Pre-Kindergarten

2016-2017 General Enrollment Information

Tuition & Admission Policies

OLGC Catholic Pre-Kindergarten 1151 William Street

Plymouth, Michigan 48170 734-453-3053

school.olgcparish.net

Welcome to Our Lady of Good Counsel Catholic Pre-Kindergarten! We appreciate that you have taken the opportunity to join with the OLGC School community in the beginning stage of your child’s Catholic educational journey. Our Lady of Good Counsel (OLGC) Pre-Kindergarten is fully licensed by the State of Michigan Department of Human Services. Our classroom and play areas meet the state licensing standards, while also meeting the educational needs of all four-year-old students enrolled in our half-day program. We are happy and eager to familiarize you with our Pre-Kindergarten curriculum, which will provide our young students with the opportunity to be prepared and successful as they go through elementary school. OLGC Pre-Kindergarten is a faith-based program focusing on the Image of God Pre-K religious program to deepen the growing needs of each child in a developmentally appropriate way. Our approach, with the assistance of this spiritual program, is to educate all students according to their spiritual, intellectual, physical, social and emotional needs by providing a balanced curriculum that encompasses a combination of teacher-directed and child-directed involvement through our daily experiences together. OLGC Pre-Kindergarten does not discriminate against students in admission or participation in any school program or activities on the basis of race, ethnic origin, sex, or handicap which is unrelated to the student’s ability to utilize and benefit from the educational opportunities, programs, and facilities offered by our school.

OLGC believes…

· Pre-Kindergarten should be a learning environment where ALL children feel safe and are free to explore through resources and opportunities presented to them in a positive manner. Students will be introduced to readiness skills in fun and interesting ways.

· Each child can practice problem-solving skills, readiness skills, responsibility, socialization, independence, courtesy and compassion for each other.

· Parents are an essential connection in a child’s success, and we encourage communication to create a strong partnership between school and home.

· By engaging in many open-ended activities, young students will be challenged to use methods of observation, discussion, and individual thought process to guide them in their learning.

· Children will become lifelong learners when learning about their world through positive, nurturing and loving interactions in ALL learning situations.

The OLGC Pre-Kindergarten Curriculum is intended to expose students to our fundamental Catholic teachings, language, math, motor skills, art, music, and technology by focusing on these key areas.

· SPIRITUAL: To assist children in becoming aware of God and how He has created each of them in a truly special and unique way.

· SOCIAL: To help children feel comfortable in school, create trust in their new environment, make new friends and to feel that they are part of a group. It is a time to have children learn to interact with peers and adults appropriately in the classroom setting.

· INTELLECTUAL: To provide a curriculum that is developmentally appropriate for Pre-Kindergarten children with a focus on Catholic teachings, literacy, math, science and technology.

· EMOTIONAL: To help children feel a sense of pride and self-confidence, develop more independence and self-control and to encourage students to ask questions, solve problems, and use words to describe their thoughts, observations, and feelings in different situations.

· PHYSICAL: To assist children in increasing both large and small motor skills and feel confident about what they can do.

The OLGC Pre-Kindergarten daily schedule includes both periods of active and quiet time in the following ways:

· Circle and Group Time: Each day students will participate in prayers, Pledge of Allegiance, calendar, songs and creative movement, show and tell, rhythmic reading, storytelling and group skills.

· Learning Center Time: A variety of activities will be continually presented to enhance the learning experience. Some activities include drawing and coloring, dramatic play, library corner, puzzles, blocks, board games, books, clay modeling, sensory table and painting.

· Prayer and Faith Time: Incorporating the Image of God program into the daily

routine, will help children learn about different Bible stories, songs, praying together and learning about Jesus. This program is designed to involve students with lessons to develop a greater understanding of their faith as they worship.

· Project Time: Different projects to enhance the curriculum and skills being taught will be introduced each week depending on the particular theme. Students will work on learning the alphabet, learning numbers, and becoming more familiar with colors and shapes.

· Motor Skills: Time will be set aside for physical play using large motor skills

each day. Physical education class is part of the weekly schedule.

· Snack Time: Time is set aside each day for students to learn about washing hands, saying prayers before meals, and sitting down to have snack in a large group setting.

