CHILD AND FAMILY INFORMATION

Child Information

(First)

(Middle)

(Last)

Other Known Names (if any)

Child's Date of Birth

Male

Female

Gender

----

Primary Caregiver Information

(First)

Address

Home Phone

E-mail Address

(Last)

Suite Number

Cell Phone

(Relationship to Child)

Postal Code

Work Phone

Additional Care Giver Information

(First)

Address

Home Phone

How many times have you moved in the last year?

(Last)

Suite Number

Cell Phone

What is the education level of the child

(Relationship to Child)

Postal Code

Work Phone

Age of Primary Cargiver

under 20 years

20-30 years

30-40 years

Over 40

how many siblings does your child have?

name of Sibling

Age of Sibling

Is this your kids first head Start program?

yes

Aboriginal Learner Data Collection Initiative

*It is mandatory that this quesiton is included on registration forms, however answering the question is optional

If you wish to declare that your child is an Aboriginal person, please specify:

331 Status Indian/First Nations

334 Inuit

332 Non-Status Indian/First Nations

333 Métis

Do not wish to declare

Alternate pickup / Emergency Contact Information

*Please note - A Parent living in the home is not considered an alternate pick up, and the emergency contacts must live within the Edmonton City Limits and have a working phone number

Contact #1

(First)

(Address)

(Home Phone)

(Last)

(suite#)

(Cell Phone)

(Relationship to Child)

(Postal Code)

(Work Phone)

Contact #2

(First)

(Address)

(Home Phone)

(Last)

(suite#)

(Cell Phone)

(Relationship to Child)

(Postal Code)

(Work Phone)

I, the Parent/Primary Caregiver, give my consent for the persons listed above to pick up my child from the bus or school with proof of identification and prior notification to both the bus driver and classroom teacher. Further, the persons listed above will act as my child's emergency contacts in the event of my absence.

Full Name

Date

Signature: _______________________________________________________________________________________________ (to be signed in person)

Is anyone denied access to the child

Yes

Income Declaration

Source of Income A:

EMPLOYMENT

ALBERTA WORKS

STUDENT FINANCE

EMPLOYMENT INSURANCE

CHILD SUPPORT

CHILD TAX

AISH/DISABILITY

CANADA PENSION PLAN

WCB

Does your current income meet the financial needs of your family?

Yes

Health Information

Does your child have any special needs we should know about? (special diet, language problems, particular fears, etc.)

Yes

Has your child had previous assessments? (speech & language, OT, etc.)

Yes

Are there family issues should we be aware of that have been occurring in the home and affecting your child?

Yes

Does your child have A family doctor?

Yes

Alberta Health Care number

Birth Certificate number

Treaty Number (If Applicable)

What reserve is your child registered to or will be registered to?

Are your child's immunizations up to date?

Yes

Unknown

Does your child have any allergies?

Yes

Allergy

Reaction

Allergy

Reaction

Allergy

Reaction

Does your child need an EpiPen?

Yes

Does your child have Asthma?

Yes

*Please note that you have said yes to your child having asthma and/or needing an EpiPen then a rescue inhaler and/or an EpiPen will need to be provided (and kept at school) prior to your child starting the program

Is your child on regular medication?

Yes

Community Resources and Services

Do you presently have involvement with another agency?

Yes

Do you need to know about more resources and services in your community for your child and family?

Yes

Not Sure

Have your children experienced any form of trauma or abuse?

Yes

Do you currently have Children Services involvement?

Yes

Children Services Worker:

(First Name)

(Phone Number)

(Last Name)

(E-mail Address)

Social Worker:

(First Name)

(Phone Number)

(Last Name)

(E-mail Address)

Family Support Worker

(First Name)

(Phone Number)

(Last Name)

(E-mail Address)

Personal and Social Development

Is the mother tongue of either parent/caregiver an Aboriginal Language?

Yes

Does either parent/caregiver speak an Aboriginal Language fluently?

Yes

Does your child speak an Aboriginal Language fluently?

Yes

What is the primary language spoken in the home?

What is the primary language your child speaks?

What do you hope that Head Start will offer you as a parent/caregiver? (Choose as many as you wish)

To meet other parents

To learn better parenting strategies

To learn about Aboriginal culture

To learn some of the local Aboriginal language

To learn how to help my child learn

Another reason

How did you hear about Aboriginal Head Start? (Choose as many as you wish)

Word of mouth: Through friends / family

Through past participants

Head Start flyer

Facebook advertisement

Social Media advertisement

Google Search

Other

Caregiver Survey: Help us to get to know your child

As the caregiver, you know your child the best, therefore your input and involvement into your child's education is very important. Please fill out the following. What 3 words best describe your child?

What are your child's strengths? What is your child good at?

What are your child's interests? What does your child like to do? (dance, sing, look at books, outside play, dress up, build with Lego, play with dolls, etc.)

What areas would you like your child to grow in? (use words instead of hitting, following directions, sharing with friends, speaking clearly, talk more, etc.)

Does your child display any behaviors that are of concern to you?

