2new job.indd - Chicago Public Schools
Transcripción
2new job.indd - Chicago Public Schools
READY. . . SET. . . REGISTER IN PRESCHOOL! 2014-2015 SCHOOL-BASED PRESCHOOL REGISTRATION FORMS The pre-registration process is essential for introducing new families and students to staff, the classroom environment, and a new school culture. During this time, please ensure the following elements are completed when you meet with each of your families: Home Language Survey Child Health History Release Form Parent Agreement Media Consent Form and Release Family Partnership Assessment and Goals Rights of Homeless Students Request for Emergency and Health Information Prior to child’s first day of attendance: Child Health Requirements Certificate of Child Health Examination Ages & Stages®: Social-Emotional (ASQ:SE) can be completed during registration. ESI-R must be completed no later than 45 days after the child’s first day of attendance.* *ExceleRate™ Illinois Gold Standard Requirement Please ensure all of these documents are completed and available in each child’s folder before the start of the new school year. Note: In accordance with the McKinney Vento Homeless Assistance Act, students in a temporary living situation are eligible for immediate enrollment (see Rights of Homeless Students). QUESTIONS? Contact the Office of Early Childhood Education: 773.553.2010 Chicago Public Schools Complete this Home Language Survey at the student’s initial enrollment in a Chicago Public School. This form must be kept in the student’s folder. School: Room: Student Name: Unit: Student ID No.: English IMPACT REGISTRATION PROCESS 1. Is a language other than English spoken in your home? No Yes (For Office use only) (Language) The Non-English language identified on either question is the Home Language. 2. Does the student speak a language other than English? No Area: Yes If two different non-English languages are identified, enter the language identified in question 2 as the (Language) Home Language. Enter ENGLISH as a Home Language ONLY when If the answer to either question is yes, the law requires the school to both questions are answered no. assess your child’s English language proficiency. Spanish Polish 1. ¿Se habla algún otro lenguaje que no sea inglés en su 1. Czy językiem innym niź angielski mówi się w domu? hogar? No Sí (Lenguaje) 2. ¿Habla el estudiante un lenguaje que no sea el inglés? No Sí Nie Tak (język) 2. Czyt uczeń mówi innym językiem niż angielski? (Lenguaje) Nie Tak (język) Si la respuesta a cualquiera de las preguntas es “Sí”, la ley requiere Jeśli udzielili Państwo twierdzącej odpowiedzi na którekolwiek z powyższych que la escuela evalúe la fluidez de su niño en el idioma inglés. pytań, przepisy wymagają, aby szkoła sprawdziła poziom znajomości języka angielskiego waszego dziecka. Chinese Arabic 如果你在兩個問題中之任一項的答案是 “是”, 則法律規定校方 要測試貴子女的英語通悉度。 Bosnian/Croatian/Serbian إذا ﻛﺎﻧﺖ اﻹﺟﺎﺑﺔ ﻧﻌﻢ ﻋﻠﻲ أي ﻣﻦ اﻟﺴﺆاﻟﯿﻦ ﻓﺈن اﻟﻘﺎﻧﻮن ﯾﺤﺘﻢ ﻋﻠﻲ .اﻟﻤﺪرﺳﺔ ﺗﻘﯿﯿﻢ اﺑﻨﻜﻢ ﻟﻠﻜﻔﺎءة ﻓﻲ اﺳﺘﺨﺪام اﻟﻠﻐﺔ اﻻﻧﺠﻠﯿﺰﯾﺔ Urdu Ukoliko ste na bilo koje od ovih pitanja odgovorili sa “Da”, škola će biti zakonski dužna da procijeni nivo znanja engleskog jezika kod vašeg djeteta Office of Language and Cultural Education Signature of School Official Date Signature of Parent/Guardian Date Notes: If the parent/guardian does not speak English and the school does not have staff who speaks the parent/guardian’s language, identify the language spoken by the parent/guardian through any assistance available in the school. If exact name of the language cannot be determined, enter “Other” as a temporary entry. The exact language must be Revised: Mar. 2009 determined within two weeks after the enrollment. Assistance from Area Compliance Facilitators is available. Questions or concerns, contact your Area Compliance Facilitator. RELEASE FORM CHILD’S NAME ___________________________ DATE __________ SCHOOL NAME ___________________________ ROOM _________ PARENT’S NAME _____________________________ The following people have permission to pick up my child from the Chicago: Ready to Learn! preschool program. SIGNATURE OF PARENT _______________________________________ NAME _______________________ RELATIONSHIP TO CHILD ____________ NAME _______________________ RELATIONSHIP TO CHILD ____________ NAME _______________________ RELATIONSHIP TO CHILD ____________ NAME _______________________ RELATIONSHIP TO CHILD ____________ FORMULARIO DE AUTORIZACIÓN NOMBRE DEL NIÑO ___________________________ FECHA_______ NOMBRE DE LA ESCUELA _____________________ SALÓN________ NOMBRE DEL PADRE _____________________________ Las siguientes personas están autorizadas a recoger a mi niño del programa preescolar Chicago: Ready to Learn! FIRMA DEL PADRE _______________________________________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ NOMBRE_____________________ RELACIÓN CON EL NIÑO ____________ Chicago Public Schools Media Consent Form and Release Consent/Release I hereby consent to have my student photographed, video taped, audio taped and/or interviewed by the Board or the news media when school is in session or when my child is under the supervision of the Board. I understand that during the school year, the Board might like to celebrate my child’s accomplishments and work. Therefore, I further consent to allow the Board to release my student’s name, academic/non-academic awards, and information concerning my child’s participation in school-sponsored activities, organizations and athletics. I also consent to the Board’s use of my student’s name, photograph or likeness, voice or creative work(s) on the Internet or on a CD or any other electronic/digital media or print media. As the child’s parent or legal guardian, I agree to release and hold harmless the Board, its members, trustees, agents, officers, contractors, volunteers and employees from and against any and all claims, demands, actions, complaints, suits or other forms of liability that shall arise out of or by reason of, or be caused by the use of my child’s name, photograph or likeness, voice or creative work(s), on television, radio or motion pictures, or on the Internet, or on a CD, or any other electronic/digital media or print media. It is further understood and I do agree that no monies or other consideration in any form, including reimbursement for any expenses incurred by me or my child, will become due to me, my child, our heirs, agents, or assigns at any time because of my child’s participation in any of the above activities or the above-described use of my child’s name, photograph or likeness, voice or creative work(s). I understand that I may cancel this release by providing written notice to the principal. I also understand that this release is valid for one school year, including the following summer. Instructions: Check Box #1 or Box #2 1. □ I consent as outlined in the above consent/release section. 