PRE-KINDERGARTEN GOALS

· Begin to instill our Christian values with the support of the Image of God faith series and other religious materials to support the Catholic faith

· Acquire academic skills based on the State standards · Encourage cooperation, choice making and consideration of others · Develop problem-solving skills · Nurture a sense of independence and responsibility · Encourage and promote self-help skills · Promote skills of observation, listening and questioning · Inspire socialization, creativity, discovery, imagination, and exploration

PRE-KINDERGARTEN SCHEDULE

Pre-Kindergarten for the 2016-2017 school year we will offer the following program options:

Half Day, Mornings: 8:05AM-11:00AM OR

Half Day, Afternoons: 12:05PM-3:00PM Snacks will not be provided for Pre-Kindergarten students. Please bring a healthy snack each day. _______________________________________________________________ Class size is limited to a maximum of 16 students during any half-day session. Students will be admitted based on their selection and space availability. A session selection may be changed dependent on final enrollment numbers. Families will be notified should a change be necessary. OLGC Catholic School has the primary obligation to those children who are siblings of students currently enrolled in other grades and to parishioners of OLGC: after that, students will be admitted on a space availability, first-come, first-served basis. If the desired session is full, families will be informed by the school office that they have been placed on a waiting list. If this occurs a family has the following options:

· Withdraw their registration, at which time their family name will be removed from the waitlist and their registration will be returned.

· Remain on the waitlist; registration payment will be held until there is a possible opening or it may be returned upon request.

ARRIVAL AND DISMISSAL All Pre-Kindergarten students must be escorted to and from the classroom by an adult. Parents need to allow enough time to sign–in and sign-out in the daily attendance log at the check in table. Parents will need to initial next to their child’s name in the attendance log. Children are expected to hang up their own backpacks and coats upon arrival to the classroom. A designated tagged area for Pre-Kindergarten parking will be made available to all currently enrolled families. Students will be dismissed promptly at the end of each session. The classroom teacher/aide will call the student’s name and the parent will need to initial in the attendance log next to their child’s name. These procedures are part of the requirement for State of Michigan licensing. If someone other than the individuals listed on the OLGC School Emergency Card is to pick up your child, the classroom teacher and the school office must be notified ahead of time. PLEASE remind anyone to bring his or her identification for verification. Students will only be dismissed to an authorized person and/or parent. Since our first priority at all times is the close supervision of our students, it is best not to attempt to have a conference with the classroom teacher during arrival and dismissal times. If there is a matter that needs immediate attention, please feel free to provide a note or schedule a conference that will be convenient for all parties involved. SAFETY GUIDELINES For the safety of all children, OLGC Catholic School adheres to the following basic guidelines:

· Entrance to the Pre-Kindergarten areas will be kept locked throughout the school day. Parents will only be able to enter the school through the secured main entrance during the school hours.

· No child will ever be left alone or unsupervised. · No child will be allowed to cause bodily harm to other children.

· Staff members have immediate access to contact parents due to illness or an emergency.

· Emergency procedures along with fire, emergency, and weather alert plans are posted by classroom exits.

· Safety drills (fire, tornado, & lockdown) are conducted, and a record of these is kept in the main school office. All exits are marked and smoke alarms are tested on a regular basis to ensure that they are in proper working order.

· Incident reports will be completed and a copy will be given to parent(s) on the day an accident occurs.

FIELD TRIPS Pre-Kindergarten classes will have planned outings during the school year. Each field trip is planned with an educational purpose. Parents will receive information with details well in advance of the scheduled outing. Parents who are interested in driving or chaperoning on any school related field trip must follow the guidelines for volunteering for special activities and field trips in accordance with the Archdiocese of Detroit stated below. VOLUNTEERING FOR SPECIAL ACTIVITIES & FIELD TRIPS Volunteering is a terrific way to partner with and be involved in your child’s educational Pre-Kindergarten experience. Parents are encouraged to participate in special activities and projects, field trips, preparation of classroom materials, or in other ways throughout the year. In accordance with the Archdiocese of Detroit regulations, all employees and volunteers are subject to a criminal background check and must complete the “Protecting God’s Children” Program. The OLGC School office can provide forms and more details regarding volunteer requirements. Listed below are some basic guidelines when volunteering in the Pre-Kindergarten at OLGC:

· Get permission from the teacher for day and time to volunteer with the understanding of following the classroom rules for the day.

