family: Name: _____________________ Age: ____ Name: _____________________ Age: ____

Name: _____________________ Age: ____ Name: _____________________ Age: ____

Do other children who live in the home attend MASD schools? YES NO

Household Income (required) check box:

Less Than $5,000 $5,001 - $10,000 $10,001 - $15,000

$15,001 - $20,000 $20,001 - $25,000 $25,001 - $30,000

$30,001 - $35,000 $35,001 - $40,000 $40,001 - $45,000

$45,001 - $50,000 $50,001 - $60,000 $60,001 - $70,000

$70,001 - $100,000 More Than $100,000

Actual Annual Verified Gross Household (Family) Income: ______________________ (Attach copies of documents used to verify income prior to enrollment)

Family income is at or below 300% of federal poverty level (Required Risk factor). Consider

all sources of income. See end of document for income chart relative to family size. (Must be

verified prior to enrollment.)

Check any community-based services the family has participated in:

Emergency/Crisis Intervention Housing Assistance

Transportation Assistance Mental Health Services

English as a Second Language (ESL) Training Adult Education

Substance Abuse Prevention or Treatment Job Training

Child Abuse and Neglect Services Domestic Violence Services

Child Support Assistance Health Education

Assistance to Families of Incarcerated Individuals Parenting Education

Assistance in Obtaining Health Insurance Marriage Education Services

Assistance in Identifying Health Care/Medical Providers None

Unknown

Primary Language spoken in the home: ________________

Does your child have any speech issues? YES NO

If yes, please explain: ____________________________________________________________

Has your child received any prior services for speech issues? YES NO

If yes, please list services: _________________________________________________________

Is your child adopted? YES NO If Yes, Age of Adoption? __________

Child’s Birth Weight:

Normal (Greater than or equal to 5.8 lbs.) Very Low (Less than or equal to 3.4)

Low (Greater than 3.4 lbs. and less than 5.8 lbs.) Unknown

Immunizations Up-to-date: YES NO

What type of insurance does your child have? CHIP Medical Assistance

Private None Unknown

Does your child have a physician they see regularly? YES NO

Does your child have a dentist they see regularly? YES NO

Other Child Eligibility Risk Factor Criterion (Must check all that apply)

Behavioral Supports: A child who was referred to PA Pre-K Counts from an appropriately

credentialed health or mental health practitioner who is not employed by the PA Pre-K Counts program;

a child who is receiving mental health treatment. Additional verification beyond the interview is

required.

Child Protective Services: A child who is a foster child, a kinship care child or receiving Children and

Youth services.

Education level of guardian: does not have a high school diploma or GED or post-secondary degree.

English Language Learner: A child whose first language is not English and who is in the process of

learning English is considered an English Language Learner.

Homeless: A child who lacks a fixed, regular, and adequate nighttime residence due to one of the

following:

A. Children who are sharing the housing of other persons due to loss of housing, economic

hardship, or a similar reason; are living in motels, hotels, or camping grounds due to the lack

of alternative accommodations; are living in emergency or transitional shelters; are

abandoned in hospitals; or are awaiting foster care placement;

B. Children who have a primary nighttime residence that is a public or private place not

designed for or ordinarily used as a regular sleeping accommodation for human beings;

C. Children who are living in cars, parks, public spaces, abandoned buildings, substandard

housing, bus or train stations, or similar settings.

Incarcerated Parent: A child for whom one of the child’s parents is currently in prison

Individualized Education Plan (IEP): A child who is currently enrolled in the Preschool Early

Intervention program with an active IEP. Verification would be a copy of the IEP or other source of

documentation from the parent or Early Intervention provider.

Migrant (non-immigrant)/Seasonal Student: A migrant child has moved from one school district to

another in order to accompany or to join a migrant parent or guardian, who is a migratory worker or

migratory fisher, within the preceding 36 months, in order to obtain temporary or seasonal employment

in qualifying agricultural or fishing work including agri-related businesses such as meat or vegetable

processing, working in nurseries such as Christmas and evergreen trees farming.

Teen mother: A child whose mother was under the age of 18 when the child was born.

ABOUT YOUR CHILD

PERSONAL HABITS:

Does your child usually eat breakfast? ______________ Mid morning snack? ______________

Is your child allergic to any foods, medications, pets, etc. ______________________________

Is there anything unusual about your child’s eating habits that you believe we should know?

