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WESTERN RESERVE LOCAL SCHOOLS

"5-1ome of the ough Riders"

Dear Parents,

This is the Preschool Application that you have requested for your child. Please be sure to fill the Preschool Application out completely including the doctor and dentist's names and phone numbers on the Medical Emergency Form.

Below are a few requirements that you will need to know before returning the application.

1) A $30.00 non-refundable supply fee will be due once your child is accepted into the preschool program. Do not send any money with the application. You will be billed for this at a later date.

Verification of Income must be sent with the application. Verification of income can be in the form of a pay stub, W-2, 1040 tax form, or medical card. Applications WILL NOT be processed without this information. Preschool tuition is based on a sliding fee schedule according to family size and income. ,,Enrollment priority is given to income eligible families. Income eligibility is based on the income earned and total number of family members living in your home.

3) The Medical/Physical Form and Dental Health Record must be turned in within 30 days of enrollment and every 13 months thereafter while your child attends preschool. If these are not turned in within 30 days, your child will not be able to attend preschool. You can send the preschool application in before these forms are completed. If your child is returning to the preschool program for a second year, the Dental Health Record is not required.

This includes a medical statement and current list of immunizations. We hope your child has a regular medical provider from whom he/she receives on-going medical care and follow-up. If your child does NOT have a regular medical provider, please inform your child's teacher so that we may assist, as appropriate, in helping you locate a local provider.

We have enclosed a copy of Lead Testing Requirements and Medical Management Recommendations per Ohio Department of Health. If your child has already been screened, please provide a copy of the results for your child's file as required for preschool licensing. If your child has NOT yet been screened as required, please discuss with your child's physician/health care provider the need to do so and forward results to our office. The purpose of this policy is to ensure the children's safety as much as possible.

4) Send copies of your child's shot record, certified birth certificate, and custody papers (if applicable). Returning students do not need to turn in this information unless custody has changed since the previous school year.

5) A Parent Handbook that contains all policies and procedures will be handed out before the first day of school.

Please return the application and all other documentation to: North Point ESC Attn: Preschool

180 Milan Avenue, Suite 6 Norwalk, OH 44857

If you have any questions, please call Debbie at 419-627-3990 between the hours of 9:00 a.m. — 3:00 p.m.

Sincerely,

Julie Blankenship Preschool Teacher

Elementary School (K-6) 3851 U.S. 20 East Collins, Ohio 44826 Phone: (419) 660-9824 Fax: (419) 660-8566

Middle School/High School (7-12) 3841 U.S. East Collins, Ohio 44826 Phone: (419) 668-8470 Fax: (419) 663-2521 MS Fax: (419) 663-5916 HS

Board Office 3765 U.S. 20 East Collins, Ohio 44826 Phone: (419) 660-8503 Fax: (419) 660-8429

"A PLice 1/1)1-2re..."Staff and St-udents Excel; and Parents an d Community Care"

PRESCHOOL APPLICATION 2017 - 2018 School Year

Western Reserve Preschool 28 River Street Wakeman, OH 44889 440-839-5086

Please circle the preferred choice: AM class

Child's Full Name

For office use: Date received: Returning student: yes no

PM class (Class choice is not guaranteed.)

Last First

Middle (full middle name) Child's nickname (name to be called in class) Birthdate Age Male or Female (circle)

Address

Street City Zip

City and State of child's birth

Parent(s)/Guardian(s) name

County of residence School district

Home telephone Emergency number

Father's employer Phone number

Employer's address Work schedule

Mother's employer Phone number

Employer's address Work schedule

List names of people authorized to pick your child up from school (must be over 18 years of age)

FAMILY INFORMATION

Names of others who reside in the home Relationship to child

How long has your son/daughter attended school in the United States?

VERIFICATION OF INCOME FORM

Name of Child Birthdate

Verification of current employment and salary is needed in order to determine the preschool program tuition for your child.