· Wash hands and wear food gloves when assisting with snacks or serving food. · Follow the lead of teacher/aide in the classroom. · Interact with children by sitting at their level, observing their work/play, and

becoming an active participant when appropriate. · Refrain from discussions regarding behavior/performance of children in the

room with other individuals outside the classroom setting. · Refrain from engaging in discussing specific issues with the teacher/aides while

volunteering. Continual supervision is imperative.

HEALTH GUIDELINES At OLGC Catholic School the health and well-being of our students is a top priority. In order to prevent the spread of germs and disease, parents are asked to adhere to the following policies: (See the OLGC Parent Handbook for additional information.)

· We encourage parents to take their child to the bathroom PRIOR to entering the classroom each day.

· If a child has any symptoms of a contagious disease, they should be kept home from school. These signs include: fever, vomiting, diarrhea, swollen glands, sore throat, cough and/or respiratory symptoms, eye/nasal discharge that is not clear, itching or any type of rash.

· Students who have had a fever or stomach problem must be free of these symptoms for a full 24 hours before returning to school.

· If a child has been taking prescribed antibiotics, he or she must have completed a 24-hour cycle of medication before returning to the classroom.

· PLEASE report ALL communicable diseases (i.e., chickenpox, measles, mumps, roseola, scarlet fever, pink eye, strep throat, head lice, impetigo, etc.) to the school office and classroom teacher as soon as possible. If there is indication of a communicable disease, the student will be sent home immediately. A general confidence notice will be sent home to all parents with information on the specific case. A student with a communicable disease may not attend school until he/she is fully recovered.

TOILETING Our State of Michigan license only permits students who are fully toilet trained. We assume all children are toilet trained when enrolled. We do understand that accidents occur and will assist when needed. However, if there is continual repeated evidence that a child is NOT FULLY POTTY TRAINED, OLGC Pre-Kindergarten administration reserves the right to withdraw the student (please refer to our Refund/Withdrawal Policy included within this document).

CLOTHING Uniforms are not required for Pre-Kindergarten students. Comfortable and washable clothing with elastic pants and easy snaps are recommended for children in the classroom. BELTS and TIGHTS are not permitted, as they are often times restrictive for students in the restroom. Since clothing can get dirty or damaged, a change of clothes including extra shirt, pants, socks, and underwear labeled in a LARGE GALLON-sized Ziploc bag should be kept in your child’s backpack AT ALL TIMES in case of accidents, paints spills, food spills, etc. SCHOOL CLOSINGS Each year parents receive a school calendar that reflects scheduled breaks and holidays. The Pre-Kindergarten will follow the OLGC Catholic School closing decisions. Watch local channels for school closing updates. Families will also receive a phone message from the school office if school has been closed for any reason. We follow the Plymouth/Canton Public School closing guidelines. Our school may close for circumstances other than weather as deemed necessary by the parish office or the Archdiocese of Detroit. FIRST DAY OF SCHOOL OLGC Pre-Kindergarten classes will begin after Labor Day. Prior to the beginning of school, parents will receive scheduling information regarding a parent/student “Meet and Greet” session in late August, school supply list, daily drop off and pick up instructions, and other important details parents will need to know prior to the start of class. CONFERENCES Regular parent/teacher conferences will be scheduled at least once a year or as needed to share information regarding a child’s experience and progress in our Pre-Kindergarten program. Parents wanting to discuss a child’s progress or any other

subject matter should not attempt to have discussions during class hours. The classroom teacher will provide a school email address for parents to use at any time to schedule an appointment or to ask questions. Emails will be answered at the teacher’s earliest convenience. IMAGE USE POLICY OLGC Catholic School and Pre-Kindergarten occasionally engage in various correspondences with our families, students, parish, faculty, and other members of the community regarding activities and educational happenings within our school community. We maintain our website on the internet, create publications for our OLGC Parish bulletin and school newsletter and publish articles in community newsletters as well as other technological productions as a form of up-to-date communication. Parents must sign the Archdiocese of Detroit Authorization to Use Student Images Policy section located in the 2016/2017 Registration Form or Handbook whether they “DO” or “DO NOT” give their authorization according to the following terms and provisions:

· Parents authorize OLGC Catholic School to use, display, adapt, copy, modify and post any such images, now or in the future, as the school deems appropriate, in publications.

· Parents understand and agree that there will be no compensation of any kind provided the parents or students to the school, or by any third party, for the images for this authorization and rights granted to the school by the parents.

