DEC - Application 2020-2021

Pueblo of Laguna • Division of Early Childhood
Registration Application - Program Year 2020-2021
Child's Name
Last
First
Middle
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit year1
Gender
Big Clan:
Little Clan:
Tribal Affiliation:
Race / Ethnicity:
Address
Mailing Address
City
State
Zip
Physical Address:
Use street names, landmarks, etc.
Village Residence:
Phone Numbers of Parents/Guardian
1. Name / Relationship to child
Phone Number
Phone Type
2. Name / Relationship to child
Phone Number
Phone Type
3. Name / Relationship to child
Phone Number
Phone Type
General
Do you have other children in a DEC program?
Number of people in family? (Child’s parents/siblings?)
Does child live with both parents?
Which parent does child live with?
Is your child receiving disability services (Early Intervention/IEP/IFSP)?
Are you currently receiving WIC?
Primary Language of Child/Family
Other (specify)

EMERGENCY MEDICAL CONSENT
This form is taken on field trips and kept in the child’s classroom and the bus
Child's Full Name
In case of an emergency, I hereby consent to diagnosis and/or treatment (diagnostic procedures, surgical and medical treatment, and blood transfusion) by authorized members of the hospital staff which in their professional judgment is deemed necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examination or treatment of the child’s condition.
I hereby give my consent for the child named above to be transported for emergency medical procedures or emergency dental care necessary to preserve the health and life of my child for program year: 2020-2021. I acknowledge that I am responsible for all reasonable charges in connection with such emergency care and treatment.
Parent / Guardian's Name
Child's Doctor / Pediatrician
Child's Dentist
Parent / Guardian Address
Home Phone
Cell / Message Phone
Current Medications
Does your child have medical insurance?
Private Insurance Name & Policy or Group Number
Medicaid Number
Does your child have any significant or chronic health problem? i.e. asthma, severe food allergy, heart condition, etc
Special Care Plan required?
Previous Surgeries
Parent / Guardian Signature
Clear
Today's Date
MonthDayYear
2 digit month, 2 digit day, 4 digit year3
Child’s Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit year4

PERMISSION FORMS
PERMISSION TO PHOTOGRAPH AND/OR VIDEO RECORDING
Division of Early Childhood • Program Year 2020-2021
Child's Name
I grant permission for my child to have his/her photograph taken by the staff of the Division of Early Childhood. I understand that these photographs are for the promotion of self-esteem, self identity, and for tracking each child’s developmental progress and other classroom use.
I understand that this permission form is valid for program year: 2020-2021
Parent / Guardian Signature
Clear
Today's Date
MonthDayYear
2 digit month, 2 digit day, 4 digit year5
PERMISSION TO POST PICTURES OF CHILD ON FACEBOOK and/or LDOE WEBPAGE
Division of Early Childhood • Program Year 2020-2021
Permission to post pictures of my child on the LDOE Facebook page and/or the Laguna Department of Education website(s)
Parent / Guardian Signature
Clear
Today's Date
MonthDayYear
2 digit month, 2 digit day, 4 digit year6
PERMISSION TO INCLUDE PICTURES OF CHILD ON EHS/PHS BULLETIN BOARDS AND NEWSLETTER
Division of Early Childhood • Program Year 2020-2021
Permission to post pictures of my child on DEC bulletin boards and newsletters
Parent / Guardian Signature
Clear
Today's Date
MonthDayYear
2 digit month, 2 digit day, 4 digit year7

CONSENT FOR SCREENING/ASSESSMENT
Division of Early Childhood • Program Year 2020-2021
Child's Name
I understand that for PY 2020-2021 my child to have screenings and assessments completed in order to gain information about his/her development and progress. I understand the office of Head Start requires child and family data for reporting purposes, including required reporting from the office of Head Start. All information will be kept confidential.
I understand that this permission form is valid for program year: 2020-2021
Child will receive the following screenings:
- Developmental Screening, Ages and Stages Questionnaire
- Health Screenings: audio, vision, dental, height and weights
- Ages and Stages Questionnaire-Social Emotional (ASQ-SE)
Statement to Parents/Guardians:
1. Health and developmental screenings noted in the paragraph above are part of Head Start requirements.
2. You will be informed of the results and may request copies of any screenings & assessments & other records.
3. All screening, assessment, and other records in your child’s name will be kept confidential.
4. I understand that Head Start programs are required to conduct developmental screenings and have evidence of completion of a physical examination and health screenings within 45 days of the child’s enrollment.
8
Parent / Guardian's Signature
Clear
Date:
MonthDayYear
2 digit month, 2 digit day, 4 digit year9

Administer Topical Solution
Division of Early Childhood • Program Year 2020-2021
The Preschool Head Start Program is requesting permission to administer topical solutions to your child during DEC program hours. Topical solutions are sprays, ointments, or creams that can be applied directly to skin. Please check the topical solution(s) of which you give permission to be used for your child while in the program.
Child’s Name:
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit year10
Parent / Guardian’s Name:
I authorize the DEC staff to use the following on my child when needed:
Signature
Clear
Today's Date:
MonthDayYear
2 digit month, 2 digit day, 4 digit year11
Should be Empty:

Pueblo of Laguna • Division of Early Childhood