ERSEA Forms Index

 

Recruitment

Recruitment and Selection Plan

Early Learning Application Cover Sheet - fillable:   English   Spanish   Amharic   Arabic   Russian   Somali   Vietnamese  NEW 2/24/2020

Resource:

Community Contacts List

Community Contact Log 

Recruitment Contact Sheet 

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

FCC 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

2019 Federal Poverty Guideline

Eligibility Verification Form (2019-2020) 

Eligibility Verification Form (2018-2019)

Selection Points Chart (2019-2020)

Selection Points Chart - Expectant Mother (2019-2020)

Resources:

12-Month Income Verification Chart

Income Worksheet

Statement of Income

Eligibility Verification Form - Highlighted

 

Selection

PSESD Over Income Request Form

Resource:

Selection Worksheet

Selection Spreadsheet

Enrollment

Health/Nutrition:

Emergency Treatment and Consent Form

Health History (1-5 Years)

Health History (0-12 months)

Pregnancy Health History

Physical and Dental Exam Procedure

Food Introduction Record

Authorization to Release Confidential Health Information Procedure

Release/Exchange Confidential Information (Non-Health)

Certificate of Immunization Status (CIS) Form:   English

Certificate of Exemption (COE) Form:   English

Susceptible List (Exempt Children) Form

Susceptible List (Need Follow-Up) Form

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   Amharic   Arabic   Russian   Somali   Spanish   Vietnamese

Family Connections - EHS Home-Based   English   Amharic   Spanish

As Needed:

Family Strengths and Goal Planning Form

Resources:

Race and Ethnicity List

Family Engagement Procedure  Revised 2/24/2020

Transitions:

Transition Action Plan

Health and Nutrition School Readiness Transition Information Form  (NCR copies available from PSESD)

Notice of Intent to Transition

 

Attendance

Continuity of Care:

Continuity of Care Request for Funds

Continuity of Care Claim Authorization to Pay Form

Alternative Attendance Plan

Early Head Start Home-Based Attendance

 

Documentation

Child Health and Developmental Summary

Documentation Protocols

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

Parent Training Topics Tracking Form

 

Transportation

Statement of Exception Release Child to Person(s) Under 18