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1 c/o the amiskwaciy Cultural Society (Revised May 2017) Page 1 CHILD AND FAMILY INFORMATION Program Site: _________________ Child’s ID Number: ________________ Class: AM PM Start Date: ______________________ New Returning Intake Date: ______________________ (For office use only) Child’s Legal Name: _________________ _____________________ ____________________ (First) (Middle) (Last) Other known name(s): _____________________________________________________ DOB: ________________________ Gender: Male Female (Month / Day / Year) Address: ______________________Suite #:___________ Postal Code: ______________ Home Phone: _______________ Work: _________________ Cell: __________________ Email Address: __________________________________________________________________ Name of Primary caregiver: ________________________ _______________________ (First) (Last) Relationship to child: Mother (bio) Step-Mother Father (bio) Step-Father Grandmother Grandfather Aunt Uncle Foster parent Other _________________________________ Address: Same as child? Yes No Name of Additional caregiver (if any): ____________________ ____________________ (First) (Last) Relationship to child: Mother (bio) Step-Mother Father (bio) Step-Father Grandmother Grandfather Aunt Uncle Foster parent Other ___________________________________ Address: Same as child? Yes No Address: ______________________Suite #:___________ Postal Code: _______________ Home Phone: _______________ Work: _________________ Cell: ___________________ ABORIGINAL HEAD START APPLICATION FORM

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Page 1: 1 ABORIGINAL HEAD START APPLICATION FORMaboriginalheadstart.com/uploads/Application 2017-2018_fillable2.pdf · mother(bio) step- father ... aboriginal learner data collection initiative

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c/o the amiskwaciy Cultural Society (Revised May 2017) Page 1

CHILD AND FAMILY INFORMATION

Program Site: _________________ Child’s ID Number: ________________

Class: AM PM Start Date: ______________________

New Returning

Intake Date: ______________________

(For office use only)

Child’s Legal Name:

_________________ _____________________ ____________________ (First) (Middle) (Last)

Other known name(s): _____________________________________________________

DOB: ________________________ Gender: Male Female (Month / Day / Year) Address: ______________________Suite #:___________ Postal Code: ______________

Home Phone: _______________ Work: _________________ Cell: __________________

Email Address: __________________________________________________________________

Name of Primary caregiver: ________________________ _______________________

(First) (Last) Relationship to child:

Mother (bio) Step-Mother Father (bio) Step-Father Grandmother

Grandfather Aunt Uncle Foster parent Other _________________________________

Address: Same as child? Yes No

Name of Additional caregiver (if any): ____________________ ____________________

(First) (Last) Relationship to child:

Mother (bio) Step-Mother Father (bio) Step-Father Grandmother Grandfather

Aunt Uncle Foster parent Other ___________________________________

Address: Same as child? Yes No

Address: ______________________Suite #:___________ Postal Code: _______________

Home Phone: _______________ Work: _________________ Cell: ___________________

ABORIGINAL HEAD START

APPLICATION FORM

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c/o the amiskwaciy Cultural Society (Revised May 2017) Page 2

How many times have you moved in the last year? ___________________________

ALTERNATE PICK UP / EMERGENCY CONTACT INFORMATION

*PLEASE NOTE – A PARENT LIVING IN THE HOME IS NOT CONSIDERED AN

ALTERNATE PICK UP, AND THE EMERGENCY CONTACTS MUST LIVE WITHIN THE

EDMONTON CITY LIMITS AND HAVE A WORKING LOCAL PHONE NUMBER

Contact #1: __________________ _______________________________

(First) (Last)

Home Phone Number: ___________________ Cell Phone: ___________________

Address: ________________________ Work Phone: ____________________

Relationship to the Child: ____________________________________________

Contact 2 #: ____________________ _______________________________

(First) (Last)

Home Phone Number: __________________ Cell Phone:_____________________

Address: ___________________________ Work Phone: __________________

Relationship to the child: ____________________________________________

Alternate Caregiver’s

I _________________________ (first/last name of caregiver) give my consent for the persons listed above to pick up my child from the bus or school with proof of identification and prior notification to both the bus driver and classroom teacher. Further, the persons listed above will act as my child’s emergency contacts in the event of my absence.