List all household members

Total yearly salary

Please attach one of the following: W-2 Check stub Medical card

Other

Print name of parent/guardian Social security number

Street address, City, Zip

Home phone number

Penalties for misrepresentation I certify that all of the about information is true and correct and that all income is reported. I understand that this information is being given for receipt of state funds, that program officials may verify the infoimation on the application, and that deliberate misrepresentation of the infounation may subject me to prosecution under applicable state and federal criminal laws.

Signature of parent/guardian Date

For Office Use

Signature of person verifying income Date

Ohio Department of Job and Family Services Ohio Department of Education

EARLY CHILDHOOD EDUCATION ELIGIBILITY SCREENING TOOL *This form is valid only for publicly funded child care when attached to a

JFS 01122 Publicly Funded Child Care Supplemental Application

•--Tell us about you (the applicant) Middle Initial Last Name First Name

Address Today's Date

City State County Zip Code

Phone Number

( )

Additional Phone Number

( )

E-mail Address

Tell us about the people in your home Race Hispanic

or Latino - Y or N

Spoken Language

Date of Birth

.. Gender M or F

U.S. Citizen Y or N

Name (First, Middle, Last)

Relationship to You

(spouse, son, friend, etc.)

- •

Self

0 African American 0 Alaska Native/American Indian 0 Asian 0 Caucasian 0 Hawaiian/Pacific Islander



0 African American 0 Alaska Native/American Indian - El Asian 0 Caucasian 0 Hawaiian/Pacific Islander


-

Page 1 of 3

JFS 01121 (3/2016)

Ohio Department of Job and Family Services Ohio Department of Education

EARLY CHILDHOOD EDUCATION ELIGIBILITY SCREENING TOOL

How do I apply for Early Childhood Education Services?

How do I apply for Publicly Funded Child Care?

You will need to:

1. Complete the screening tool. 2. Do not submit to the Ohio Department of Education. 3. Submit this form to your provider.

You will need to:

1. Complete the screening tool, JFS 01121. 2. Complete the JFS 01122 Publicly Funded Child Care Supplemental Application. 3. Submit both the JFS 01121 and JFS 01122 to your local county agency. 4. Attach verifications to the JFS 01122 (see verification requirements below).

How do I complete this 1. Fill out this application: Answer as many questions as you can. application? 2. Be sure to sign the application.

When will I receive ECC: You will be notified by your provider when you may begin care. assistance? Child care: Eligibility for the child care program is based on the date a signed

application is submitted to the county agency. Eligibility for this program is determined within 30 days from the earliest date either the JFS 01121 or JFS 01122 is submitted.

What verifications do I need for publicly funded child care?

You will need to: 1. Submit the JFS 01121 and JFS 01122. 2. Provide proof of income: Verification of all money coming into your household. (such as pay stubs, tax records, award letters, child support) 3. Proof of any child support paid. 4. Proof of citizenship or qualified alien status for children in need of care: If the county agency verifies that a caretaker receives or has received OWF for a child, verification of citizenship is not required. 5. Provide proof of a qualifying activity for all caretakers in the household: Verification of a qualifying activity includes but is not limited to an official school schedule, work schedule, employment verification, self-sufficiency contract, etc. 6. Provide the name and address of an eligible child care provider chosen for each child in need of care.

What is Step Up To Quality?

Step Up To Quality was created to help families identify early learning and development programs that go beyond the minimum standards of licensing. Star Rated programs demonstrate higher levels of quality in a variety of ways. Ask your provider if they are participating.

JFS 01121 (3/2016)

Tell us about your needs for your child(ren) What hours/days do you need services? (i.e. child

care or preschool) Check all that apply Child 1 Provider Name and Address Child's Needs

Name Do you have concerns about your child's growth and/or development?

II Sun II Mon • Tues II Wed • Thurs NI Fri II Sat

M Mornings • Afternoons 1 Evenings

IN Yes • No

Describe: • Weekends

Child's Mother's Maiden Name What is the child's home school district?