2. □ I DO NOT consent to my child being photographed, video taped, audio taped and/or interviewed by the Board or the news media when school is in session or when my child is under the supervision of the Board. Furthermore, I do not consent for the Board to release my student’s name, academic/non-academic awards, and information concerning my child’s participation in school-sponsored activities, organizations and athletics. I do not consent for the Board to use my student’s name, photograph or likeness, voice or creative work(s) on the Internet or on a CD or any other electronic/digital media or print media. ____________________________________________ ________________________________________________ Signature of Parent/Guardian/Student if age 18 or older Printed Name of Parent/Guardian/Student if age 18 or older ___________________________________ Student’s Name ___________________________________ Student ID # ___________________________________ Date ___________________________________ School I understand that I have the right to inspect and copy my student’s records, challenge the contents of such records; and limit my consent to the designated records or designated portions of information within the records. Department of Policy and Procedures July 2012 ```` Escuelas Públicas de Chicago Consentimiento de prensa y dispensa de responsabilidad Consentimiento/Dispensa Por la presente autorizo a que mi estudiante sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta de Educación de Chicago o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Entiendo que en el curso del año escolar la Junta quiera celebrar los logros y el trabajo de mi niño. Por lo tanto, también autorizo a la Junta la divulgación del nombre de mi niño, de sus premios académicos y no académicos y de información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. También autorizo a la Junta el uso de fotografías o retratos de mi niño, o de su voz o trabajo creativo, en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. Como padre o tutor legal del niño, libero de toda responsabilidad a la Junta, a sus miembros, síndicos, agentes, oficiales, contratistas, voluntarios y empleados ante cualquiera y todos los reclamos, demandas, acciones, quejas, juicios u otras formas de responsabilidad que puedan surgir por cualquier razón, o puedan ser causadas por el uso del trabajo creativo, fotografía, retrato o voz en televisión, radio o películas, o en medios impresos, Internet o cualquier otro medio electrónico/digital. Es entendido además, y estoy de acuerdo, en que no se me debe a mí, a mi niño, a nuestros herederos, agentes o designados ningún dinero o consideración de ninguna especie, incluyendo el reembolso de cualquier gasto realizado por mí o por mi niño durante la participación en cualquiera de las actividades mencionadas, o por el uso de su trabajo creativo, fotografías, retrato o voz. Entiendo que puedo cancelar este consentimiento mediante una comunicación por escrito al director escolar. También entiendo que esta dispensa es válida por un año escolar, incluyendo el verano siguiente. Instrucciones: marque la caja #1 o caja #2 1. □ Autorizo lo señalado arriba en la sección consentimiento/dispensa. 2. □ NO autorizo que mi niño sea fotografiado, grabado en video, grabado en audio y /o entrevistado por la Junta o por medios de prensa cuando la escuela esté funcionando o cuando el niño se encuentre bajo la supervisión de la Junta. Tampoco autorizo que la Junta divulgue el nombre de mi niño, sus premios académicos y no académicos e información relacionada con su participación en actividades auspiciadas por la escuela, organizaciones y deportes. No autorizo a la Junta el uso del nombre de mi estudiante, fotografías o retratos, de su voz o trabajo creativo en Internet o en un CD educativo, o en cualquier otro medio electrónico/digital o impreso. ____________________________________________ Firma padre o tutor, o del estudiante si tiene 18 años o más _____________________________________________ Nombre en imprenta del padre o tutor, o del estudiante si tiene 18 años o más ___________________________________ Nombre del estudiante ___________________________________ Número de ID del estudiante ___________________________________ Fecha ___________________________________ Escuela Entiendo que tengo el derecho de inspeccionar y copiar los registros de mi estudiante, de disputar el contenido de dichos registros; y limito mi consentimiento a los registros designados o porciones designadas de información contenida en los registros. Departamento de Política y Procedimientos Julio 2012 Rev. 01/2014 Chicago Public Schools Request for Emergency and Health Information School Name: _____________________________________________________________________________________ PARENTS/GUARDIANS: The school must have on file emergency information that can be used to contact you. Please print clearly. Whenever there is a change in this information, immediately notify the school in writing. ___________________ Student ID# __________________________________________________________________________________________ Last Name First Name Middle Name ______________________ Birth Date (mm/dd/yyyy) ___________________________________________________________________________________ Student Home Address Confidential Information Box 1 doubled-up in a hotel/motel in a car/park/other public place in a shelter _____________________ Student Home Phone # Confidential Information Box 2 Complete this box only if (1) it reflects your child’s current living situation; OR (2) it reflects your living situation if you are a youth not living with a Parent or Guardian. (Your answer will help school staff with enrollment and may enable the student to receive additional services.) Check one box: awaiting foster care placement __________________ Homeroom # Is there a current Order of Protection or No Contact Order which concerns this student? Yes No School Note: If “Yes,” follow CPS Policy 704.4 procedures. Enter information in Legal Alert field and update contact information, as needed, in SIM. in transitional housing School Note: If any box is checked, see the CPS Policy 702.5. Parent/Guardian and Emergency Contact Information: Add extra contacts on the back of this form, if needed. Parent/Guardian Contact Parent/Guardian Contact Contact Name Relationship to Student Check all that apply: Lives With Gets Mailings Lives With Gets Mailings Emergency Permission to Pickup Emergency Permission to Pickup Home Address, if different from student’s Home Phone Number, if different from student’s Cell Phone Number Email Address Name and Address of Employer Work Phone Number * Communication Language * CPS communicates via phone calls. Select the language that should be used to communicate with you. Languages available for mass communication at this time are English and Spanish (note: other languages upon availability). List the name of a relative or neighbor who can also be notified in an emergency and has permission to pick up the student: _________________________________________________________________________________________________________________________________ Name Home Address Telephone # Relationship Family Doctor’s Name, Address, and Phone Number: I authorize you to call my family doctor, if necessary, in an emergency. ____________________________________________________________________________________________________________________________________ Student Health Insurance: (select only one of the three) Illinois Medical Card/All Kids: provide student’s medical ID # __________________________________________(9-digit number located on back of card) No Insurance: are you interested in applying for the Illinois Medical Card/All Kids? Yes No Private/Employer Health Insurance: no additional information needed Children of Military Personnel (optional) As the Parent or Guardian, are you a member of a branch of the armed forces of the United States? Yes If yes, are you either deployed to active duty or expect to be deployed to active duty during the school year? No Yes No I certify that the information on this form is correct: ____________________________________________________________________________(Parent/Guardian Signature)___________________________(Date) Growth & Nutrition Immunization & TB User Defined Funding Disability Emergency Medical Record Developmental Transportation Checklist Mental Health Health History Notif.Letter Referral Case Notes Goals Sp. Case Child Assessment Visits Child Reports Child Health History Prior to Enrollment Child Name: Fake Baby Child ID: 265637 DOB: 01-01-2009 Age: 5y / 2m / 23d I. Preliminary Questions Gender: Male 1. How much did this child weigh at birth? Has anyone in the family ever had any serious illnesses or abnormalities (e.g. heart disease, diabetes, cancer, tuberculosis, asthma, etc.)