Parent / Caregiver

Name: _________________________

Signature: ____________________

Date: _______________________ (Month / Day / Year)

Is anyone denied access to the child? Yes No

Who is denied access to the child? #1 ________________ _________ _______ (FIRST NAME) (LAST NAME)

If applicable – Are custody documents on file? Yes No

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c/o the amiskwaciy Cultural Society (Revised May 2017) Page 3

Is this your child’s first Head Start program? Yes No

If No, date previously attended and where child attended:

__________________________________________________________

(Month / Day / Year)

ABORIGINAL LEARNER DATA COLLECTION INITIATIVE

(Enrollment Type)

It is mandatory that this question is included on registration forms, however answering the

question is not mandatory.

If you wish to declare that your child is an Aboriginal person, please specify:

331 Status Indian / First Nations 334 Inuit

332 Non-Status Indian / First Nations 333 Métis

CHILD’S CITIZENSHIP STATUS

CANADIAN CHILD OF A CANADIAN CITIZEN

PERMANENT RESIDENT/LANDED IMMIGRANT STUDENT AUTHORIZATION-VISA

CHILD OF AN INDIVIDUAL LAWFULLY ADMITTED TO TEMPORARY RESIDENTS

CANADA FOR PERMANENT CITIZENSHIP

INCOME DECLARATION

ANNUAL FAMILY INCOME:

LESS THAN $12,000 $12,000 - $15,000 $15,001 - $18,000 $18,001 - $21,000

$21,001 - $24,000 $24,001 - $27,000 $27,001 - $30,000 $30,001 - $33,000

$33,001 – 36,000 $36,001 - $39,000 $39,001 - $42,000 OVER $42,000

SOURCE OF INCOME A:

EMPLOYMENT SOCIAL SERVICES/SFI STUDENT FINANCE

EMPLOYMENT INSURANCE CHILD SUPPORT IMMIGRATION CANADA

AISH/DISABILITY CANADA PENSION PLAN WCB

SOURCE OF INCOME B:

EMPLOYMENT SOCIAL SERVICES/SFI STUDENT FINANCE

EMPLOYMENT INSURANCE CHILD SUPPORT IMMIGRATION CANADA

WCB AISH/DISABILITY CANADA PENSION PLAN

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Does your current income meet the financial needs of your family? YES NO

Which needs are not being met?

_______________________________________________________________

_______________________________________________________________

How is this affecting your family?

_______________________________________________________________

_______________________________________________________________

What is the education level of the primary caregiver of the child?

Grade ________

Technical training: Area of study: _____________________________

College or university: Area of study:_____________________________

Other ________________________________________________________

Age of the primary Parent/Caregiver?

Under 20 years old 30-40 years old

20-30 years old Over 40 years old

Type of family?

Single parent Two parent Foster parent Other_______

Grandparents Kinship care Group home

Residents in the home?

Mother (bio) Step-Mother Father (bio) Step-Father Child’s grandmother

Child’s grandfather Child’s Uncle Child’s Aunt

Child’s siblings & number of siblings______________ Child’s Cousin(s) Family Friend(s) Other________

Names and Ages of Siblings:

Name: __________________________________ Age: ____________

Name: __________________________________ Age: ____________

Name: __________________________________ Age: ____________

Name: __________________________________ Age: ____________

Name: __________________________________ Age: ____________

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HEALTH INFORMATION

Does your child have any special needs that we should know about? (Special diet,

language problems, particular fears etc.) Yes No

_________________________________________________________________

_________________________________________________________________

Has your child had previous assessments (speech& language, OT…) Yes No

_________________________________________________________________

_________________________________________________________________

What family issues should we be aware of that have been occurring in the home

and affecting your child?

_________________________________________________________________

_________________________________________________________________

Does your child have a family doctor? Yes No, we go to a Medicentre

Child’s Doctor: ___________________ Type: Family Pediatrician

Specialist (ears, nose, throat…) ___________________

Doctor’s Address: _____________________ Phone: ____________________

Medicentre: ___________________________ Phone: ____________________

Alberta Health Care Number: _______________________________________ Birth Certificate Number: __________________________________________

Treaty Number: __________________________________________________

Is child’s immunization up to date? Yes No Don’t know Attached

If immunized out of Edmonton, where? _______________________________

_______________________________________________________________

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CHILD’S PHYSICAL HEALTH Does your child have allergies? Yes No

ALLERGY REACTION MEDICINE/TREATMENT

Does your child need an Epi pen? Yes No

Does your child have asthma? Yes No

What is the treatment?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Does the child require asthma treatment at school? Yes No

Is this child on regular medication? Yes No

What medications?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

How is the medication administered?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

How often?