______________________________________________________________________________

What is your child’s usual bedtime? ___________ Wake-up time? ___________________

Does your child take a morning nap? __________ Afternoon nap? __________________

At what age did your child walk? ______________ Talk? ___________________________

At what age was your child toilet trained? _______

How does your child state his/her need to go to the bathroom? __________________________

Does your child have periodic accidents? ________

Are there any other areas that you are concerned about? _______________________________

PLAY AND SOCIABILITY:

Does your child prefer to play alone: ____ Always ____ Often ____ Seldom ____ Never

Does your child want the involvement of _____ adults? _____children?

Are your child’s playmates _____ girls? _____ boys? _____ younger? _____ older?

What play materials does your child use most? _______________________________________

Does your child have the opportunity to play outdoors? ________________________________

What experience does your child have with music at home? _____________________________

What opportunities for hearing stories are offered? ___________________________________

How often do family members read to your child?

At least once a day At least once a week At least once a month Less than once a month

How many children’s books are in your home? 0-5 5-10 11-20 More than 20

PERSONALITY AND EMOTIONAL DEVELOPMENT:

Do you regard your child as affectionate? _____________ To Whom? __________

Does your child accept new people easily? ___________________________________________

Does your child have any fears? _____________________ Of what? ______________________

When you find it necessary to exert authority with your child, what do you do?

Mother: _______________________________________________________________________

Father: ________________________________________________________________________

MEDICAL:

List any diseases your child has had: _______________________________________________

Does your child have any medical conditions of which we should be made aware (such as

convulsions, diabetes, nosebleeds, etc.) Also, please state anything to which your child is

susceptible (colds, etc.) __________________________________________________________

______________________________________________________________________________

Does your child take any medicine regularly? __________ What? ________________________

Local hospital I prefer that my child be transported to for emergency treatment: ____________

______________________________________________________________________________

OTHER:

List below any further information about your child or your family which you believe will be

helpful to us in understanding your child’s behavior and needs: __________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Are there any financial, religious or cultural factors that we need to consider here at school? __

______________________________________________________________________________

______________________________________________________________________________

To the best of my knowledge, the information provided is accurate. I understand that I may be asked to

verify or substantiate information provided.

________________________________________________ ________________

Parent/Guardian Signature Date

________________________________________________

Parent/Guardian Name – Please Print

________________________________________________ ________________

Staff Verifying Income and Risk Factors Signature Date

________________________________________________

Staff Verifying Income – Please Print

ZERO INCOME DECLARATION LETTER

Name of Parent _________________________________________________________

Name of Child _________________________________________________________

Program Name _______________________________ Program Year _________

Date __________

I am signing this letter to declare that I currently do not have any income from any source. My

financial support comes from (please describe):

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

I agree to notify the above program about changes in my income within 30 days of the

change.

I certify that the information submitted is accurate and true to the best of my knowledge. I

understand that by completing, signing, and dating this form, I declare I have no household

income and that the information I am providing is correct. I understand that providing false

information may result in denial of services.