? If yes, please explain. Yes No 2. Yes No 3. Yes No 4. Yes No 5. Weight Status at: Birth Were there any problems with this child immediately after birth? If yes, please explain. Is your child taking any medications every day? If yes, please explain. Will medication be needed at school? If yes, please explain. II. Has this child ever had the following illnesses? If so, please give date and explain below Measles Ear/Nose/Throat Problems Eye Problems Mumps Urinary/Kidney Problems Heart Disease Chickenpox Muscle/Bone Problems Pneumonia Scarlet Fever Anemia Asthma Respiratory Blood Pressure Diabetes Tuberculosis Rheumatic Fever Intestinal Problems Seizures Bee Sting Allergy Comments: III. Has your child ever had the following? If yes, please give date and explain. Hospitalizations Operations Serious Injuries Other Health Problems/Illnesses Allergies to Medications(i.e. penicillin, sulfa drugs) IV. Developmental History: Check the box if child... Focus eyes and follow light or objects with eyes by 2 months? Coo and Gurgle by 3 to 4 months? Sit alone on or before the 8th month? Page 1 of 6 Walk alone on or before the 15th month? Say simple words on or before the 2nd year? Toilet train on or before the 3rd year? Mental development appears normal? Any concerns about your child's behavior? Where? At Home At School In Public Child is evaluated or has received a behavioral health diagnosis? Would you like to be contacted by a Behavior Health Specialist? Explain/Comments: V. Immunization History *Is child up-to-date on all immunizations appropriate for his/her age? *Has child received all immunizations possible at this time but has not received all immunizations appropriate for his/her age? *Child Met State's guidelines for an exemption from immunizations *Has received no immunizations. None of the above Explain/Comments: VI. Dental Information *Do you have dental insurance? If yes, specify dental plan *Does the child have an Ongoing Source of Continuous and Accessible Dental Care? (Dental Home) Yes Please Select Dentist Name No Date of last visit Were there any problems for the child/comments: VII. Nutrition Assessment No 1. Does your child's weight appear normal? Yes No 2. Does your child eat fruits and vegetables? Yes No 3. Is your child involved in active play daily? Yes No 4. Does your child have dental problems now? Yes 5. Does your child have difficulty chewing or swallowing now? Yes No How often does your child eat these foods? Please check the number of times per day your child eats these foods Food Groups 0 1 2 3 4 5 6 Recommended 1. Milk Group: Milk(Whole, 2%, 1%, skim) yogurt, cheese, milkshakes) 3 2. 2 Page 2 of 6 Follow-up Meat, Poultry, Fish, Dry Beans, Eggs: Beef, chicken, turkey, pork, fish, eggs, peanut butter, Nut Group: dried beans, nuts, peas, lentils Bread, Cereal, Rice & Pasta Group: Bread (all kinds), hot or cold cereal, crackers, tortillas, noodles or 3. pasta (all kinds), rice Vitamin C Rich Group: Orange, grapefruit, lemon, lime, strawberries, tangerine, watermelon, mangoes, 4. tomatoes, cabbage 4 5. Other Fruits & Vegetables Group: Apple, banana, pear, grape, peach, potato, green beans, corn 3 1 3 per week Vitamin A Rich Group (per week): Dark green or orange vegetables & fruits such as greens, carrots, broccoli, winter squash, spinach, pumpkin, sweet potato, apricots, canned plums, mangoes Fatty Foods: (a) Bacon, lunch meat, sausage, hot dogs, fried foods (b) butter/margarine, sour cream, 7. regular salad dressings, mayonnaise 6. 8. Soda and Flavored Drinks: Pop, kool aid, fruit drinks 9. Sugar and Sweets: Candies, cake, cookies, high sugar cereals 10.Salty Snacks: Chips, salted pretzels, pickles VIII. Food Substitution 1. Is your child restricted from foods due to religious, vegetarian, medical or personal beliefs? Yes No If yes, please check all that apply: Pork Beef Poultry Fish Eggs Milk Other: (please specify) Yes No 2. Does your child have any food allergies or intolerances? If yes, please check all that apply: Milk Milk Products Eggs Legumes (Dry Beans/Peas) All foods containing eggs Tree Nuts/Seeds Peanuts Whole Wheat Wheat Gluten Fish Shellfish Beef Soy Vegetables, specify Fruits/Juice, specify Other, specify 3. What kind of reaction does your child have when your child eats the specified food? Life Threatening Rash Diarrhea Swelling Difficulty Breathing Other: Yes No 4. Is your child on any special diet prescribed by a doctor? If yes, please specify: NOTE TO STAFF - If yes to questions 2,3, and /or 4 above: - Parent must obtain physician's statement to be submitted to delegate agency staff. Note: substitutions for non-medical reasons (i.e. religious, vegetarian, etc.) will be approved on a case-by-case basis with the Nutrition Manager or Nutritionist. Substitutions for medical reasons will be accommodated only with a signed statement from a licensed physician or other medical authority. IX. Lead Poisoning Screening 1. Is paint peeling or chipping on any part of your house? Yes No Yes No 2. Is your house being remodeled? Yes No 3. Has your child or anyone in your family been treated or monitored for lead poisoning (i.e. blood lead > 10) 4. Page 3 of 6 Does your child live with someone whose job or hobby involved exposure to lead (i.e. painting, soldering, automobile battery manufacturing or recycling, vehicle radiator repair, auto painting, or stained glass work)? Yes No Yes No 5. Do you or anyone else who lives with or cares for your child use Azarcon, Greta, Rueda, Coral, Alcaron, Liga, or Maria Luisia? No 6. Do you use pottery (ceramics, earthenware) that is old or has been bought outside the US for cooking, eating, drinking, or storing food? Yes No 7. Does your family buy canned food or packed candies from other countries? Yes No 8. Does your child eat dirt or clay or other non-food items? Yes 9. Does your child or family frequently travel outside the US? Yes No X. Asthma / Allergy Screening 1. Has your child ever been diagnosed by a medical professional as having asthma? a) Date of diagnosis: Yes b) How many episodes per year? No c) Is it seasonal? At what time of the year do the episodes most often occur? d) Is it well controlled? How? 2. Yes No Treatment in ER 3. Yes Has your child experienced any of the following due to asthma? If yes, please check the ones that apply: No If yes, then # of times: If yes, then # of times: Hospitalizations Have you ever given your child any medications for asthma? If yes, please check all that your child has used in last year: Albuterol Intal Ventolin Pedia Pred Tedral Prelone Proventil Primitine Mist Marax Quiboron Other: Yes Yes Yes No No 4. Does your child use a Nebulizer or Inhaler? 5. How many colds does your child have in a year? 6. Does your child suffer from hay fever or eczema? 