__________________________________________________________

Are there any side effects? Yes No

Description:________________________________________________________

_________________________________________________________________

_________________________________________________________________

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COMMUNITY RESOURCES AND SERVICES Do you presently have involvement with another agency? Yes No

Do you need to know about more resources and services in your community for

your child and family?

Yes No Not sure

Have your children experienced any form of trauma or abuse? Yes No

If Yes, Please explain: ____________________________________________

Do you currently have or had Children Services involvement? Yes No

Children Services Worker: _________________________________________ (First & Last Name)

Phone: ______________________ Email: _______________________

Social Worker: _________________________________________ (First & Last Name)

Phone: ______________________ Email: _______________________

Family Support Worker: _________________________________________ (First & Last Name)

Phone: ______________________ Email: _______________________

PERSONAL AND SOCIAL DEVELOPMENT

Is the mother tongue of either parent/caregiver an Aboriginal Language? YES NO

Does either parent/caregiver speak an Aboriginal Language Fluently? YES NO

Does your child speak an Aboriginal Language Fluently? YES NO

What is the primary language spoken in the home? ___________________________

What is the primary language your child speaks?

English Other: ____________________________

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How would you describe your child’ ability to speak? (√) All that apply.

Is your child?

Yes

No

Sometimes

Easy to understand

Difficult to understand

Talkative

Stutters

Speaks in sentences

longer than three (3)

words

Shy/quiet

Other: ____________________________________________________ ____________________________________________________ Please indicate how you deal with your 3-4 year old child’s behavior? Do you do

the following… usually, sometimes or never?

Usually Sometimes Never

Time out

Move child away

Ignore the behavior

Spank

Distract the child onto something else

Speak Louder

Other

_____________________________________________________________

Do you practice traditional Aboriginal culture at home? Yes No

What are you hoping that your child will gain from Head Start? (Choose as many

as you wish)

To learn some of his or her Aboriginal language

To learn about his or her culture

To get ready for kindergarten (ECS)

To learn to play with others his or her own age

To improve his or her behavior social skills

To improve his or her language or communications skills

Another reason- please explain _________________________________

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What do you hope that Head Start will offer you as a parent or caregiver? (Choose

as many as you wish)

To meet other parents

To learn better parenting strategies

To learn about Aboriginal culture

To learn some of the local Aboriginal language

To learn how to help my child learn

Another reason- please explain _________________________________

How did you hear about Aboriginal Head Start? (Choose as many as you wish)

Word of Mouth: Through Friends

Through past participants

Head Start Flyer

What business/location did you find our flyer at?

_______________________________________________________

Facebook Advertisement

Newspaper Advertisement

Other… ___________________________________________________

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Consent to ordinary medical and dental care:

This authority includes treatment for minor illnesses and injuries and other procedures that

are performed routinely and do not require hospitalization.

The Head Start staff have the authority to admit the child to hospital but not to authorize any

treatment or tests except according to the following clause:

Consent to emergency treatment or surgical procedures. This authority includes immediate

measures necessary to preserve the child’s life, health and physical wellbeing. The authority

must be used only if contacting the parents or caregivers will delay treatment enough to

endanger the child’s life. After giving treatment, the staff must immediately notify the parents

or caregivers.

Delegation of Powers in Case of Emergency Name of Child:

____________________ ____________________ ______________________

(First) (Middle) (Last)

Date of Birth: ______________________________________________________

(Month / Day / Year)

Band/First Nation: _________________________________________________

Treaty Number: ___________________________________________________

Alberta Health Care number: _________________________________________

I, the Parent/Primary Caregiver, delegate the Powers and Duties set out above in this

delegation to the staff of the Aboriginal Head Start Program regarding my child.