· Parents may cancel their authorization at any time by signing a non-release form and delivering it to the school at 1151 William Street, Plymouth, MI 48170. In addition, parents may, at any time, direct the school in writing at this same address to remove any particular image from its website. Within a reasonable time after such direction, the school will remove the images of the students from its website and delete them from further publications.

· The school will not be liable to the parents and/or the students, regardless of the form of action or theory of recovery, for any direct, indirect, incidental, consequential, special, punitive, or exemplary damages in connection with, or in any way related to, the authorization of the school’s use of the images of the students authorized on the registration form.

· Parents understand that by signing the registration form they have made this authorization based solely on their judgment and not on any representations or promises from the school. The Image Use Policy referenced above constitutes the entire agreement with respect to the school’s use of the images. This policy may be amended or supplemented upon written communication from the school to the parents.

PRE-KINDERGARTEN ADMISSIONS & TUITION POLICIES

2016/2017 SCHOOL YEAR REGISTRATION REQUIREMENTS

· Be at least four years of age by SEPTEMBER 1st of the same year. · Be FULLY potty-trained (NO pull-ups). · Provide a copy of your child’s Birth Certificate at the time of registration. · Submit an Immunization & Health Form certified by a health care organization

or a physician by the designated deadline and the Statement of Good Health Form.

· Submit the signed Parent Notification of the Licensing Notebook Form from the State of Michigan.

· Enrollment will be considered to be complete when all information, forms, and required payment(s) have been received by the designated deadlines.

IMMUNIZATION All children must comply with the State of Michigan required immunization and health laws prior to admission. A Health Appraisal Form must be completed and certified by a health care organization or a physician on or before the first day of school. Should a parent or parents of a student choose not to have their child immunized, a waiver must be signed by the parents and kept on file in the OLGC school office. For current requirements, parents may visit the State of Michigan website at www.mich.gov. MEDICAL CONSIDERATIONS Medications: Due to State of Michigan, Archdiocese of Detroit, and OLGC policies, along with insurance regulations, we have the following regulations regarding medications:

· Parents may administer any medicine to their own child (ren) at school. · School personnel may not administer any medication, prescription, or over-the-

counter medicine, without signed physician forms and written directions from the parent(s) and the child’s doctor. ALL prescription medication must be in its original container(s). Physician forms are available in the school office. These

forms must contain the drug name, dose, time, method of administration, and duration (length of time for the medication to be dispensed) and must be on file in the school office.

Inhalers and epi-pens at school: In accordance with Public Act 10 of 2000 (AOD Policy 5010), students may use metered dose asthma inhalers or epinephrine auto-injectors (epi-pens) or epinephrine inhalers provided written approval to use these devices from the licensed physician and parents is received by the OLGC School Principal, along with a written emergency care plan. The principal will notify the student’s classroom teacher. For all medical considerations, parents must complete a Comprehensive Health Information Form. Open Registration begins on Sunday, January 24, 2016. The following required forms must be submitted to the school office at the time of registration. (Please contact the school office @ 734-453-3053 regarding the registration process and financial matters.) REQUIRED FORMS AT REGISTRATION

· Pre-Kindergarten 2016-2017 Registration Form · Registration fee payment · Copy of birth certificate · Completed and signed State of Michigan Parent Notification of the Licensing

Notebook form · Completed and signed Statement of Good Health form · Copy of Baptismal Certificate

Forms/Information to be submitted on the first Day of School or by communicated dates

· Child Information Sheet * · Criminal Background Check Form (needed prior to volunteering in the classroom) · T-shirt form* · Immunization and Health Appraisal Form · Completed Comprehensive Health Information Form · Copy of custody papers, if applicable

*Indicates forms handed out by classroom teacher After the OLGC School office has received all required paperwork and your registration has been accepted, a statement will be mailed to the home address and will reflect terms and dates based upon the payment option selected at the time of a family registration.

TUITION RATES AND FINANCIAL POLICY At OLGC we understand the sacrifices made by each family to ensure a quality Catholic education for your children. The tuition rates are based upon what it takes to provide each student in our program with the best possible educational opportunity at an affordable cost. Because tuition alone does not completely cover the cost of educating our students each year, OLGC Parish contributes a significant amount to offset the school’s budget.

PRE-KINDERGARTEN TUITION RATES Please refer to the tuition payment plan provided in the school registration packet.