7. Is your child allergic to any of the following? If yes, please check all that apply: No Animals Perfume Birds Pollen Grass Flowers Dust Trees Smoke Weather Changes Other: Yes No 8. Does anyone in the household smoke? (i.e. home/car) Comments: XI. Medical Coverage Page 4 of 6 Yes No Yes No *Child Receives Medical Services Through Ongoing source of Continuous, Accessible Medical Care *Is child up-to-date on a schedule of age-appropriate preventive and primary health care, according to the relevant state's EPSDT schedule for well child care (PIR C8(1) ) *1. Does your family have a regular doctor or a regular place to receive health services? If yes, please answer the following: Doctor's Phone Please Select name: #: Address: Doctor's name: Phone #: Date of Physical: Address: Yes * Primary Please Select Insurance Please answer the following: Medical Home Intervention No All Kids Outcome Medicaid Outcome Indian Health Services Outcome Migrant Community Health Centers Outcome Outcome Other *2. Do you use the (DO NOT USE)? Yes No Yes No *3. Do you have "regular" (DO NOT USE)? Yes No *4. Do you have "emergency only" (DO NOT USE)? Yes No *5. Do you have Healthy Families (DO NOT USE)? Yes No If yes, what city? date of last physical? *6. Do you have private / other health insurance? If yes, what is the name of the insurance? Please Select Comments: XII. Health History Consents Section No 1. Dental screening/exam and treatments (to detect problems with teeth and gums). Yes No 2. Blood pressure screenings (if not noted on the physical exam). Yes No 3. Nutrition/growth screening and referral (to detect problems with delayed growth/overweight/underweight children). Yes No 4. Speech and language screenings (to detect problems with speaking and understanding). Yes No 5. Developmental screening (to assess levels in language, cognition, visual, small motor, gross motor, social, and emotional aspects). Yes No 6. Behavioral observations (to further assess social and emotional development). Yes No 7. Yes No 8. Yes No 9. No 10. Vision screening/exam to detect problems with vision & Auditory/Hearing screening (to detect problems with ears). Yes Yes In cases of emergency medical/dental care, I give my permission to Head Start staff to secure needed emergency medical care if parents/guardian cannot be immediately contacted. That necessary health information concerning my child may be released to the appropriate agencies assisting in the care of my child and the school my child will be attending after Head Start. Blood test to check lead levels and/or anemia, if no results are available. Page 5 of 6 Comments: Signed By Staff: _________________________ Date: mm-dd-yyyy Parent/Guardian: _________________________ Date: mm-dd-yyyy Submit Health History Fields marked with (*) are required for PIR report Page 6 of 6 PARENT AGREEMENT FORM CHILD’S NAME: __________________________________ DATE ________________ SCHOOL NAME: _________________________________ ROOM _______________ I wish to have my child take part in the Chicago: Ready to Learn! program. I take full responsibility for his/her safe transportation to and from school. I understand the importance of daily attendance and agree to bring my child to school everyday he/she is well enough to fully participate in the program, including daily outdoor play. Additionally, I will adhere to the school schedule so that my child is dropped off and picked up on time. I understand that I am expected to serve as a parent volunteer. I am willing to attend meetings, workshops or conferences at the school as may be requested. I give my permission for my child to be taken on trips related to the preschool program, including walking trips within the community. Home Visit Preference I understand that the relationship between home and school is vital to a child’s future success, and recognize that two home visits a year are an integral part of the preschool program. I prefer to have my child’s preschool staff conduct a home visit in the following setting: _____ My home _____ Other place of my choice: _____________________________________ __________________________________________ SIGNATURE OF PARENT/GUARDIAN FORMULARIO DE CONSENTIMIENTO DE PADRES NOMBRE DEL NIÑO:_________________________________ FECHA____________ NOMBRE DE LA ESCUELA:____________________________ SALÓN ___________ Yo deseo que mi niño participe en el programa Chicago: Ready to Learn! Asumo total responsabilidad por su transporte hacia y desde la escuela. Entiendo la importancia de la concurrencia diaria y estoy de acuerdo en llevar a mi niño a la escuela todos los días en que se encuentre en condiciones de participar enteramente del programa, incluyendo en los juegos al aire libre. Además, cumpliré con el programa escolar para que mi niño sea dejado y recogido puntualmente. Entiendo que se espera de mí que sirva como padre voluntario. Estoy dispuesto a asistir a reuniones, talleres o conferencias en la escuela, según sea requerido. Doy mi autorización para que mi niño participe en las salidas relacionadas con el programa preescolar, incluyendo caminatas en la comunidad. Preferencia de visita al domicilio Entiendo que la relación entre el hogar y la escuela es vital para el éxito futuro del niño, y reconozco que dos visitas anuales al domicilio son una parte integral del programa preescolar. Prefiero que el personal del programa realice la visita domiciliar de la siguiente manera: _____ En mi casa _____ En otro lugar de mi preferencia: _________________________________ __________________________________________ FIRMA DEL PADRE/TUTOR Family Partnership Assessment and Goals Please check, sign and date one category below: ( ) Yes, I am interested in developing family goals as part of the Family Partnership Agreement. I may need information or assistance with: (please check all that apply) _____ Basic Life Skills _____ Housing _____ Child Development _____ Literacy _____ Domestic Violence _____ Child Care _____ Legal Assistance _____ Mental Health _____ Education _____ Employment _____ Health/Nutrition _____ Substance Abuse _____ Parent Involvement _____ Other: _____________________________________________________________ My personal goal for this year is: (Example: GED; job training; employment) Steps needed to reach this goal are: _______________________________________________________ I may need assistance to reach this goal: _______Yes ______No If yes, please explain: ________________________________________________________________________ ( ) No, I am not interested in developing family goals, at this time. I understand that I may choose to develop family goals at anytime during my child’s enrollment. The process of developing family goals as part of the Family Partnership Agreement has been explained to me. ___________________________________ Parent Signature __________________________ Date ___________________________________ Staff Signature ___________________________ Date ___________________________________ School ___________________________ Classroom Room Colaboración Familiar Evaluación y Metas Por favor, marque, firme y póngale fecha a una de las categorías que figuran más abajo. ( ) Sí, estoy interesado en desarrollar metas familiares como parte del Acuerdo de Colaboración Familiar. Necesito información o asistencia con: (por favor marque los que necesita) _____ Nociones Básicas de supervivencia _____ Asistencia legal _____ Educación _____Vivienda _____ Desarrollo infantil _____ Violencia Doméstica _____ Cuidado de niños _____ Alfabetización _____ Trabajo _____ Salud Mental _____ Salud/Nutrición _____ Abuso de Sustancias _____ Participación de los padres _____ Otro: _______________________ Mi meta personal para este año es: (Ejemplo: GED; capacitación laboral; trabajo) Los pasos necesarios para alcanzar la meta son: _______________________________________________________ Necesito ayuda para alcanzar esta meta: _______Sí ______No Si la necesita por favor explique: ________________________________________________________________________ ( ) No, no estoy interesado en desarrollar metas familiares en este momento. Entiendo que puedo hacerlo en cualquier momento durante el período de estudio de mi hijo/a. El proceso de desarrollo de metas familiares como parte del Acuerdo de Colaboración Familiar, me ha