Parent / Caregiver

Name: _________________________

Signature: ____________________

Date: ________________________ (Month / Day / Year)

Parent/Caregiver Delegation of Power and Duty

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c/o the amiskwaciy Cultural Society (Revised May 2017) Page 11

I _______________________ (first/last name of caregiver) hereby authorize the following

agencies to observe my child _______________________ (first/last name) in the Head Start program and provide necessary documentation and consultation to Aboriginal Head Start staff in order to enhance my child’s learning in the classroom.

• Alberta Health Services

• Child Adolescent and Family Mental Health (CASA)

• Glenrose Hospital (Assessment Facility)

• Edmonton Student Health Initiative Program (ESHIP) ______ Initials

I understand that as part of the services provided by Head Start, these services and screenings may be completed with and/or provided for my child.

• Measurement of Height and Weight

• Dental Screening • Hearing Screening

• Vision Screening

• Brigance Inventory of Early Childhood Development II (IED-II) • Safe Preschoolers Education & Awareness Kit (S.P.E.A.K.) • Speech and Language Referral/Assessment, if required

• Occupational Therapist Referral/Assessment, if required

• Physical Therapist Referral/Assessment, if required ______ Initials

I also give permission for the information collected to be used by Head Start and the above agencies for educational, research and statistical purposes. I understand that the information will be coded in such a way that the identities of individual children and parents will be kept confidential for research and statistical purposes. ______

Initials I hereby give my consent and agree to the above screening(s) and services indicated with my initials.

Parent / Caregiver

Name: _________________________

Signature: ____________________

Date: ________________________ (Month / Day / Year)

Health Promotion and Assessment

Permission Form

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c/o the amiskwaciy Cultural Society (Revised May 2017) Page 12

I understand that the Head Start may release the following information on my child to Early

Education Programs and/or institutions and may collect the following information from

previous Early Education Programs and/or institutions that will support my child’s educational

programming:

Individual Program Plan (IPP)

Speech and Language Report, if applicable

Occupational Therapist Report, if applicable

Physical Therapist Report, if applicable

______ Initials

I understand that the Head Start may collect the following information from previous Early

Education Programs and/or institutions that will support my child’s educational programming:

Individual Program Plan (IPP)

Speech and Language Report, if applicable

Occupational Therapist Report, if applicable

Physical Therapist Report, if applicable

______

Initials

I understand that the information collected by Head Start will be kept confidential.

Parent / Caregiver

Name: ___________________________

Signature: _____________________

Date: ________________________ (Month / Day / Year)

Collection and Release of Information

Form

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TRANSPORTATION

Does your child require transportation: Yes No, caregiver will provide

transportation

Yes, program transportation Pickup/Drop Off: Home – Home Daycare – Daycare

Home – DaycareDaycare – Home

Number of Siblings on Bus: ___________

Daycare Name: ____________________________________________________

Daycare Address: ___________________ Phone Number: __________________

Transportation Procedures The amiskwaciy Cultural Society provides the Aboriginal Head Start Program with four 24 passenger school busses and access to the program’s spare bus if needed. These vehicles are used to transport those children who are registered in our program and who live within the designated boundaries set forth by the Aboriginal Head Start Program. Estimated hours for pick up. 7:30 – 8:15 a.m. or 11:30 – 12:45 p.m. Estimated hours for drop off. 11:30 – 12:30 p.m. or 4:00 – 5:00 p.m. The bus will pick up/drop off your child at home or/at the designated child care facility. Parents/Guardians are required to bring the child to the bus upon pick up and meet the bus upon drop

off. The bus drivers are not allowed to leave the bus at any time. The bus will stop at each home for exactly 3 minutes. Please have your child dressed and ready for the bus. If your child is not ready to go or no one attempts to signal the driver, she/he will carry

on with the route and there will be no reattempt at any later time. Drop off – If no one is home at time of drop off, the driver will attempt to call parent/guardian. The bus driver will then make a second attempt at the end of the route. If

still no one is available to receive the child, the bus driver will attempt to contact emergency phone numbers and if still no one is available, they will then contact the Children’s Services Crisis Line. A transportation permission form must be signed for all children who ride the bus. If a parent/guardian has an alternate caregiver receiving their child upon drop off or pick up from school, teachers must be informed verbally and in written form. Individuals will be required to show proper

identification. If your child will not be riding the bus on any given day, the bus driver MUST be notified the night before or at least half an hour before s/he arrives at your residence. If your child is sick or away from school and will not be riding the bus for any number of days, the drivers MUST be contacted in order to resume bus riding for his/her child.