Child's City of Birth

Child 2 Provider Name and Address Child's Needs

What hours/days do you need services? (child care or preschool) Check all that apply


• Sun II Mon II Tues II Wed • Thurs III Fri II Sat

• Mornings • Afternoons • Evenings

• Yes • No

Describe:

• Weekends



,

Child 3 Provider Name and Address Child's Needs

What hours/days do you need services? (child care - or preschool) Check all that apply


M Sun II Mon • Tues • Wed II Thurs • Fri II Sat

• Mornings II Afternoons • Evenings

IN Yes E No

Describe:

111 Weekends



Page 2 of 3 JFS 01121 (3/2016)

Signature of Applican

Tell us about your finances Will you or the people in your home receive income this month? 0 Yes D No

Income refers to all the money that you and the people in your home receive such as earnings from employment, child/spousal/medical support, disability benefits, retirement benefits, Workers' Compensation, Social Security, SSI, Veterans Benefits, etc.

If yes, please complete the table below.

Name Type of Income

Amount of Income -

(before taxes)

How Often Received

(weekly, bi-weekly, etc)

Date Last Received

Work or School Schedule (please list times)

0 Suri LI Thurs D Mon D Fri 1=1 Tues LI Sat LI Wed

LI Sun LI Thurs M on 0 Fri

LI Tues LI Sat D Wed

D Sun LI Thurs 0 Mon 0 Fri LI Tues LI Sat 0 Wed

D Sun LI Thurs 0 Mon LIFri

Tues 0 Sat 0 Wed

El Sun LI Thurs

Mon LIFri

Tues 0 Sat

LI Wed

Do you or anyone in your household pay Child or Spousal Support? LI Yes CI No

How Much?

Page 3 of 3

JFS 01121 (3/2016)

CONSENT TO RELEASE CHILD'S PHOTO/VIDEO AND OTHER INFORMATION

To publicize the achievements of our preschool students and the great work they do, we like to occasionally publish our students' names, photos, and/or achievements in our school publications or release the information to local newspapers. We may also post the information on the school's website.

We understand that you may not want to have your child's name, photo, and/or achievements published. Please fill out this form to let us know your wishes.

School district Classroom teacher

Student's name

171 I consent to have my child's name, photo, and/or achievements published in school newspapers/newsletters, release to local newspapers, and posted on the school's website as it relates to activities and participation in the preschool program.

I do not want my child's name, photo, and/or achievements published in school newspapers and/or newsletters, released to local newspapers or posted on the school's website.

Parent/Guardian Signature Date

CONSENT FOR PARENT ROSTER

In accordance with Rule 3301-37-04 of the Ohio Revised Code, a roster for each classroom, which includes names, addresses and telephone numbers of parent(s)/guardian(s) of children attending the preschool program must be prepared annually and given to parents/guardians upon request, but to no other person. I would like my name and telephone number to be included in this roster. I would not like my name and telephone number to be included in this roster.


CONSENT FOR FIELD TRIPS

My child has permission to attend all school-sponsored field trips during the present school year. Written notice of each field trip will be sent home with your child.


INTEREST SURVEY

Dear Families,

To help us understand and better communicate with your child, please take a few minutes to complete this Interest Survey. The information will help us be able to make your child feel more at ease at school. (And besides that, it's fun for us to read!)

Child's Name:

Nickname: (Child's name as you want them to recognize it in print.)

Brother's/Sister's Name(s) and Ages:

Babysitter's Name:

Friend's Name(s):

Favorite Toy(s):

Favorite Food(s):

What does he/she call grandparents?

Any pets and their names:

What language does your son/daughter use most frequently at home?

What language do the adults at home most often speak?

Any other people, events, etc. your child especially likes/dislikes to talk about:

Is there anything of which your child is fearful? If so, what are some ways he/she is calmed?