sido explicado. ___________________________________ Firma del padre __________________________ Fecha ___________________________________ Staff Signature ___________________________ Date ___________________________________ School ___________________________ Classroom Room CHILD HEALTH REQUIREMENTS Chicago: Ready to Learn! School-based Preschool Programs All physical exams must be signed and dated by a physician or advanced nurse practitioner, and should include the clinic stamp. The exam must contain the following screenings: Chicago: Ready to Learn! Programas de Educación Temprana localizadas en las escuelas públicas Todos los exámenes físicos deben ser firmados por el doctor ό la enfermera capacitada y debe de incluir el sello de la clínica. El examen debe contener los siguientes análisis: • Prueba anual de Hemoglobina/Hematocrito incluyendo resultados numéricos. • Prueba de Plomo anual incluyendo resultados numéricos. • Presión arterial, Estatura/Pesó y el Cálculo del Índice De Masa Corporal anual. • Evaluación de Diabetes anual, hecho por el doctor durante el examen físico. • Un examen anual de la Vista/audición es requerido y se hará por las Escuelas Públicas de Chicago (CPS) y el Departamento de Familia y Servicios de Apoyó (DFSS) durante el año. Sin embargo su doctor familiar puede administrar estos exámenes. • Annual Hemoglobin/Hematocrit screening with numerical results. • Annual Lead screening with numerical results. • Annual Blood pressure. • Annual Height/Weight and BMI. • Annual Diabetes screening (done by the physician at the time of the physical exam). • Annual Hearing/Vision screenings are also required, and will be done by CPS and Chicago Dept. of Family Support Services (DFSS) hearing/vision screeners during the year. However, parents may have their child screened at their pediatrician’s office. Annual TB risk assessment for new and Returning Students Students are screened using the Pediatric Risk Assessment Questionnaire Developer by the American Academy of Pediatrics and based on the CDC guidelines. The questionnaire should be done by your health care provider at the time of your child’s annual exam. Results from the questionnaire should be documented on the Physical Exam form. Further testing will be required if one or more risk factors are present. All students must show written evidence of up-to-date immunizations. 1. 2. 3. 4. 5. 6. 7. DtaP=Diptheria, Tetanus and Pertussis IPV=Inactivated Polio MMR=Measles, Mumps, and Rubella HIB=Haemophillus Influenzae type B HBV=Hepatitis B PCV=Pneumococcal congugate Vaccine Varicella=Chickenpox Parent Volunteers: Parents who volunteer must submit evidence of being free of Tuberculosis. TB (Tuberculosis) skin test screenings are good for 2 years. Cuestionario anual de Tuberculosis para todo estudiante que sea nuevo ό regrese. Los estudiantes son evaluados con el cuestionario pediátrico de riesgo por La Academia Americana de Pediatría y basado en la guía del Centro de Control de Enfermedades. El cuestionario debe ser llenado por el doctor durante el examen físico anual. Los resultados deben ser anotados en el formulario. Si hay más de un factor de riesgo presente un examen adicional posteriormente será requerido. Todos los estudiantes de Head Start deben de mostrar por escrito evidencia que las vacunas estén al día. 1. 2. 3. 4. 5. 6. 7. DTaP= Difteria, Tétano y Tos Ferina IPV = Polio MMR=Sarampión Paperas y Rubéola Hib = Haemophilius Influenza tipo B HepB = Hepatitis B PCV= Neumocócica conjugada VAR= Varicela Padres Voluntarios Padres que son voluntarios deben presentar prueba de no tener Tuberculosis. El examen es válido por 2 años. Revised DE/AP 5/13 FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013 State of Illinois Certificate of Child Health Examination Student’s Name Birth Date Last First Address Middle Street City Sex Race/Ethnicity School /Grade Level/ID# Month/Day/Year Parent/Guardian Zip Code Telephone # Home Work IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. 1 MO DA YR 2 MO DA YR 3 MO DA YR 4 MO DA YR 5 MO DA YR TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV Vaccine / Dose 6 MO DA YR DTP or DTaP Tdap; Td or Pediatric DT (Check specific type) Polio (Check specific type) Hib Haemophilus influenza type b Hepatitis B (HB) COMMENTS: Varicella (Chickenpox) MMR Combined Measles Mumps. Rubella Measles Single Antigen Vaccines Rubella Mumps Pneumococcal Conjugate Other/Specify Meningococcal, Hepatitis A, HPV, Influenza Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature ALTERNATIVE PROOF OF IMMUNITY Title Date 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR Physician’s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature 3. Laboratory confirmation (check one) Measles Lab Results Date Title Mumps MO DA Rubella Date Hepatitis B Varicella (Attach copy of lab result) YR VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN Date Code: Age/ Grade R L R L R L R L R L R L Vision Hearing IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) R L R L R L P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts Printed by Authority of the State of Illinois Sex Birth Date Last First HEALTH HISTORY ALLERGIES Middle School Grade Level/ ID # Month/Day/ Year TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER MEDICATION (List all prescribed or taken on a regular basis.) (Food, drug, insect, other) Diagnosis of asthma? Child wakes during night coughing? Yes Yes No No Loss of function of one of paired organs? (eye/ear/kidney/testicle) Yes No Birth defects? Yes No No Yes No Hospitalizations? When? What for? Yes Developmental delay? Blood disorders? Hemophilia, Sickle Cell, Other? Explain. Diabetes? Yes No Yes No Yes No Surgery? (List all.) When? What for? Serious injury or illness? Yes No Head injury/Concussion/Passed out? Yes No TB skin test positive (past/present)? Yes* Seizures? What are they like? Yes No TB disease (past or present)? Yes* No *If yes, refer to local health department. No Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No Yes No Family history of sudden death before age 50? (Cause?) Yes No Dizziness or chest pain with exercise? Eye/Vision problems? _____ Glasses Contacts Last exam by eye doctor ______ Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Ear/Hearing problems? Yes No Bone/Joint problem/injury/scoliosis? Yes Bridge Plate Other Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian No PHYSICAL EXAMINATION REQUIREMENTS Braces Dental Signature Date Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered ? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born No test needed Test performed in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. Skin Test: Date Read / / Result: Positive Negative mm ______________ Blood Test: Date Reported / / Result: Positive Negative Value ______________ Date LAB TESTS (Recommended) Results Date Hemoglobin or Hematocrit Urinalysis Sickle Cell (when indicated) Developmental Screening Tool SYSTEM REVIEW Skin Ears Endocrine Gastrointestinal Normal Comments/Follow-up/Needs Eyes Results Normal Comments/Follow-up/Needs Amblyopia Yes LMP Genito-Urinary No Nose Neurological Throat Musculoskeletal Mouth/Dental Spinal Exam Cardiovascular/HTN Nutritional status Diagnosis of Asthma Respiratory Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid) NEEDS/MODIFICATIONS required in the school setting Other DIETARY Needs/Restrictions SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student’s health with school or school health personnel, check title: Nurse Teacher Counselor Principal EMERGENCY ACTION needed while at school due to child’s health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child’s participation in PHYSICAL EDUCATION Print Name Address Yes No Modified (If No or Modified please attach explanation.) INTERSCHOLASTIC SPORTS (MD,DO, APN, PA) Signature Phone (Complete Both Sides) Yes No Date Limited ESTADO DE ILLINOIS DEPARTAMENTO DE SERVICIOS HUMANOS CERTIFICADO DE EXAMEN DE SALUD DEL NIÑO(A) Por favor escriba en letra de molde Fecha de Nacimiento Nombre del Estudiante Apellido Nombre Dirección Calle Inicial Ciudad Sexo Escuela Grado / Núm. de Identificación Mes/Día/ Año Padres / Tutor Zona Postal Núm. de Teléfono de Casa Trabajo VACUNAS : Para ser completado por el proveedor de cuidado d salud. Indique el mes/día/año para cada dosis administrada. El día y el mes se requiere si usted no puede determinar si la vacuna se administró después del intervalo mínimo o edad. Si una vacuna específica está médicamente contraindicada, una declaración aparte por escrito se debe adjuntar explicando la razón médica por esta contraindicación. 