Parent Name ___________________________________________________

Parent Signature ___________________________________________________

Reviewer Name ___________________________________________________

Reviewer Signature ___________________________________________________

Date ___________________

2016 Federal Poverty Level Guidelines

100%

138%

Family Size Annual Monthly Weekly Family Size Annual Monthly Weekly

1 $11,770 $981 $226 1 $16,242 $1,354 $312

2 $15,930 $1,328 $306 2 $21,983 $1,832 $422

3 $20,090 $1,675 $386 3 $27,724 $2,310 $532

4 $24,250 $2,022 $466 4 $33,465 $2,788 $642

5 $28,410 $2,369 $546 5 $39,205 $3,266 $752

6 $32,570 $2,716 $626 6 $44,946 $3,744 $862

7 $36,730 $3,063 $706 7 $50,687 $4,222 $972

8 $40,890 $3,410 $786 8 $56,428 $4,700 $1,082

Each Add’l $4,160 $347 $80 Each Add’l $5,741 $478 $110

150%

200%

Family Size Annual Monthly Weekly Family Size Annual Monthly Weekly

1 $17,655 $1,471 $340 1 $23,540 $1,962 $453

2 $23,895 $1,991 $460 2 $31,860 $2,655 $613

3 $30,135 $2,511 $580 3 $40,180 $3,348 $773

4 $36,375 $3,031 $700 4 $48,500 $4,041 $933

5 $42,615 $3,551 $820 5 $56,820 $4,734 $1,093

6 $48,855 $4,071 $940 6 $65,140 $5,427 $1,253

7 $55,095 $4,591 $1,060 7 $73,460 $6,120 $1,413

8 $61,335 $5,111 $1,180 8 $81,780 $6,813 $1,573

Each Add’l $6,240 $520 $120 Each Add’l $8,320 $693 $160

250%

300%

Family Size Annual Monthly Weekly Family Size Annual Monthly Weekly

1 $29,425 $2,452 $566 1 $35,310 $2,943 $679

2 $39,825 $3,319 $766 2 $47,790 $3,983 $919

3 $50,225 $4,186 $966 3 $60,270 $5,023 $1,159

4 $60,625 $5,053 $1,166 4 $72,750 $6,063 $1,399

5 $71,025 $5,920 $1,366 5 $85,230 $7,103 $1,639

6 $81,425 $6,787 $1,566 6 $97,710 $8,143 $1,879

7 $91,825 $7,654 $1,766 7 $110,190 $9,183 $2,119

8 $102,225 $8,521 $1,966 8 $122,670 $10,223 $2,359

Each Add’l $10,400 $867 $200 Each Add’l $12,480 $1,040 $240

*Chart is for 48 contiguous states and the District of Columbia; for Hawaii and Alaska please visit the website of the

HHS Assistant Secretary for Planning and Evaluation (ASPE): http://aspe.hhs.gov/poverty/14poverty.cfm.

Revised February 2011      

Administrative Procedures Appendix #6a Income and Family Size Verification Guidance 

 Income Verification Guidance: The following are included in verifying income: 

• Earned income from all sources including gross wages from work, cash, and in‐kind payments received by an individual in exchange for services and net income from self employment 

• Unearned income including cash and contributions received by an individual for which the individual does not perform a service such as alimony, child support, military family allotments or other regular support from an absent family member, pensions, public assistance (including Temporary Assistance for Needy Families, Supplemental Security Insurance, Emergency Assistance money payments and non‐Federally Funded General Assistance or General Relief money payments), and dividends, interest, net income, net royalties and periodic receipts from estates or trusts. 

• Unearned benefits received periodically by an individual, such as unemployment compensation, workman’s compensation, gambling or lottery winnings, or retirement benefits. 

 Income Deductions: The following are deducted when determining family income: 

• Voluntary or court‐ordered child support or child support paid by the parent or caretaker or family member to a present or former spouse not residing in the same household. 

• A medical expense not reimbursed through medical insurance that exceeds 10% of the family gross monthly income. 

 Income Exclusions: The following are excluded when determining family income: 

• Employment earnings of an individual who is an emancipated minor 

• Tax refunds, including earned income tax credits 

• Withdrawals of bank, credit union or brokerage deposits or money borrowed 

• Loans or grants, such as scholarships or income from federal student aid or participation in work‐study program 

• Payments to Volunteers in Service to America, such as AmeriCorps or Foster Grandparent programs 

• Any foster care payments by a foster care placement agency, including payments to permanent legal custodians or adoption assistance payments by county children and youth agency 

• Food Stamps  Whose Income is Counted?: 

• The parent or caretaker of the child 

• The parent or caretaker’s spouse or the other biological parent if living together 

• Children’s, excluding a child’s earned income 

Revised February 2011      

• “Caretaker” means the father or mother of a child, an adult who has legal custody of a child, an adult who is the guardian of a child, or an adult who stands in loco parentis, as defined in this rule, with respect to a child and whose presence in the home is needed as the caretaker of the child. 

• “Spouse” means married to the parent of the eligible child. If not married but residing with the parent of the eligible child, person’s income does not count. 

 Time Period: The period of time for income verification is the twelve months immediately preceding the month in which the application or reapplication for enrollment of a child is made, or for the calendar year immediately preceding the calendar year in which the application or reapplication is made.  Verification of Income: 

• Acceptable verification of earned income from employment includes pay stubs reflecting earnings, W‐2 forms, the IRS form used for reporting tips, a written employer statement of anticipated earnings or other document that establishes the parent’s or caretaker’s anticipated earnings from employment. 

• Acceptable verification from self employment includes tax returns, business records or other documents establishing profit from self employment. 

• Acceptable verification of unearned income includes a copy of a current benefit check, an award letter that designates the amount of a grant or benefit, such as a letter from the Social Security Administration stating the amount of the social security benefit, a bank statement, a court order, or other document or data base report that establishes the amount of unearned income. 

• If a family receives or pays child support, the eligibility agency shall verify the amount of support received or paid by the family by documents from the Department of Public Welfare.  