Parents/guardians are required to read, agree and abide by these procedures.

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c/o the amiskwaciy Cultural Society (Revised May 2017) Page 14

I, _________________________ (first/last name of caregiver) understand the

transportation procedures and hereby give consent for my child

_________________________(first/last name of child) to

be transported by the Aboriginal Head Start Program from

September 2017 to June 2018.

Parent / Caregiver

Name: ___________________________

Signature: _____________________

Date: ________________________ (Month / Day / Year)

Field Trip Blanket Permission Form The following form is a Blanket Permission Form which will allow your child to attend and be transported by the Aboriginal Head Start bus to ANY and ALL field trips in and around the Edmonton City limits. Regularly scheduled field trips and activities will be listed on your child’s monthly classroom calendar

that is handed out at the beginning of each month, and this form will grant permission for your child to attend.

I do understand the above and hereby give my permission for my child to attend ANY and ALL

program planned field trips and activities during the 2017-2018 Academic School Year. I do give permission for my child to be transported by the Aboriginal Head Start bus to and from

ANY and ALL program planned field trips and activities during the 2017-2018 Academic School Year.

I do authorize the Aboriginal Head Start program staff to obtain emergency medical treatment

for my child in cases of emergency.

I also understand that I WILL NOT hold the Aboriginal Head Start program liable for injury to my child during ANY or ALL of these planned field trips and activities without just cause.

Name of child Name of parent

_________________________ _________________________ (Please Print) (Please Print) Signature of Parent Date

_________________________ _________________________ (Please Sign) (Month / Day / Year)

Transportation Permission Form

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Audio/Visual Recording Consent

No consent given

I _________________________(first/last name of caregiver) the parent/caregiver of

_________________________(first/last name of child) do hereby acknowledge that the

Aboriginal Head Start , and the amiskwaciy Cultural Society may use, reproduce or distribute

any photographs, slides, video or other similar material associated with the program and

related events and activities for promotional and archival purposes. There is no time limit to

this consent; however, the consent can be revoked at any time with written notice to the

Program Manager. Audio and visual recordings will be securely stored at the amiskwaciy

Cultural Society office.

Parent / Caregiver

Name: ___________________________

Signature: _____________________

Date: ________________________ (Month / Day / Year)

Waiver

As Guardian / Caregiver I hereby understand that the Aboriginal Head Start Program, and

The amiskwaciy Cultural Society will not be responsible for the following:

Lost or stolen and/or Damage of personal items.

Any occurrence, after program hours where a child has been dropped off at specified

childcare location. (i.e.: Home, daycare, babysitter)

Restricting contact without legal documentation on file. (Both office and school files)

To inform the Aboriginal Head Start program of any changes to parent/caregiver or

emergency contact information as soon as they occur.

Parent / Caregiver

Name: ___________________________

Signature: _____________________

Date: ________________________ (Month / Day / Year)

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Parent participation plays a major role for the success of the Aboriginal Head Start

Program. Your participation as a parent/primary caregiver will benefit the Program

as well as yourself and your child. The parent/primary caregiver portion of the

Program requires you to become involved. We attempt to be flexible in order to

accommodate your hours available. Parent participation is crucial for the continued

success of our Head Start program.

I (caregiver) do agree to fulfill my parental/primary caregiver obligation to the Aboriginal Head

Start Program. I understand that my participation in the Program will benefit my child and

myself as a parent/primary caregiver. I will become involved in the following ways:

1. I will attend parent/primary caregiver gatherings/functions. 2. I will ensure my child attends Head Start on a regular basis. 3. I will contact the bus driver when my child will not be taking the

Head Start Bus. 4. I will permit home-visits by Head Start staff regarding my child to access

community services. 5. I will volunteer a minimum of 9 hours in the Head Start Program. This could

include, classroom participation, fieldtrips, making play-dough, material

preparation or any of the listed below.