What are your hopes for your child's preschool experience this year? (What is most important to you,

such as experiences, opportunities, skills, etc.?)

What hobbies or special skills would you be willing to share?

EMERGENCY/MEDICAL/TRANSPORTATION AUTHORIZATION FORM

Child's name Grade Telephone Address School district Building

The purpose of this form is to enable parent(s)/guardian(s) to authorize the provision of emergency treatment for your child who becomes ill or injured while under school authority, when you cannot be reached.

Residential parent(s)/guardian(s) Mother/guardian name Phone:Work Home Cell Father/guardian name Phone:Work Home Cell

Contact information if parents cannot be reached in case of emergency: (2 contacts required)

Phone Cell

Phone Cell

PART I OR PART II MUST BE COMPLETED

Part I: To Grant Consent

I hereby give consent for the following medical care providers and local hospital to be called.

Physician Phone Dentift Phone Medical specialist Phone Local hospital Emergency room phone

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

List all allergies and any special precautions or treatments indicated for these allergies.

Name Address

Name Address

List any medications, food supplements, modified diets, or fluoride supplements currently being administered to the child.

List any chronic physical problems and any history of hospitalizations.

List any diseases the child has had.

Has your child had chicken pox?

Signature of parent/guardian Date Address

Part II: Refusal to Consent

I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action

Signature of parent/guardian Date Address

HEIGHT:

PHYSICAL ASSESSMENT

WEIGHT:

Did the examination reveal any abnomialities in the following areas? YES NO YES NO

General Appearance Heart/BP

Skin Lungs

Lymph Nodes Abdomen

Eyes/Vision Genitalia

Ears/Hearing Skeletal system

Nose/Throat

Neuro muscular

Teeth/Gums/Dental

Allergies

Tongue/Palate Specify

Rev. 1/22/13 MEDICAL/PHYSICAL FORM

Child's Name DOB

School Phone

Parent/Guardian Name Address

Required For Children Enrolled In An Early Childhood Education Grant Program Or

Preschool Special Education Program

Reason Not Completed (Check Which Applies)

Assessments/Screenings Completed (Circle One)

Date Completed

Health Professional

Decision

Examples: religious conviction, insurance coverage, other

Lead Yes No Hemoglobin Yes No

Immunizations

Circle One

Complete For Age

No

In Process

**INEVIUNIZATION RECORD 4-11ST BE ATTACHED.**

EXEMPT FROM IIVEVIUNIZATIONS

Circle One

Religious Conviction Yes No

Health Concern Yes No

Other:

No

Limitations or Health Condition (including allergies, medications, dietary restrictions)

This child has been examined and is in suitable condition to participate in group care. Date of Exam

Signature of Examining Physician or Physician's Assistant or Advanced Practice Nurse (circle one)

Address:

Phone:

Lead Testing Requirements and Medical Management Recommendations

for Children Ages 6 to 72 Months Revised 5/2007

Ohio Department of Health Bureau of Child and Family Health Services • Ohio Childhood Lead Poisoning Prevention Program (0cLPPP)

There is no safe level of lead in the blood. Any confirmed level of lead in the blood is a reliable indicator that the child has been exposed to lead.

Administer two tests at age 1 and 2 years, or up to age 6 years if no test has been administered before (or as medically necessary) based on the following criteria.

1) Is the child on Medicaid? If yes, TEST — IT'S OHIO LAW AND A FEDERAL REQUIREMENT. If no, go to step 2.

2) Does the child live in a High Risk ZIP Code? (contact OCLPPP or visit www.odh.ohio.gov for list) If yes, TEST — IT'S OHIO LAW! If no, go to step 3.

3) Ask the parent five key questions to assess risk. Use the Risk Assessment Questionnaire (RAQ) and ask if the child: • Lives in or regularly visits a house built before 1950? This includes a day care center, preschool, or home of a baby sitter

or relative. • Lives in or visits a house that has peeling, chipping, dusting or chalking paint? • Lives in or visits a house built before 1978 with recent ongoing, or planned renovation/remodeling? • Has a sibling or playmate who has or did have lead poisoning? • Frequently comes in contact with an adult who has a hobby or works with lead? Examples are construction, welding,

pottery, painting, and casting ammunition.