Acceptable forms of documentation maintained on file include, but are not limited to: 

• Paystubs‐ a minimum of one if the year to date salary is included, if no year to date, 3 paystubs should be maintained  

o Income is determined by calculating the weekly or monthly income and multiplying it by the appropriate multiplier, 52 for weekly, 26 for bi‐weekly, 12 for monthly 

o If the paystub income varies, calculate the average rate and multiply by # of stubs used/# the multiplier (see above).   EXAMPLE: 3 stubs equaling $900.00, 1200.00 and 950.00  if the average rate is $1016/week * 52 weeks the annual salary is  $ 52,832.00 Assuming this is a family of 3 or more, the child is eligible 

• W‐2’s‐ a copy of all family members W‐2 should be maintained.  Income is typically counted from box #1 on the W‐2s 

o Family is identified as the parent/guardian responsible for the child o If the parents are living with grandparents, the grandparent’s income would not be 

taken into consideration unless they are the guardian • Tax forms‐ a copy of the current or prior year’s form   • Employer Verification‐ A letter provided by the employer, including employer contact 

information, verifying wages and number of hours worked 

Revised February 2011      

• TANF‐ Cash assistance TANF award documentation • CCIS Eligibility Detail Page • Food Stamps Case number • Family Letter indicating No Income • Disability documentation • Unemployment documentation 

 Note: COMPASS may be used to verify eligibility if the system indicates the family receives TANF or Food Stamps.  No other information provided on COMPASS is acceptable for income verification.  Pre‐K Counts Providers are still required to collect the family size and income for data entry in PELICAN..   Family Size The number of people in the house to be counted for the purposes of reporting “family size” include the child or children for whom PA Pre‐K Counts is being requested and the following individuals who live with that child or children in the same household: 

• Parent of the child. The parent is the biological or adoptive mother or father, stepmother or father, caretaker and spouse who exercise care and control over the child requesting PA Pre‐K Counts. 

• A biological, adoptive, unrelated or foster child or stepchild of the parent or caretaker who is under 18 years of age and not emancipated. 

• A child who is 18 years of age or older but under 22 years of age who is enrolled in high school, a general educational development program,  or a post‐secondary program leading to a degree, diploma or certificate and who is wholly or partially dependent on the income of the parent or caretaker or spouse of the parent or caretaker.  

• Foster children should be entered as a family size of 1.       

           

Administrative Procedures Appendix #6b Additional Risk Factor Guidance

Family income that is 300 percent below the federal poverty guideline is the primary risk factor for participation in PA

Pre‐K Counts. Additional risk factors that are identified must be reported in the Early Learning Network. These risk factors

can be determined by careful interviewing. Ask specific questions and follow up with requests for additional

documentation as needed.

Additional Risk Factors include:

• Child receiving behavioral supports:

A child who is referred to PA Pre‐K Counts from an appropriately‐credentialed health or mental health provider who is not

employed by the PA Pre‐K Counts program; a child who is receiving mental health treatment. Additional verification

beyond the interview is required.

• Child or family who receives Protective Services:

A child who is a foster child, a kinship care child, or receiving Children and Youth services

• Education Level of Guardian:

Does not have a high school diploma or GED or post‐secondary degree.

• English Language Learner:

A child whose first language is not English and who is in the process of learning English is considered an English

Language Learner. Ask these two questions, as established by the Pennsylvania Department of Education, to determine

if a child qualifies as an English Language Learner.

o What is/was the child’s first language?

o Does the child speak a language other than English? (do not include languages learned in school)

• Homeless

A child who lacks a fixed, adequate and regular place of nighttime residence due to one of the following:

o Children who are sharing the household of other persons due to the loss of housing, economic hardship or a similar

reason and are residing in motels, hotels or camping grounds due to the lack of alternate accommodations; are living in

emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement

o Children who have a primary nighttime residence that is public or private place not designed for or ordinarily used as a

regular sleeping accommodation for human beings

o Children who are living in cars, parks, public places, abandoned buildings, substandard housing, bus or train stations,

or similar settings

• Incarcerated Parent:

A child for whom one of the child’s parents is currently incarcerated.

• Preschooler with an Individualized Education Plan (IEP):

A child who is currently enrolled in the Early Intervention program with an active IEP. Verification includes a copy of the

IEP or other source of documentation from the parent or the Early Intervention agency.

• Migrant (non immigrant) Seasonal Student:

A migrant child has moved from one school district to another in order to accompany or join a migrant parent or guardian

who is a migratory worker or fisher within the preceding 36 months, in order to obtain temporary or seasonal employment

in qualifying agricultural or fishing work, including agri‐related businesses such as meat or vegetable processing, or

working in nurseries such as Christmas and evergreen tree farming.

• Teen mother:

A child whose mother was under the age of 18 when the child was born.

