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