1 MES DÍA VACUNAS / DOSIS 2 MES DÍA AÑO AÑO 3 MES DÍA AÑO 4 MES DÍA AÑO 5 MES DÍA 6 MES DÍA AÑO AÑO Difteria, Tétano y Pertusis (DTP o DTaP) Difteria y Tétano (DT o Td Pediátrica) Polio Inactivo (IPV) Polio Oral (OPV) Haemófilo influenza tipo b (Hib) Hepatitis B (HB) Comentarios: Varicela (Chickenpox) Combinado Sarampión, Paperas y Rubéola (MMR) Sarampión (Rubéola) Rubéola (sarampión de 3-días) Paperas Neumocócico (no se requiere para ingresar a la ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 ¨PCV7 ¨PPV23 escuela Marque tipo específico (PCV7, PPV23) Fecha Otro (Especifique: Hepatitis A, meningococcal), Proveedor de Cuidado de Salud (MD, APN, PA, profesional de salud escolar, oficial de salud) que verifica el historial de vacunas arriba tiene que firmar a continuación. Firma Título Fecha Firma Título (Si agrega fechas en la sección del historial de vacunas, escriba sus iniciales al lado de la fecha y firme aquí.) Firma Título (Si agrega fechas en la sección del historial de vacunas, escriba sus iniciales al lado de la fecha y firme aquí.) COMPROBANTE ALTERNATIVO DE INMUNIDAD 1. El diagnóstico clínico se acepta si es verificado por un médico comprobar por medio de evidencia de laboratorio.) Fecha Fecha * (Todos los casos de sarampión diagnosticados en o después del 1ero de julio de 2002, se deben * SARAMPIÓN (Rubéola) MES DÍA AÑO PAPERAS MES DÍA AÑO VARICELA MES DÍA AÑO Firma del Médico 2. El historial de la enfermedad de varicela (chickenpox) se acepta si se comprueba por un proveedor de cuidado de salud, profesional de salud escolar u oficial de salud. La persona que firma a continuación verifica que la descripción del padre / tutor del historial de enfermedad de la varicela indica una infección pasada y acepta tal historial como documentación de la enfermedad. Fecha de la Enfermedad: 3. Confirmación del laboratorio (marque uno ) Firma ¨ Sarampión Resultados de Laboratorio ¨ Paperas Fecha MES Titulo ¨ Hepatitis B ¨ Rubéola DÍA AÑO Fecha ¨ Varicela (Adjunte copia del reporte de laboratorio, si está disponible.) DATOS SOBRE LA EVALUACIÓN DE VISIÓN Y AUDICIÓN Pre -escolar- anualmente comenzando a la edad de 3, Edad escolar – en el grado requerido durante el año escolar. Fecha Edad/Año D I D I D I D I D I D I D I Visión Audición Imprimió con la Autoridad del Estado de Illinois (Complete Ambos Lados) IL444-4737S (R-01- 05) D I D I D I Código: P = Pasó F = Falló U = No se pudo examinar R = Referido G/C=Lentes/ Lentes de Contacto Fecha de Nacimiento Nombre del Estudiante Apellido HISTORIAL Nombre Inicial Sexo Grado / Núm. De Ident. Escuela Mes / Día / Año PARA SER COMPLETADO Y FIRMADO POR EL PADRE / TUTOR Y VERIFICADO POR EL PROVEEDOR DE CUIDADO DE SALUD DE SALUD ALERG IAS (Alimentos, drogas, insectos, otro) MEDICINAS (Anote todas las recetadas o tomadas con regularidad.) ¿Diagnosis de Asma? ¿Niño(a) despierta tosiendo en la noche? Sí Sí No No ¿Defectos de Nacimiento? Sí No ¿Retrasos del Desarrollo? Sí No Sí No Sí No ¿Problemas De La Sangre? Hemofilia, Glóbulos Falciformes, Otro Explique ¿Diabetes? ¿Herida de la Cabeza / golpe / desmayo? Sí No ¿Convulsiones? ¿Cómo Se Manifiestan? Sí No ¿Problemas Cardiacos / Falta de Respiración? Sí No ¿Soplo Cardiaco / Presión Arterial Alta? Sí No Indique Severidad ¿Pérdida de las Funciones de uno de los pares de Órganos? (Ojos /Oídos / Riñones / Sí Testículos) ¿Hospitalizaciones? ¿Cuándo? ¿Para Qué? Sí ¿Cirugía? (Anótelas Todas) ¿Cuándo? ¿Para Qué? ¿Heridas Graves o Enfermedad? ¿Prueba positiva de la piel para el TB (Pasado o Presente)? ¿Enfermedad de TB (P asado o Presente)? ¿Problemas de Audición? Sí Sí No Sí No Sí * ¿Uso de Alcohol / Drogas? ¿Historial Familiar de Muerte Repentina antes de los 50 años? (¿Causa?) No No Sí Sí No No Sí No *Si contestó sí, referencia al departamento de salud local Dental 9 Ganchos 9 Puente 9 Placas Otro ¿Otras Preocupaciones? La información en este formulario se puede compartir con el personal apropiado para propósitos de salud y educación. Firma del Padre / Tutor Fecha No ¿Problemas de los huesos / Articulaciones / Heridas / Escoliosis? LA SECCIÓN TOTAL QUE SIGUE DEBE SER COMPLETADA POR MD/DO/APN/PA (* INDICA EXAMINACIÓN ORDENADA POR REQUSITOS DE EXAMEN FÍSICO No Sí * ¿Uso de Tabaco (Tipo, Frecuencia)? ¿Mareos O Dolor De Pecho Al Hacer Sí No Ejercicio? ¿Problemas con los Ojos / Visión? Lentes 9 Lentes de Contacto 9 Último Examen ________ ¿Otras Preocupaciones? (bizco, párpados caídos, entrrecerrar los ojos, dificultad cuando lee) No ALTURA PESO INSTITUCIONES DE CUIDADO DE NIÑOS CON LICENCIA DEL ESTA DO) BMI B/P EVALUACIÓN DE DIABETES BMI>85% edad / sexo Sí¨ No¨ Y uno de los dos siguientes: Historial Familiar Sí ¨ No ¨ Minoria étnica Sí¨ No ¨ Muestras de Resistencia a la Insulina (hipertensión, dislipidemia, síndrome de ovario policístico, acantosis nigricans) Sí¨ No ¨ Está en Riesgo Sí ¨ No ¨ CUESTIONARIO DEL PLOMO* se requiere para niños de 6 meses a 6 años registrados en una escuela con licencia o escuela pública, centro de cuidado de niños, preescolar, guardería infantil y / o kindergarten. ¿Se Indicó Examen de Sangre? Sí ¨ No ¨ Fecha del Examen de Sangre Resultado de Examen de Sangre (Si el niño(a) reside en Chicago, se requiere examen de la sangre.) Examen de la piel para el TB Se recomienda sólo para niños en grupos de alto riesgo, incluye a niños que tienen sistema inmune supreso debido a infección del VIH (HIV) u otras condiciones, inmigrantes recién llegados de países de alta prevalencia, o aquellos adult os expuestos en categorías de alto riesgo. Vea las guías del CDC. Fecha que se leyó / / Resultado mm PRUEBAS DE LAB. *INDICA EXÁMENES ORDENADOS POR LAS INSTITUCIONES DE CUIDADO DE NIÑOS DEL ESTADO Fecha Resultados Fecha Glóbulos Falciformes (Sickle Cell) * (como se requiera) Hemoglobina * o Hematocrito* Análisis de Orina SISTEMA DE REVISIÓN Resultados Otro Normal Normal Comentarios / Seguimiento / Necesidades Piel Endocrino Oídos Gastrointestinal Sí ¨ No¨ Ambliopía Sí ¨ No¨ Ojos Normal Evaluación objectiva Sí ¨ No¨ Resultado______________ Referencia al Oftalmólogo/Optometrista Sí ¨ No¨ Naríz Génito-Urinario Comentarios / Seguimiento / Necesidades LMP Necrológico Músculo esqueleto Examinación de espina dorsal Garganta Boca / Dental Estado de Nutrición Cardiovascular/HTN Salud Mental Respiración NECESIDADES/MODIFICACIONES requeridas en el ámbito escolar INSTRUCCIONES ESPECIALES / DISPOSITIVOS DIETA Necesidades / Restricciones ejem. lentes de protección, ojo de vidrio, protector de pecho para la arritmia, marcapasos, aparato de prótesis, puentes dentales, dentaduras, sostén / copa para deportes SALUD MENTAL / OTRO: ¿Piensa usted que hay algo más que la escuela debe saber sobre el estudiante? Si a usted le gustaría hablar de la salud de este estudiante con la escuela o personal de salud escolar, marque