EMERGENCY CONTACT / PARENTAL CONSENT FORM

CHILD’S NAME

BIRTHDATE

ADDRESS

MOTHER’S NAME/LEGAL GUARDIAN HOME OR CELL PHONE NUMBER(S)

ADDRESS WORK TELEPHONE NUMBER(S)

FATHER’S NAME/LEGAL GUARDIAN HOME OR CELL PHONE NUMBER(S)

ADDRESS WORK PHONE NUMBERS(S)

EMERGENCY CONTACT PERSON(S) NAME TELEPHONE NUMBER(S) 1.

2.

3.

PERSON(S) TO WHOM CHILD MAY BE RELEASED NAME TELEPHONE NUMBER(S) 1.

2.

3.

NAME OF CHILD’S PHYSICIAN/MEDICAL CARE PROVIDER TELEPHONE NUMBER

ADDRESS

SPECIAL DISABILITIES (IF ANY) ALLERGIES (INCLUDING MEDICATION REACTION)

MEDICAL OR DIETARY INFORMATION NECESSARY IN AN EMERGENCY SITUATION MEDICATION, SPECIAL CONDITIONS

ADDITIONAL INFORMATION ON SPECIAL NEEDS OF CHILD

HEALTH INSURANCE COVERAGE FOR CHILD OR MEDICAL ASSISTANCE BENEFITS POLICY NUMBER (REQUIRED)

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

OBTAINING EMERGENCY MEDICAL CARE ADMINISTERING MINOR FIRST-AID PROCEDURES

WALKS AND TRIPS SWIMMING

TRANSPORTATION BY THE FACILITY PHOTOS

_____________________________________________________________ ________________________________________

SIGNATURE OF PARENT OR GUARDIAN DATE

_____________________________________________________________ ________________________________________

SIGNATURE OF PARENT OR GUARDIAN DATE

PRE-K COUNTS PROGRAM

Student Name:_____________________________________

Birthdate:_________________________________________

Please check the appropriate answer:

____ I wish for school personnel to do a vision exam.

____ I wish for my family optometrist to do the vision exam.

____ I wish for school personnel to do a dental exam.

____ I wish for my family dentist to do the dental exam.

____ I wish for school personnel to do a hearing exam.

____ I wish for my family audiologist to do the hearing exam.

If you choose to have your family doctors provide the exams, you must provide the results to

the MASD Pre-K Counts Program.

Parent/Guardian Signature:__________________________

Date:____________________________________________

CHILD HEALTH REPORT (55 PA CODE §§3270.131, 3280.131 AND 3290.131)

CD 51 09/08

CHILD’S NAME: (LAST) (FIRST)

PARENT/GUARDIAN:

DATE OF BIRTH: HOME PHONE NUMBER:

ADDRESS: CHILD CARE FACILITY NAME:

FACILITY PHONE: COUNTY: WORK PHONE:

I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child. PARENT’S SIGNATURE:

DO NOT OMIT ANY INFORMATION

This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.

HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY): NONE

DESCIRBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IS NECESSARY.

NONE

CHILD’S ALLERGIES (DESCRIBE, IF ANY): NONE

LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES.

NONE

IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES?

YES NO IF NO, PLEASE EXPLAIN YOUR ANSWER:

HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT WWW.AAP.ORG)

YES NO

NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY.

VISION (subjective until age 3)

HEARING (subjective until age 4)

LEAD

RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD

IMMUNIZATIONS DATE DATE DATE DATE DATE COMMENTS

HEP-B

ROTAVIRUS

OTAP/DTP/TD

HIB

PNEUMOCOCCAL

POLIO

INFLUENZA

MMR

VARICELLA

HEP-A

MENINGOCOCCAL

OTHER

MEDICAL CARE PROVIDER:

SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN’S ASSISTANT

ADDRESS: TITLE:

PHONE: LICENSE NUMBER: DATE FORM SIGNED:

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Hand Sanitizer Parent Permission Form

Dear Parents, McKeesport Pre-K Counts is required to obtain parent permission for administering hand sanitizer. Hand sanitizer will be used when entering the room, after coughing or sneezing, and before using shared sensory items. The use of hand sanitizer will tremendously help us to reduce the spread of illness, especially during the winter months. Staff members and children will NOT use hand sanitizer as a substitute for hand washing as required by safety regulations. Hand washing is still required after toileting and prior to eating. Hand sanitizers will be inaccessible to children when not in immediate use. A staff person will be physically present with and supervising any child who is using hand sanitizer. If you have any questions or concerns please talk to your child’s teacher.

I / we give permission for ______________________________ to receive hand sanitizer. Signed _____________________________________________ Date _______________________________________________ School Year Attended ___________________