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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

Resources:

12-Month Income Verification Chart

Income Worksheet

Statement of No Income

 

Selection

Annual Selection Plan - fillable

Request for Over Income Slots  NEW 8/2018

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 8/2018

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

 

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