el título: ¨ Enfermera ¨ Maestro ¨ Consejero ¨ Principal ACCIÓN DE EMERGENCIA se necesita mientras está en la escuela debido a la condición de salud del niño(a) (ejem., convulsiones, asma, picadura de insectos, alergias de alimentos, alergia al cacahuate (maní), problemas de sangrado, diabetes, problemas del corazón)? Sí ¨ No ¨ Si contestó sí, por favor descríbalo. Basado en el examen de este día, yo apruebo que este niño(a) participe en: (Si la respuesta es No o es Modificada, po r favor adjunte explicación) EDUCACIÓN FÍSICA Sí ? No ? Modificada ? DEPORTES ENTRE ESCUELAS (por un año) Sí ¨ No ¨ Limitado ¨ Médico / Enfermera de Práctica Avanzada / Asistente de Médico que hace el examen Nombre (letra de molde) Dirección Firma Fecha Teléfono (Complete ambos lados) Yes Illinois Department of Public Health PROOF OF SCHOOL DENTAL EXAMINATION FORM To be completed by the parent (please print): Student’s Name: Address: Last Street First Middle City Birth Date: ZIP Code Name of School: Grade Level: Parent or Guardian: Address (of parent/guardian): / Telephone: Gender: £ Male (Month/Day/Year) / £ Female To be completed by dentist: Oral Health Status (check all that apply) £ Yes £ No Dental Sealants Present £ Yes £ No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1st molars. £ Yes £ No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present. £ Yes £ No Soft Tissue Pathology £ Yes £ No Malocclusion Treatment Needs (check all that apply) £ Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling £ Restorative Care — amalgams, composites, crowns, etc. £ Preventive Care — sealants, fluoride treatment, prophylaxis £ Other — periodontal, orthodontic Please note____________________________________________________________________________________ Signature of Dentist _________________________________________ Date ____________________________ Address ___________________________________________________ Telephone _______________________ Street City ZIP Code Illinois Department of Public Health, Division of Oral Health, 535 W. Jefferson St., Springfield, IL 62761 217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us Printed by Authority of the State of Illinois P.O.#346085 5M 10/05 Departamento de Salud Pública de Illinois FORMULARIO COMPROBANTE DEL EXAMEN DENTAL ESCOLAR Para ser completado por el padre/madre (por favor impresión): Nombre del Estudiante: Dirección: Apellido Nombre Calle Inicial Ciudad Código Postal Fecha de Nacimiento: / / (Mes/Día/Año) Número de Teléfono: Nombre de la Escuela: Grado: Sexo: Nombre del padre/madre o encargado: Dirección del padre/madre o encargado: £ Masculino £ Femenino To be completed by dentist: (Para ser completado por el dentista:) Oral Health Status (check all that apply) £ Yes £ No Dental Sealants Present £ Yes £ No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1st molars. £ Yes £ No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present. £ Yes £ No Soft Tissue Pathology £ Yes £ No Malocclusion Treatment Needs (check all that apply) £ Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling £ Restorative Care — amalgams, composites, crowns, etc. £ Preventive Care — sealants, fluoride treatment, prophylaxis £ Other — periodontal, orthodontic Please note____________________________________________________________________________________ Signature of Dentist _________________________________________ Date ____________________________ Address ___________________________________________________ Telephone _______________________ Street City ZIP Code Departamento de Salud Pública de Illinois, División de la Salud Oral 217-785-4899 • TTY (sólo para personas con impedimento auditivo) 800-547-0466 • www.idph.state.il.us Impreso con Autoridad del Estado de Illinois Help Your Child Succeed in School: Build the Habit of Good Attendance in Preschool Did You Know? Missing 20% (18 days) of school can make it harder to learn to read Missing 1-2 days every few weeks can cause your child to fall behind Being late to school may lead to poor attendance Good Attendance Promotes Children To: Have a positive attitude about school Feel good about themselves and their routine Do well in high school, college, and at work What You Can Do: Set a regular bed time and morning routine Find out what day and time your child's school starts Develop back-up plans for getting to school if something comes up When Do Absences Become a Problem? CHRONIC ABSENCE 18 or more days WARNING SIGNS 10 to 17 days GOOD ATTENDANCE 9 or fewer absences Ayude su Niño Ser Exitoso en la Escuela: Construya el Hábito de Buena Asistencia en el Preescolar ¿Sabía Usted? Faltando 20% (18 días) de la escuela se le puede hacer más dificil a los niños aprender a leer Faltando 1 a 2 días a la semana puede causarle atrazo en los estudios Llegando tarde a la escuela puede resultar en baja asistencia Buena Asistencia Promueve Niños a: Tener una actitud positiva hacia la escuela Sentirse bueno de si mismo y sus rutinas Ser exitoso en la escuela superior, colegio y en el trabajo Lo Que Usted Puede Hacer: Establecer un horario regular de dormir y rutina de la mañana ¿Cuándo es que las ausencias se convierten en un problema? AUSENCIA CRÓNICA 18 o más días Sepa que día y hora empieza la escuela de su hijo SEÑALES DE ADVERTENCIA 10 a 17 días Crear un plan alternativo para llegar a la escuela si ocurre algo BUENA ASISTENCIA 9 o menos ausencias RIGHTS OF HOMELESS STUDENTS The Chicago Public Schools shall provide an educational environment that treats all students with dignity and respect. Every CPS homeless student shall have equal access to the same free and appropriate educational opportunities as students who are not homeless. This commitment to the educational rights of homeless children, youth, and youth not living with a parent or guardian, applies to all services, programs, and activities provided or made available by the CPS. A student is considered “homeless” if he or she is presently living: * in a shelter * sharing housing with relatives or others due to lack of housing * in a motel/hotel, camping ground, or similar situation due to lack of alternative, adequate housing * at a train or bus station, park, or in a car * in an abandoned building * temporarily housed while awaiting DCFS foster care placement All Homeless Students Have Rights To: • Immediate school enrollment. A school must immediately enroll students even if they lack health, immunization or school records, proof of guardianship, or proof of residency. • Enroll in: *the school he/she attended when permanently housed (school of origin) *the school in which he/she was last enrolled (school of origin) *any school that non-homeless students living in the same attendance area in which the homeless child or youth is actually living are eligible to attend. • Remain enrolled in his/her selected school for as long as he/she remains homeless or, if the student becomes permanently housed, until the end of the academic year. Academic success is helped when the student remains in the same school. • Priority in certain preschool programs. Parents or guardians are encouraged to seek enrollment in these programs. • Participate in a tutorial-instructional support program, school-related activities, and/or receive other support services. • Obtain information regarding how to get fee waivers, free uniforms, and low-cost or free medical referrals. • Transportation services: A homeless student attending his/her school of origin has a right to transportation to go to and from the school of origin as long as (s)he is homeless or, if the student becomes permanently housed, until the end of the academic year. CPS staff shall inform homeless parents/guardians or youth of