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 ERSEA Forms Index

 

Recruitment

Annual Recruitment Plan - fillable

Resource:

Community Contacts List

Early Head Start Recruitment Flyer - Fillable:  English   Spanish

Early Head Start Recruitment Flyer - Printable

Early Head Start Home-Based Recruitment Flyer - Fillable:  English   Spanish

Early Head Start Home-Based Recruitment Flyer - Printable

ECEAP Recruitment Flyer - Fillable:  English   Spanish

ECEAP Recruitment Flyer - Printable

Head Start Recruitment Flyer - Fillable:  English   Spanish

Head Start Recruitment Flyer - Printable

Shared Waitlist Sites Recruitment Flyer - Fillable:  English   Spanish

Shared Waitlist Sites Recruitment Flyer - Printable

 

Eligibility

Eligibility Verification Form  Updated 11/26/2018

Resources:

12-Month Income Verification Chart

Income Worksheet

Statement of No Income

 

Selection

Annual Selection Plan - fillable

PSESD 121 Over Income Request Form  NEW 12/7/2018

Resource:

Selection Worksheet  NEW 8/2018

Enrollment

Health/Nutrition:

Emergency Treatment and Consent Form   English  Spanish  UPDATED 10/17/2018

Pre-10/1/18 - Emergency Treatment and Consent Form   English   Spanish   UPDATED 10/17/2018

Health History (1-5 Years)

Health History (0-12 months)

Pregnancy Health History

Food Introduction Record

Release/Exchange Confidential Health Information (Non-Health)  UPDATED 8/2018

As Needed:

Child Supplemental Food Plan

Parent/Guardian Request for Milk Substitute

Child Health Plan and Provider Orders — Non-Food Allergies

Child Health Plan and Provider Orders — Dietary Accommodations - Food Allergies/Intolerances

Child Health Plan and Provider Orders — Respiratory Disorder

Child Health Plan and Provider Orders — Seizure Disorder

Child Health Plan and Provider Orders — Skin Condition

Child Health Plan and Provider Orders — Reflux Infants and Toddlers

Child Health Plan and Provider Orders — Other Health Conditions

Declining Early Learning Health Services

Resources:

Health History Tool (1-5 Years)

Health History Tool (0-12 months)

Health/Nutrition Enrollment Flowchart

Dietary Accommodations and Food Preferences Flowchart

Immunization Requirements Procedure

Lead Letter to Providers

Diabetes Management in the Classroom

Medical/Dental Exam Letter

Family Engagement:

Family Connections:  English  Spanish  Revised 10/17/2018

Pre-10/1/18 - Family Connections:  English   Spanish  Revised 10/17/2018

Family Connections - EHS Home-Based   English   Spanish  UPDATED 9/19/2018

As Needed:

Consent for Use of Interpreter

Family Strengths and Goal Planning Form

Resources:

Race and Ethnicity List

Family Engagement Opportunities

Family Engagement Guidance  Revised 10/22/2018

Transitions:

Transition Action Plan  Revised 8/2018

 

Attendance

Continuity of Care:

Continuity of Care Procedure

Continuity of Care Request for Funds Guidance

Continuity of Care Request for Funds

Continuity of Care Claim Authorization to Pay Form

Alternative Attendance Plan  NEW 1/28/2019

 

Documentation

Child Health and Developmental Summary  NEW 8/2018

Documentation Protocols

Family Contact Log:  PDF (print)   Word (fillable)

Family Engagement Notebook Procedure

Parent Training Topics Tracking Form

 

Transportation

Statement of Exception Release Child to Person(s) Under 18 (2018-2019 Program Year)  NEW 10/22/2018