Spanish - PICA Head Start
Transcripción
Spanish - PICA Head Start
PARENTS IN COMMUNITY ACTION, INC. HEAD START Y HEAD START TEMPRANO S P A N I S H Inscriba a sus niños de 0 a 5 años de edad www.picaheadstart.org Línea de Información de PICA 612-377-4444 • LÍMITES FEDERALES DE INGRESOS 2016 Personas en la Familia Ingresos Máximos 1 $11,880 2 $16,020 3 $20,160 4 $24,300 5 $28,440 6 $32,580 7 $36,730 8 $40,890 Sume $4,160 por cada persona adicional. Cómo inscribir a su niño 1 F AVOR DE PRESENTAR PERSONALMENTE SU SOLICITUD EN CUALQUIERA DE ESTOS CENTROS EDUCATIVOS Se aceptan solicitudes de las 9:00 a.m. a las 5:00 p.m. Usted puede llamar para hacer una cita si no puede venir durante este horario. CIUDADES AL OESTE Helen H. Taylor Center 4901 Olson Memorial Highway Golden Valley, MN 55422 Teléfono: (763) 541-7422 CIUDADES AL SUR South Branch Center 7145 Harriet Avenue Richfield, MN 55423 Phone: (612) 871-7422 Pond Center 9600 Third Avenue South Bloomington, MN 55420 Teléfono: (612) 871-7422 EL NORTE DE MINNEAPOLIS Donald M. Fraser Center 700 Humboldt Avenue North Minneapolis, MN 55411 Teléfono: (612) 377-7422 EL NORESTE DE MINNEAPOLIS Northeast Center 342 Thirteenth Avenue N.E. Minneapolis, MN 55413 Teléfono: (612) 379-7422 CIUDADES AL NOROESTE Town Hall Center 8500 Zane Avenue North Brooklyn Park, MN 55443 Teléfono: (763) 425-7422 Aubrey Della Center 6415 Brooklyn Boulevard Brooklyn Center, MN 55429 Teléfono: (763) 535-7422 EL SURESTE DE MINNEAPOLIS Glendale Center 96 St. Mary’s Avenue S.E. Minneapolis, MN 55414 Teléfono: (612) 874-7422 EL SUR DE MINNEAPOLIS McKnight Center 4225 Third Avenue South Minneapolis, MN 55409 Teléfono: (612) 825-7422 Park Place Center 2745 Park Avenue South Minneapolis, MN 55407 Teléfono: (612) 870-7422 Portland Village Center 1829 Portland Avenue South Minneapolis, MN 55404 Teléfono: (612) 871-7422 PICA Training Center 4255 Third Avenue South Minneapolis, MN 55409 Teléfono: (612) 822-7422 REQUISITOS DE SALUD PARA HEAD START Pídele a mi doctor que me haga un Examen para Niños y Adolescentes (Child & Teen Checkup) 2 Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 (612) 377-7422 Child’s Last Name CHILD PHYSICAL First Name Parent/Guardian Name Middle Initial Address Child’s Medical Insurance Name Birth Date Telephone # Child’s Medical Insurance Number MN Health Care ID Early and Periodic Screening Diagnosis and Treatment (EPSDT) exam required. Starred items (*) are required by Federal Head Start regulations and recommended by the American Academy of Pediatrics for children 3-5 years old. Enter date if date of test is other than “exam date” recorded below. TEST A. PRESENT AGE* B. HEIGHT (CM)* DATE RESULTS TEST G. VISION (Type of Test)* ACUITY, R/L CORNEAL REFLEX COVER TEST COMMENTS H. OTHER TESTS (Complete C. WEIGHT (KG)* BMI D. BLOOD PRESSURE E. F. Pass Pass q q 2000Hz Fail Fail q q Pass Pass q q 4000Hz Fail Fail q q Pass Pass q q Fail Fail COMMENTS PHYSICAL EXAMINATION/ ASSESSMENT A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. GENERAL APPEARANCE POSTURE, GAIT SPEECH HEAD SKIN EYES: (1) External Aspects (2) Optic Fundoscopy EARS: (1) External & Canals (2) Tympanic Membranes NOSE, MOUTH, PHARYNX DENTAL (1) Examine Teeth (2) Examine Gums (3) Referral to Dentist? HEART LUNGS ABDOMEN (Include hernia) GENITALIA BONES, JOINTS, MUSCLES NEUROLOGICAL/SOCIAL (1) (2) (3) (4) (5) (6) P. Q. Gross Motor Fine Motor Communication Skills Cognitive Self-Help Skills Social Skills GLANDS (Lymphatic/Thyroid) DEVELOPMENTAL ASSESSMENT Normal For Age Not Evaluated Abnormal TB Sickle Cell Lead* (4) Ova & Parasites (5) Urinalysis (6) Other (1) (2) (3) Pure Tone at 20dB 1000Hz q LEFT EAR q RESULTS or send past results) HEMATOCRIT or HEMOGLOBIN* Result HEARING (Type of Test)* RIGHT EAR DATE q q q q q NA NA NA NA NA q q q q q AB AB AB AB AB q q q q q NE NE NE NE NE q q q q q q q q q q q q q q q q q q q q q q NA NA NA NA NA NA NA Yes NA NA NA NA NA NA NA NA NA NA NA NA NA NA q q q q q q q q q q q q q q q q q q q q q q AB AB AB AB AB AB AB No AB AB AB AB AB AB AB AB AB AB AB AB AB AB q q q q q q q NE NE NE NE NE NE NE q q q q q q q q q q q q q q NE NE NE NE NE NE NE NE NE NE NE NE NE NE Note to physician: Please fill out all items in Health Record. Specify any condition that may result in an emergency situation: How is child’s overall physical status? Specify type and dose of any current medication or therapies: Describe any allergies: Describe any dietary restrictions: Describe any dietary recommendations: Describe any diagnosed disabilities: Please print or type physician or nurse practitioner’s name and telephone number. Print MD/NP Name First Last MD/NP Signature Phone Exam Date FINDINGS, TREATMENTS, AND