2new job.indd - Chicago Public Schools

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
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
 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.