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

Eligibility Verification Form - Highlighted  NEW 6/20/2019

 

Selection

PSESD Over Income Request Form  Revised 9/3/2019

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

Physical and Dental Exam Procedure  Revised 8/20/2019

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  Revised 9/4/2019

Resources:

Race and Ethnicity List  Revised 4/1/2019

Family Engagement Procedure  Revised 10/3/2019

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 Request for Funds

Continuity of Care Claim Authorization to Pay Form

Alternative Attendance Plan   Revised 9/3/2019

Early Head Start Home-Based Attendance  NEW 8/14/2019

 

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   Revised 8/29/2019