REFUNDS AND WITHDRAWAL POLICY Since tuition and fees reflect purchases and hiring policies that have already been put into place, refunds will only be given in accordance with the following criteria:

· Applications are due by February 12, 2016 for the 2016/2017 school year. · Siblings of currently enrolled students are given first priority. Children of parish

members receive first consideration for admission. Children of other Catholic parishes are considered next. Non-Catholic children may be admitted when there is space available, but only if their parents agree to their children's participation in the integrated religious education program offered by the school.

· To qualify for in parish tuition, a family must be registered at OLGC. They must participate in weekly attendance at mass (barring the obvious), and participate in parish activities and fundraising. The measurement for weekly attendance will be the use of offertory envelopes.

· Tenure in the parish, as determined by parent date of registration in the parish, shall determine admission priority.

· To be eligible for the school year in September, the application must be received before the preceding February 12th.

· Applicants accepted for admission will be notified by April. · A new list for each grade level will be made every year based on parent date of

registration in the parish with all applications received by February 12th of that year. · No refunds, credit, or reduction will be given due to absences, vacations, snow days,

illness, holidays, etc. · No refunds will be given for any portion of a month’s tuition. If a child attends during

any portion of a given month, payment for the full month is owed. · If a student leaves the school, only prepaid tuition (not fees) will be refunded based on

unused months remaining. · If a family withdraws from school and has previously negotiated special financial

terms, tuition owed will be calculated. · If a student is asked to leave for any reason(s) as described in the OLGC School

Handbook, no refunds will be given for any fees. · The school office reserves the right to amend the refund policy for families who

experience extenuating circumstances resulting in withdrawal (i.e., hardship, health, etc.).

BCAL-5053 (8-10) MS Word

PARENT NOTIFICATION OF THE LICENSING NOTEBOOK Child Care Organizations Act, 1973 Public Act 116

Michigan Department of Human Services All child care centers must maintain a licensing notebook which includes all licensing inspection reports, special investigation reports and all related corrective action plans (CAP). The notebook must include all reports issued and CAPs developed on and after May 27, 2010 until the license is closed.

• This center maintains a licensing notebook of all licensing inspection reports, special investigation reports and all related corrective action plans.

• The notebook will be available to parents for review during regular business hours.

• Licensing inspection and special investigation reports from at least the past two years are available on the Bureau of Children and Adult Licensing website at www.michigan.gov/michildcare.

I have read the above statement issued by . Name of Child Care Center

Child(ren)’s Name(s)

Parent Name

Parent Signature

Date

Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.

HEALTH APPRAISAL

Dear Parent or Guardian: The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD’S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL CHILD’S NAME (Last, First, Middle) DATE OF BIRTH (mm/dd/yy)

/ / ADDRESS (Number & Street) (City) (ZIP Code) TODAY’S DATE (mm/dd/yy)

MI / / PARENT/GUARDIAN (Last, First, Middle) HOME TELEPHONE NUMBER

( )

ADDRESS (Number & Street) (City) (ZIP Code) WORK TELEPHONE NUMBER

MI ( )

SECTION I - HEALTH HISTORY

# Is your child having any of the problems listed below? Birth History: ! ! ! 1 Allergies or Reactions (for example, food, medication or other) ! ! ! 2 Hay Fever, Asthma, or Wheezing ! ! ! 3 Eczema or Frequent Skin Rashes ! ! ! 4 Convulsions/Seizures ! ! ! 5 Heart Trouble ! ! ! 6 Diabetes ! ! ! 7 Frequent Colds, Sore Throats, Earaches (4 or more per year) Are there any current or past diagnosis(es) ! Yes ! No ! ! ! 8 Trouble with Passing Urine or Bowel Movements If yes, please describe: ! ! ! 9 Shortness of Breath ! ! ! 10 Speech Problems ! ! ! 11 Menstrual Problems ! ! ! 12 Dental Problems: Date of Last Exam / / ! ! ! Other (please describe):

! ! Does your child take any medication(s) regularly? If yes, list medications: Reason for Medication [

/ / Was the health history reviewed by a health professional? Parent/Guardian Signature Date ! Yes ! No Examiner’s Initials:

Yes

No Reso

lved

SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTSRequired for Child Care and Head Start / Early Head Start

Tests and Measurements

No Yes

Was child tested for: Test results: Norm

al

Refe

rred

Unde

r Car

e

Visual Acuity

Muscle Imbalance

Other:

Audiometer

Other:

Sugar

Albumin

Microscopic

Level ug/dl [

VISION

Date: / /

HEARING

Date: / /

URINALYSIS

Date: / /

BLOOD LEAD LEVEL

Date: / /

! !