transportation services to and from school and school-related activities. Types of transportation services: * For homeless students: - CTA transit cards, transfer fares, and if a student is age 12 years or older a CTA riding permit * For parents of homeless students: - CTA transit cards for a parent/guardian of homeless Pre-K to Grade 6 students to accompany them to/from school * For preschool through 6th grade, alternative transportation such as busing in parental “hardship” situations where documentation is provided. Examples of “hardship” situations are: - parent employment, job training, or educational program - mental and/or physical disability - children need to be transported to/from schools at different locations - rules of shelter or similar facility will not permit parent/guardian to leave to transport children to/from school - court order, DCFS, or DCFS contract agent requires activities that do not enable parent/guardian to transport children to/from school - other good cause why parent/guardian cannot use public transportation to transport children to/from school Dispute Resolution: If you disagree with school officials about enrollment, transportation or fair treatment of a homeless child or youth, you may file a complaint with the principal. The principal must respond and attempt to resolve it quickly. The principal must refer you to free and low cost legal services to help you, if you wish. During the dispute, the student must be immediately enrolled in the school and provided transportation until the matter in resolved. The Homeless Education Dispute Resolution Process Form is available at all Chicago Public Schools and offices, including the Department of Educational Support for Students in Temporary Living Situations (773) 553-2242. Every Chicago Public School has a Students in Temporary Living Situations (STLS) Liaison who will assist you in making enrollment and placement decisions, providing notice of any appeal process, and filling out dispute forms. If you have questions about enrollment in school, or want more information about the rights of homeless students in the Chicago Public Schools, call the CPS Department of Educational Support for Students in Temporary Living Situations at (773) 553-2242 or the Chicago Public Schools at (773) 553-1000. If you want more information about the rights of homeless students in Illinois, call the Illinois State Board of Education at (1-800) 215-6379. DERECHOS DE LOS ESTUDIANTES SIN HOGAR Las Escuelas Públicas de Chicago prov eerán un amb ien te educativo qu e tr ate a todos los estud ian te s con d ign id ad y r e spe to . Cada alumno sin hogar de CPS tendrá acceso igualitario a las mismas oportunidades educativas gratuitas y apropiadas que los demás. Este compromiso con los derechos educativos de los niños y jóvenes sin hogar, y jóvenes que no viven con un padre o tutor, se aplica a todos los servicios, programas y actividades ofrecidas o hechas disponibles por CPS. Un estudiante es considerado “sin hogar” s i e n l a a c t u a l i d a d v i v e : * en un refugio * comparte alojamiento con familiares u otros debido a la falta de un techo fijo * en un motel/hotel, campamento o situación similar, debido a la falta de alojamiento alternativo, adecuado * en una estación de trenes o de autobuses, parque o automóvil * en un edificio abandonado * alojado temporalmente mientras aguarda ubicación por DCFS (Servicios a Niños y Familias) en un hogar temporario Todos los estudiantes sin hogar tienen derecho a: • Matriculación inmediata en una escuela. La escuela deben inscribirlos inmediatamente aun cuando carezcan de registros de salud o de vacunas, prueba de tutela o de domicilio. • Matricularse en: *la escuela a la que asistían cuando tenían vivienda permanente (escuela de origen) *la última escuela en la que estuvieron inscriptos (escuela de origen) *cualquier escuela en la que sean elegibles los niños o jóvenes de la misma área de asistencia. • Permanecer inscripto en la escuela elegida durante el tiempo que permanezca sin hogar, o si el estudiante consigue vivienda permanente, hasta el fin del año académico. El éxito académico es ayudado cuando el estudiante permanece en la misma escuela. • Prioridad en ciertos programas preescolares. Se alienta a padres y tutores a buscar inscripción en esos programas. • Participar en programas de tutorías-apoyo de instrucción, actividades escolares relacionadas y/o a recibir otros servicios de apoyo. • Obtener información relacionada a dispensas y uniformes gratuitos, además de servicios médicos de bajo costo o gratuitos. • Servicios de transporte: Un estudiante sin hogar que asista a su escuela de origen tiene el derecho a recibir transporte hacia y desde la escuela de origen durante el tiempo en que permanezca en esa situación, o, si el estudiante consigue alojamiento permanente, hasta el fin del año académico. Personal de CPS debe informar a los padres/tutores de los estudiantes sin alojamiento sobre los servicios de transporte hacia y desde la escuela, y para las actividades escolares relacionadas. Tipos de servicios de transporte: * Para los estudiantes sin hogar: - Tarjetas de tránsito de CTA, transferencias, y si el estudiante tiene 12 años o más, el permiso para viajar en CTA * Para los padres de estudiantes sin hogar: - Tarjetas de tránsito de CTA para que los padres/tutores de estudiantes sin hogar acompañen hacia y desde la escuela a niños desde preescolares al 6º. Grado * Para preescolares al 6o. grado, transporte alternativo como autobuses en los casos de padres en “dificultades” documentadas. Ejemplos de situaciones difíciles son: - empleo de los padres, capacitación laboral o programa educativo - discapacidad mental y/o física - niños que necesiten ser transportados desde y hacia la escuela en lugares diferentes - reglas del refugio o instalación similar que no permitan salir al padre/tutor para transportar al niño hacia o desde la escuela - orden de la corte, de DCFS o contrato de un agente del DCFS que requiera actividades que no permitan al padre/tutor transportar al niño hacia y desde la escuela - otra causa válida por la cual el padre/tutor no pueda usar el transporte público para llevar y traer al niño de la escuela Solución de disputas: Si usted no está de acuerdo con las autoridades escolares sobre la matrícula, transporte o tratamiento justo de un niño o joven sin domicilio, puede presentar una queja al director. Este debe responder e intentar resolverlo rápidamente. El director debe referirlo a servicios legales gratuitos o de bajo costo para que lo ayuden, si así lo desea. Durante la disputa, el estudiante debe ser matriculado inmediatamente en la escuela y recibir transporte hasta que el tema sea resuelto. El Formulario del Proceso para Resolver Disputas está disponible en todas las escuelas públicas de Chicago y oficinas, incluyendo el Departamento de Apoyos Educativos para Estudiantes en Situaciones Temporales de Vivienda (773) 553-2242. Cada escuela pública de Chicago tiene un enlace para los Estudiantes en Situaciones Temporales de Vivienda (STLS) que lo ayudará con las decisiones de matrícula y ubicación, le informará sobre el proceso de apelación y con el llenado de los formularios de disputa. Si tiene alguna pregunta sobre la matrícula escolar, o quiere saber más sobre los derechos de los estudiantes sin hogar en las Escuelas Públicas de Chicago, llame al Departamento de Apoyos Educativos para Estudiantes en Situaciones Temporales de Vivienda al (773) 553-2242, o al número de las oficinas centrales (773)553-1000. Si necesita más información sobre los derechos de los estudiantes sin hogar en Illinois, llame a la Junta de Educación de Illinois por el (1-800) 215-6379.