6. I am willing to contribute to the program by sharing my skills, talents, and

knowledge in (check as many as apply to you) :

□ Traditional Foods □ Story Telling

□ Drumming □ Crafts

□ Singing □ Personal Career

□ Other: ________________________________

Parent/Primary Caregiver

Name: ___________________________

Signature: ________________________

Date: ___________________________ (Month / Day / Year)

Parent/Primary Caregiver Participation Agreement

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c/o the amiskwaciy Cultural Society (Revised May 2017) Page 17

Parent/Primary Caregiver Consent Form Brigance Head Start Screen Evaluation

The Aboriginal Head Start in Urban and Northern Communities (AHSUNC) Program is a

national program funded by the Public Health Agency of Canada (PHAC). AHSUNC is an

early learning program that serves more than 4,000 First Nations, Inuit and Metis children

and their family in 126 communities. It is a comprehensive program designed to support

the spiritual, emotional, intellectual and physical needs of participating children.

Purpose of the Brigance Head Start Screen Evaluation

The purpose of the Brigance Head Start Screen is to evaluate the education/school

readiness component of the program by collecting information on AHSUNC participants.

This screen is being used to evaluate the AHSUNC program, not individual children. The

results will help show if the AHSUNC program is effectively helping children improve school

readiness skills from the start to the end of the school year. The results can also be used to

adapt and enhance the activities offered by the program, according to the needs of the

children.

Description of the Brigance Head Start Screen

The screen will be given to each child twice - once at the beginning of the school year and

once at the end. The Brigance Head Start Screen is a well-tested and well-researched tool.

It is used by many school boards and child psychologists throughout North America as a

quick and reliable way of monitoring a child’s developmental progress. Each child will be

asked to show how he/she can perform certain skills: drawing, moving their bodies,

understanding directions and words and some skills that are important for school.

Administering the Brigance Screen takes about 15 to 30 minutes.

How information will be used

AHSUNC teachers will record the results of the screen onto answer sheets. Before these

sheets are sent to PHAC for analysis, the teachers will replace the child’s name with a code.

This code will make sure that the screen results remain anonymous when they are

submitted to PHAC. An external consultant will put all the data together into a report. The

information provided in this report will support national program accountability and provide

insight on where improvements to the program can be made. Complete reports will be

shared with your AHSUNC project when available.

Confidentiality

The information associated to your child’s name will never be shared without your consent

with anyone other than staff at your child’s AHSUNC site. If changes are made to the study

or new information becomes available, you will be informed.

Participation

Participating in this evaluation of the AHSUNC program is voluntary (optional). Parents

and/or guardians can choose to give their permission, or not, for their child(ren) to

participate. Also children do not have to answer any question that they do not want to

answer, and they can stop participating in the screening at any time. Choosing not to

participate in the screen will in no way affect your quality of service and that of your

child(ren). Your information will be protected according to the requirements of the Canada’s

Privacy Act. There are no known harms to participating in the Brigance Head Start Screen.

I, ____________________________________ (print name), consent for my child to

participate in the Brigance Head Start Screen Evaluation.

_____________________________________ (signature) _______________________

Date (dd/mm/yy)

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Orientation Agreement

This is to verify that I, __________________________________ (first/last name of

caregiver) have had the opportunity to go over all the information shared in the

Aboriginal Head Start program with a family support worker. I fully understand all

information shared and have asked the necessary questions for me to understand

what it takes to have my child participate in the Head Start program. I have been

informed and completed the following:

□ Overview of the Application form

Provided the program with a copy of:

□the child’s Alberta Health care card

□the child’s Birth Certificate

□the Delegation of Powers (if required)

□the child’s Treaty Status card (optional)

□Documents Pending □ Alberta Health care card □ Birth Certificate

□ Delegation of Powers

□ Signing of all Parental Consent forms

□ I understand all Program Policies and Procedures

□ I understand the 9 hours commitment for volunteering in the program

□To inform the Aboriginal Head Start program of any changes to parent/caregiver or

emergency contact information as soon as they occur.

□ I was given an opportunity to ask questions and gain clarity of my responsibilities in relation

to the Head Start program

□ I understand that the program is obligated by law to report to the appropriate authorities

should they suspect any form of abuse.

If I should have any further questions or concerns relating to my child or the program in any

way, I will contact my site family support worker to discuss the matters directly.

Parent/Caregiver Interviewer

_________________ ___________________ Name (First/Last) Name (First/Last)

_____________________ ________________________ Signature Signature

_____________________ ________________________ Date (Month/Day/Year) Date (Month/Day/Year)