Pueblo of Laguna • Division of Early Childhood

The Laguna Division of Early Childhood requests that each child have a minimum of two current emergency contact numbers on file. Please be certain that contact numbers listed are currently in service.

Child Release from Program or Preschool Head Start Bus Check-out Information: We are unable to release a child to any unauthorized person or to an individual appearing to be under the influence of alcohol or drugs. We cannot release a child to any person under the age of 18, from the center or from program activities such as field trips, unless that person is the parent. Identification (picture ID or driver's license) may be required before a child is released. We cannot release a child to a person who does not have an approved car seat.

Please note, it is DEC Policy that a person who is listed on the sex offender registry cannot be named as an emergency contact, pick up a child from the program, take a child off the bus, or participate in any DEC activity.

REMEMBER: ANY CHANGES OR UPDATES MUST BE MADE IN PERSON

Parent/Legal Guardian - Primary Contact 1

Parent/Legal Guardian - Primary Contact 2

Contact 3

Contact 4

Contact 5

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.

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

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)

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.

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.