RECOMMENDATIONS. Please Complete Individualized Child Care Plan (ICCP) for chronic health issues. Treatment Plan and Recommended Follow-Up or Results Date Abnormal Findings/Diagnoses 3 Child Care Immunization Form Must be on file before a child attends child care Name Birthdate Date of Enrollment Minnesota law requires children enrolled in child care to be immunized against certain diseases or have a legal medical exemption or conscientious exemption on file. Parent/Guardian: You may attach a copy of the child’s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated, including a history of disease or laboratory evidence of immunity, and CO for vaccines that are contrary to parent or guardian’s conscientiously held beliefs. Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status, section 2A to document medical exemptions (including a history of varicella disease), and 2B to document a conscientious exemption. For updated copies of your child’s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 800-657-3970. DO NOT USE (✓)or(*) Type of Vaccine st 1 Dose Mo/Day/Yr nd 2 Dose Mo/Day/Yr rd 3 Dose Mo/Day/Yr th 4 Dose Mo/Day/Yr th 5 Dose Mo/Day/Yr Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP) • • • st 3 doses during 1 year (at 2-month intervals) th 4 dose at 12-18 months th 5 dose at 4-6 years 5th dose not required if 4th dose was given on or after the 4th birthday Indicate vaccine type: DTaP or DTP Polio (IPV, OPV) • • • 2 doses in the first year rd 3 dose by 18 months th 4 dose at 4-6 years 4th dose not required if 3rd dose was given on or after the 4th birthday Measles, Mumps, and Rubella (MMR) • • • Required for children 15 months and older st st 1 dose on or after 1 birthday nd 2 dose at 4-6 years Haemophilius influenza type b (Hib) • • • • 2-3 doses in the first year 1 dose required at 12 months or older For unvaccinated children 15-59 months, 1 dose is required Not required for children 5 years or older Varicella (chickenpox) • • • Required for children 15 months or older st st 1 dose on or after 1 birthday nd 2 dose at 4-6 years Pneumococcal Conjugate Vaccine (PCV) • • • • Required for children age 2-24 months 3 doses in the first year th 4 dose after 12 months At least 1 dose is recommended for children 24-59 months in child care Hepatitis B (hep B) • • 2-3 doses in the first year rd 3 dose (final dose) by 18 months Hepatitis A (hep A) • 2 doses separated by 6 months for children 12 months and older Recommended Rotavirus (2-3 doses between 2 and 6 months) Influenza (annually for children 6 month or older) 4 Name Instructions, please complete: Box 1 to certify the child’s immunization status Box 2 to file an exemption (medical or conscientious) 1. Certify Immunization Status. Complete A or B to indicate child’s immunization status. A. Children who are 15 months or older: B. Children who are younger than 15 months: For children who are 15 months or older and who have received all the immunizations required by law for child care. For children who are younger than 15 months OR have not received all required immunizations. I certify that the above-named child is at least 15 months of age and has completed the immunizations which are required by law for child care. I certify that the above-named child has received the immunizations indicated. In order to remain enrolled, this child must receive all required vaccines within 18 months of the initial enrollment date. The dates on which the remaining doses are to be given are: Signature of Parent/Guardian OR Physician/Nurse Practitioner/Physician Assistant/Public Clinic Signature of Physician/Nurse Practitioner/ Physician Assistant/Public Clinic _____________________________Date _____________________________Date 2. Exemptions to Immunization Law. Complete A and/or B to indicate type of exemption. A. Medical exemption: B. Conscientious exemption: No child is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a child to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement: No child is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the child or others they come in contact with. In a disease outbreak, children who are not vaccinated may be excluded in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below). List exempted immunization(s): I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s). ¨ I am opposed to all vaccines. ¨ I am opposed only to vaccines indicated below. ___________________ __________________ ___________________ __________________ Signature of physician/nurse practitioner/physician assistant ___________________________Date ∗ History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in __________(year) Signature of parent or legal guardian _____________________Date Subscribed and sworn to before me this: ________day of _______________________20___ Signature of physician/nurse practitioner/physician assistant (If disease occurred before September 2010, a parent can sign.) Signature of notary (A copy of the notarized statement will be forwarded to the commissioner of health.) Developed by the Minnesota Department of Health – Immunization Program www.health.state.mn.us/immunize 5 (12/13) Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 (612) 377-7422 ID Name ICCP RECORD Birthdate Site Physician treating child’s condition Name/Title Clinic Address Phone # 1. Class FAX Diagnosed Medical Condition: a) When was your child first diagnosed? b) If yes, describe how often it occurs: c) What symptoms and behaviors does your child experience? d) List any restrictions at day care: 2. Is it an ongoing health issue? ☐ Yes ☐ No Treatment and Medications (Complete MEDICATION PERMISSION form) a) Routine treatment(s) and medication(s): b) As needed (PRN) treatment(s) and medication(s): 3. Emergency Care: If your child does not respond to medication and treatment, the emergency plan is: 4. Child’s Knowledge (to be completed by parent): 5. Session a) What is your child’s understanding of the medical condition? b) Does your child understand about any restrictions at day care? c) Can your child tell the teacher when treatment or medication is needed? ☐ Yes ☐ No d) Does your child cooperate with treatment and medication? ☐ Yes ☐ No Additional Information and/or Health Care Provider Recommendations: Parent Signature/Date Health Care Provider Signature/Date (not needed for eczema) 6 Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 (612) 377-7422 Patient Name: ASTHMA ACTION PLAN SITE: Weight: # DOB: Doctor or Nurse Practitioner Name: Clinic Name: Symptom Triggers: ROOM: Peak Flow: Asthma Severity: Phone: The Green Zone means take the following medicine(s) every day: Controller Medicine(s): Dose: Green Zone “Go All Clear!” − Breathing is easy − Can play, work, and sleep without asthma symptoms Peak Flow Range Spacer Used: (80%-100% of personal best) to Take the following medicine if needed 10-20 minutes before sports, exercise, or any other strenuous activity: The Yellow Zone means keep taking your Green Zone controller medicine(s) every day and add the following medicine(s) to help keep the asthma symptoms from getting worse. Yellow Zone “Caution…” Peak Flow Range Reliever Medicine(s): − Wakes up at night − Coughs or wheezes − Chest is tight (50%-80% of personal best) to Dose: Use Quick Reliever 2-4 puffs, every 20 minutes for up to 1 hour or use nebulizer once. If your symptoms are not better or you do not return to the GREEN ZONE after 1 hour, follow RED ZONE instructions. If you are in the Yellow Zone for more than 12-24 hours, call your provider. If your breathing symptoms get worse, call your provider. The Red Zone means start taking your Red Zone medicine(s) and call your doctor NOW! Take these medicines until you talk with your doctor. If your symptoms do not get better and you can’t reach your doctor, go to the emergency room or call 911 immediately. Red Zone “STOP!” “Medical Alert” − Medicine is not helping − Nose opens wide to breathe − Breathing is hard and fast − Trouble walking − Trouble talking − Ribs show Reliever Medicine(s): Dose: Peak Flow Range (Below 50% of personal best) to I give my permission for this asthma action plan to be used by the following, and for them to share information with each other about my child’s asthma for one year beginning today, so that they can work together to help my child manage his/her asthma. This plan, when signed and dated, may replace or supplement the school’s/daycare’s consent to administer medication form, and allows my child’s medicine to be administered at school/daycare. q My child’s school/school health office q My child’s daycare provider PICA HEAD START q Insurance case management/Education program q My child’s clinic/hospital q Visiting nurse/Home care agency q Coach q Student may carry and use this medicine at school after approval by the school nurse. q My child is allowed to self-administer medications Date Parent Signature Entered By MD/NP/PA Signature 7 Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 (612) 377-7422 Child’s Last Name DENTIST EXAM & TREATMENT FORM First Name Middle Initial Parent/Guardian Name Address Child’s Dental Insurance Name Child’s Dental Insurance Number Birth Date Telephone # Minnesota Health Care Programs # Dear Parent/Guardian: To ensure good oral health, every child one year and older must have a dental examination within the last six months, or no later than 90 days after