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 ERSEA Forms Index

 

Recruitment

Annual Recruitment Plan - fillable

Early Learning Application Cover Sheet - fillable  NEW 3/1/2019

Resource:

Community Contacts List

Community Contact Log  NEW 3/29/2019

Recruitment Contact Sheet  NEW 2/22/2019

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  NEW 2/15/2019

Eligibility Verification Form (2019-2020)  NEW 3/1/2019

Eligibility Verification Form (2018-2019)

Selection Points Chart (2019-2020)  NEW 4/1/2019

Selection Points Chart - Expectant Mother (2019-2020)  NEW 4/1/2019

Resources:

12-Month Income Verification Chart

Income Worksheet

Statement of Income  Revised 4/16/2019

 

Selection

Annual Selection Plan - fillable

PSESD 121 Over Income Request Form  Revised 4/17/2019

Resource:

Selection Worksheet  Revised 4/1/2019

Enrollment

Health/Nutrition:

Emergency Treatment and Consent Form   English    Spanish  English-Revised 4/1/2019

Health History (1-5 Years)

Health History (0-12 months)

Pregnancy Health History

Food Introduction Record

Release/Exchange Confidential Information (Non-Health)

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  English-Revised 3/25/2019

Family Connections - EHS Home-Based   English  Revised 3/25/2019

As Needed:

Family Strengths and Goal Planning Form

Resources:

Race and Ethnicity List  Revised 4/1/2019

Family Engagement Procedure  Revised 4/2/2019

Transitions:

Transition Action Plan

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

Notice of Intent to Transfer/Transition Child or Pregnant Mother and Records Form

 

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

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 (2018-2019 Program Year)