! !

! !

! !

No Yes

Was child tested for: Test results: Norm

al

Refe

rred

Unde

r Car

eHeight

Weight

Other

]Reading:

Type:

Neg.: ! Pos.: ! mm

HEIGHT & WEIGHT

Other:

HEMOGLOBIN / HEMATOCRIT

BLOOD PRESSURE

TUBERCULIN

Date: / /

! !

! !

! !

! !

NOTE: Blood lead level required for all children enrolled in Medicaid must be tested at one and two years of age, or once between three and six years of age if not previously tested. All children under age six living in high-risk areas should be tested at the same intervals as listed above.

! !

Examinations and/or Inspections Essential Findings Deviating from Normal:

Exam Date: / /MDCH/BCAL-3305 (formerly OCAL 3305/BRS-3305) Page 1 of 2 Rev. August 2013

SECTION III - IMMUNIZATIONSStatements such as “UP-TO-DATE” or “COMPLETE” will not be accepted. Admission to school may be denied on the basis of this information.*

VACCINES (Circle Type)Hepatitis B

(HepB)

DTaP/DTP/DT/Td

Tdap

Haemophilus Influenzae

type b (HIB)

Polio

(IPV/OPV)

Pneumococcal Conjugate

(PCV7/PCV13)

Rotavirus (RV1/RV5)

Measles,Mumps, Rubella (MMR)

Varicella (Chickenpox)

1 3

2

1 4

2 5

3 6

1

1 3

2 4

1 3

2 4

1 3

2 4

1 3

2

1 2

1 2

History of Chickenpox Disease? ! Yes ! No If yes, date:

I certify that the immunization dates are true to the best of my knowledge

/ /

Health Professional’s Signature Title Date

DATE ADMINISTEREDMM/DD/YYYY VACCINES (Circle Type)

Hepatitis A (HepA)

Influenza (IIV/LAIV)

Meningococcal (MCV4 / MPSV4)

Human Papillomavirus

(HPV4/HPV2)

OTHER Vaccines

Specify Date & Type

1 2

1 3

2 4

1 2

1 3

2

Type of Vaccine(s) Date of Vaccine(s)

1

2

3

DATE ADMINISTEREDMM/DD/YYYY

Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable

*NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for the first time must be adequately immunized, vision tested and hearing tested. Exemptions to these requirements are granted for medical, religious and other objections, provided that the waiver forms are properly prepared, signed and delivered to school administrators. Forms for these exemptions are available at your child’s school or local health department.

Parent/Guardian refused immunizations: !

SECTION IV - RECOMMENDATIONS(Required for Child Care and Head Start/Early Head Start)No Ye

s

! !

! !

Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:

Should the child’s activity be restricted because of any physical defect or illness?If yes, check and explain degree of restriction(s): ! Classroom ! Playground ! Gymnasium ! Swimming Pool ! Competitive Sports ! Other

Other Recommendations

SECTION V - DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL)

I have examined ’s teeth. As a result of this examination, my recommendation for treatment is: child’s name

/ / Dentist’s Signature Date

PHYSICIAN’S SIGNATURE

/ / Examiner’s Signature Date Examiner’s Name (Print or Type) Degree or License

MI ( ) Number & Street City ZIP Code Telephone

Information required for:

Early On - Hearing and Vision Status; Diagnosis; Health StatusChild Care Licensing - Physical Exam, Restrictions, ImmunizationsHead Start/Early Head Start - Determination that child is up-to-date on a schedule of age-appropriate preventive and primary health care, including medical, dental, and mental health. The schedule must incorporate the well-child care visit required by EPSDT and the latest immunizations schedule recommended by the Centers for Disease Control and Prevention, State, tribal, and local authorities. An EPSDT well-child exam includes height, weight, and blood tests for anemia at regular intervals based on age.**************Developed in Cooperation with the Departments of Human Services, Education, Community Health, Michigan American Association of Pediatrics, Early Childhood Investment Corporation, Child Care Licensing, Head Start, Michigan State Medical Society, Michigan Association of Osteopathic Physicians and Surgeons.

MDCH/BCAL 3305 (formerly OCAL 3305/BRS-3305) Page 2 of 2 Rev. August 2013