the child starts school. If your child does not have a regular dentist, you may choose to have your child seen at PICA through Children’s Dental Services. If your child does have a dental provider, please have them complete the section below and bring it with you to registration. Dentist Report This child received the following treatment in my office: q Dental Exam q X-rays TAKEN q X-rays READ q Cleaning q Topical fluoride application q Sealant q Fillings q Emergency q Extractions q Steel crowns q Space maintainers q Other, explain: q ALL treatments ARE complete. q ALL treatments are NOT complete – the following is still needed: q TAKE X-rays q READ X-rays q Topical fluoride application q Cleaning q Sealant PRINT Dentist’s Name q Fillings q Extractions q Steel crowns q Space maintainers q Other, explain: Dentist’s Signature Dentist’s Telephone Parent Signature Next Appointment DATE: Date of Exam Date 8 Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 Name Child Emergency Card ☐ Female ☐ Male Gender Birth Date Address City Zip Parent/Guardian First Name Parent/Guardian Last Name Pick Up Address Pick Up Contact Notes Drop Off Address Drop Off Contact Notes Child’s Health Insurance Health Insurance ID MN Health Care ID Doctor’s Office/Clinic Child’s Dental Insurance Dental Insurance ID Doctor’s Name Address City Phone City Phone Hospital Address Dentist’s Office Dentist’s Name Address City Phone IN CASE OF EMERGENCY THE FOLLOWING ADULTS ARE AUTHORIZED TO SERVE AS CONTACTS. MY CHILD MAY ALSO BE RELEASED TO THESE PEOPLE. Parent or Guardian First Name Parent or Guardian Last Name Relationship to Child Other Guardian in Household First Name Other Guardian in Household Last Name Relationship to Child Cell/Work Phone Number Cell/Work Phone Number Full Name Relationship Address School/Work name Full Name Relationship Address School/Work name Full Name Relationship Address School/Work name Home Phone Number City/ST School/Work Contact City/ST School/Work Contact City/ST School/Work Contact ________________ ________________ ________________ Phone Numbers ______ ______ ______ Type ________________ ________________ ________________ Phone Numbers ______ ______ ______ Type ________________ ________________ ________________ Phone Numbers ______ ______ ______ Type In the case of a medical/dental emergency I hereby authorize Parents In Community Action, Inc. (PICA) staff to take my child to a health facility for treatment. I also authorize any licensed medical practitioner to provide whatever treatment is deemed necessary. I accept responsibility for any costs arising from such treatment that are not covered by insurance and/or Medical Assistance. Parent/Guardian Signature Date In the event of an emergency, we will make every effort to contact you or one of the Emergency Contacts listed above. Your child will NOT be released to anyone other than those adults listed on this form. Please allow 48 hours for changes to go into effect. 9 ALGUNOS DE LOS SERVICIOS DISPONIBLES EN PICA HEAD START Servicios para Familias ü ü ü ü ü ü Apoyo Transporte de puerta a puerta Banco de alimentos mensual Servicios dentales en las escuelas Evento “Conexión Familiar” Preparación escolar Terapia lingüística y psicoterapia ü ü ü ü ü ü Superación de la farmacodependencia Apoyo para discapacitados en inglés y español Apoyo para la alfabetización Salud mental Nuevo Contrato de Vida (para gente sin hogar) Apoyo prenatal Oportunidades para Participación de Padres ü ü ü ü ü ü ü ü ü ü ü ü Comités consultivos Comité del Centro Clases de ciudadanía Inglés como segunda lengua (ESL) Clases de primeros auxilios y de RCP Clases de equivalencia de preparatoria (GED) Apoyo a los abuelos Involucramiento masculino Actividades en la Sala de Padres Tiempo de Padres y Niños (PAC) Consejo de Políticas Valorando el Involucramiento de los Padres (VIP) Oportunidades para Capacitación de Padres ü Ayudante de autobús ü Desarrollo infantil ü Habilidades secretariales ü Bienestar familiar ü Servicio de alimentos ü Transporte 10 Parents In Community Action, Inc. Solicitud de Head Start - ¡Llénela hoy! Información sobre la matrícula en Head Start Una publicación de Parents In Community Action, Inc. 700 Humboldt Avenue North Minneapolis, MN 55411 (612) 377-7422 www.picaheadstart.org Línea de información disponible las 24 horas del día: (612) 377-4444 PICA Head Start - Child Care and So Much More… Enroll Your Children In Head Start Now! ¡Inscriba a sus niños en Head Start ahora! Hadda U Buuxi Cunugaaga Head Start-ka! Sau Koj Tus Menyuam Npe Kawm Head Start Tam Sim No! Head Starttii Keessat Qooda Fudhadha, Ijoollee Galcha! ©2016 Parents In Community Action, Inc. – skc - Translation -bek