If the family answers "yes" or "do not know" to any of the above questions, TEST. If the family answers "no," provide anticipatory guidance and follow up at the next visit.

All blood lead test results, by law, are required to be reported to ODH by the analyzing laboratory.

Blood Lead Levels (BLL) Recommended Medical Management Actions

0-5 pg/dL • Provide anticipatory guidance: Discuss sources, effects of lead, and hazards associated with renovating

pre-1978 homes during well child care at 6, 9 and 12 months. • Test blood lead level (BLL) again in 12 months.

6-9 pgIck

In addition to medical management actions listed above: • Explain that there is no safe level of lead in the blood. • Discuss wet cleaning to remove lead dust on surfaces; eliminating

access to deteriorating lead-paint surfaces; and ensuring regular meals which are low in fat and rich in calcium and iron.

• Refer to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) or for other nutritional counseling.

10-14 pg/dL

In addition to medical management actions listed above: • Test BLL again in 2 months. • Refer to Help Me Grow program. State or local health department will conduct a public health lead investigation.

15-19 pg/dL

In addition to medical management actions listed above: • Confirm results by venous or second capillary blood sample within one month.

If BLL persists in this level (i.e., 2 confirmed tests at least 2 months apart), proceed according to actions for BLL 20-44.

20-44 pg/dl.

In addition to medical management actions listed above: • Take medical, environmental and nutritional Hx; test for anemia and iron deficiency; assess neurologic,

psychosocial and language development; screen all siblings under 6; and evaluate risk of other family members (e.-" ' -

g pregnant women) - : .

• Refer to the Bureau for Children with Medical Handicaps (BcmH) program, if appropriate.

• Test BLL every 1-2 months until the BLL remains <15pg/dL for at least 6 months and lead hazards have been removed or made lead-safe, and no new exposure exists.

, „ -

4 p L . -

'

In addition to medical management actions listed above: • Confirm fingerstick (capillary) results by venous blood sample within 24 hours. • Consider chelation therapy: . Obtain a venous specimen to ensure that therapy is based on current and reliable information.

. Refer to a specialist. • Test BLL again in 1 month. _

This level is a medical emergency: Order an urgent repeat venous BLL test, but begin chelation immediately!

Utilize medical management actions listed above.

Help Me Grow Hotline: 1-800-755-GROW (1-800-755-4769) Bureau Children with Medical Handicaps (RCMP): 614-466-1700

State of Ohio (DOH) • 6/06 • [email protected]

ODH Information and Referrals Bureau of Early Intervention (El): 614-644-8389 Women, Infants and Children (WIc): 614-466-4110

Medicaid Provider Hotline: 800-686-6108 0014 ociPPP: 614-466-5332

DENTAL HEALTH RECORD

Child's name

DOB School Phone

Parent/guardian name Address

1. Has the child previously seen a dentist? No Yes Dentist's Name

2. Does the child have any trouble with teeth, gums, or mouth? No Yes

3. Oral condition before treatment: Missing Decayed Filled

4. Examination and treatment record:

tooth letter or number surface description of work date service performed

procedure number

8. Is baby bottle tooth decay present? 0 No CI Yes

9. Is the child receiving: Topical Fluoride Application? 0 No 0 Yes Fluoride Supplement Diet? 0 No El Yes If yes, tablets liquid Fluoridated water? EI No El Yes

10. Is all planned treatment complete? 0 No E Yes If not, itemize on chart below.

tooth

surface description of work

letter

11. Approximate number of visits required for treatment?

12. Next scheduled appointment

13. Comments:

Dentist's Name Street Address City, State, Zip Phone

Dentist's Signature Date of examination

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