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 ERSEA Forms Index

 

Recruitment

Recruitment and Selection Plan  NEW 5/1/2019

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

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

Resource:

Selection Worksheet  Revised 4/1/2019

Selection Spreadsheet  NEW 5/2/2019

Enrollment

Health/Nutrition:

Emergency Treatment and Consent Form  Revised 4/1/2019

Health History (1-5 Years)  Revised 5/14/2019

Health History (0-12 months)  Revised 5/14/2019

Pregnancy Health History

Food Introduction Record

Authorization to Release Confidential Health Information Procedure  Revised 5/22/2019

Release/Exchange Confidential Information (Non-Health)

Certificate of Immunization Status (CIS) Form:   English  Revised 5/22/2019

Certificate of Exemption (COE) Form:   English  Revised 5/22/2019

Susceptible List (Exempt Children) Form  Revised 5/22/2019

Susceptible List (Need Follow-Up) Form  Revised 5/22/2019

As Needed:

Child Supplemental Food Plan  Revised 4/30/2019

Parent/Guardian Request for Milk Substitute  Revised 4/30/2019

Child Health Plan and Provider Orders — Non-Food Allergies  Revised 5/14/2019

Child Health Plan and Provider Orders — Dietary Accommodations - Food Allergies/Intolerances  Revised 5/14/2019

Child Health Plan and Provider Orders — Respiratory Disorder  Revised 5/14/2019

Child Health Plan and Provider Orders — Seizure Disorder  Revised 5/14/2019

Child Health Plan and Provider Orders — Skin Condition  Revised 5/14/2019

Child Health Plan and Provider Orders — Reflux Infants and Toddlers  Revised 5/14/2019

Child Health Plan and Provider Orders — Other Health Conditions  Revised 5/14/2019

Declining Early Learning Health Services  Revised 5/14/2019

Resources:

Health History Tool (1-5 Years)  Revised 5/14/2019

Health History Tool (0-12 months)  Revised 5/14/2019

Health/Nutrition Enrollment Flowchart

Dietary Accommodations and Food Preferences Flowchart  Revised 6/10/2019

Immunization Requirements Procedure  Revised 5/22/2019

Lead Letter to Providers

Diabetes Management in the Classroom

Medical/Dental Exam Letter

Family Engagement:

Family Connections:  English   Amharic   Arabic   Russian   Somali   Spanish   Vietnamese  NEW 5/22/2019

Family Connections - EHS Home-Based   English   Amharic   Spanish  Revised 5/22/2019

As Needed:

Family Strengths and Goal Planning Form

Resources:

Race and Ethnicity List  Revised 4/1/2019

Family Engagement Procedure  Revised 5/1/2019

Transitions:

Transition Action Plan

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

Notice of Intent to Transition  Revised 5/2/2019

 

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)