Is there any information that could help us gain a better understanding of your child?

Parent / Caregiver Delegation of Power and Duty

Consent to ordinary medical and dental care: This authority includes treatment for minor illnesses and injuries and other procedures that are performed routinely and do not require hospitalization. The Head Start staff have the authority to admit the child to hospital but not to authorize any treatment or tests except according to the following clause: Consent to emergency treatment or surgical procedures. This authority includes immediate measures necessary to preserve the child's life, health and physical wellbeing. The authority must be used only if contacting the parents or caregivers will delay treatment enough to endanger the child's life. After giving treatment, the staff must immediately notify the parents or caregivers.

Delegation of Powers in case of Emergency

Child's Legal Name:

(First)

Date of Birth

(Band / First Nation)

(Middle)

Male

Female

Gender

(Treaty number)

(Last)

(Alberta Heath Care Number)

Parent / Caregiver

(First)

(Last)

(Date)

Signature: ___________________________________(to be signed in person)

Online and Virtual Learning

I, the Parent/Primary Caregiver, understand that Aboriginal Head Start may provide programming, at any time, for my child, through a virtual program platform if required. I understand that active participation is essential and agree to participate in online activies as required and expected. All information shared (both from the program and from families) has the possiblity to be seen by everyone enrolled in the online group. Aboriginal Head Start cannot guarantee that the information will remain confidential as all families participating will have access to the same information as you and may share this on other social media platforms. Aboriginal Head Start will not be responsible or liable for misconduct of images or information shared in the Virtual Classroom We ask that all images, videos and instructions be used for what they are intended for and to refrain from any misconduct of information.

Direct teaching in the classroom is our primary mode of teaching. Our secondary online mode of teaching is available in the event our primary mode is unachievable. While participating in the online learning, children may receive materials delivered to their home so that they can participate in the program. It is the expectation of our online programming to have parent participation by joining weekly ZOOM calls and connecting via email and Facebook Site groups regularly. While your child will receive benefits of an online program, direct education may be difficult as the classroom teacher is working with in-person children attending program. When participating in our primary direct teaching in the classroom forum, transportation boundaries will be adhered to. The program will ensure to provide valuable learning opportunities that engage, challenge and support the develoopment of your child!

By signing below, you show understanding of the above statement and agree to participate in the programming provided, either through the secondary online program or through the primary direct teaching in the classroom.

Facebook Name:

Parent / Caregiver

Full Name

Current Date:

Child

Full Name

D.O.B

Signature: _______________________________(to be signed in person)

Health Promotion and Assessment Permission

I, the Parent/Primary Caregiver, hereby authorize the following agencies to observe my child in the Head Start program and provide necessary documentation and consultation to Aboriginal Head Start staff in order to enhance my child's learning in the classroom.

*Please initial beside all the services you are in agreement with

Alberta Health Services

Child Adolescent and Family Mental Health (CASA)

Glenrose Hospital (Assessment Facility)

Edmonton Student Health Initiative Program (ESHIP)

I understand that as part of the services provided by Head Start, these services and screenings may be completed with and/or provided for my child.

*Please initial beside all the services you are in agreement with

Measurement of Height and Weight

Dental Screening

Hearing Screening

Vision ScreeningHealth Initiative Program (ESHIP)

Brigance Inventory of Early Childhood Development II (IED-I

Safe Preschoolers Education & Awareness Kit (S.P.E.A.K.)

Speech and Language Referral/Assessment, if required

Occupational Therapist Referral/Assessment, if required

Physical Therapist Referral/Assessment, if required

I also give permission for the information collected to be used by Head Start and the above agencies for educational, research and statistical purposes. I understand that the information will be coded in such a way that the identities of individual children and parents will be kept confidential for research and statistical purposes.

Intials: _________________ ( in person)

Parent / Caregiver

Full Name:

Current Date

Child

Full Name:

D.O.B

Signature: ____________________________ (to be signed in person)

Collection and Release of Information

I understand that the Head Start may release the following information on my child to Early Education Programs and/or institutions and may collect the following information from previous Early Education Programs and/or institutions that will support my child's educational programming:

*Individual Program Plan

*Speech and Language Report, if applicable

Occupational Therapist Report, if applicable Physical Therapist Report, if applicable

Intials: ______________ (in person)

I understand that the Head Start may collect the following information from previous Early Education Programs and/or institutions that will support my child's educational programming:

*Individual Program Plan

*Speech and Language Report, if applicable

*Occupational Therapist Report, if applicable

*Physical Therapist Report, if applicable

Initials: _________________(in person)

I understand that the information collected by Head Start will be kept confidential.

Parent / Caregiver

Full Name:

Current Date

Child

Full Name:

D.O.B

Signature: ________________________(to be signed in person)

Transportation

Does your Child require transportation?

Yes

No, caregiver will be providing transportation

PLEASE NOTE: Child's residence and/or child care provider must be located in the bus boundaries to receive bus services.

Number of siblings on the bus

The following people have permission to sign my child on and off the bus: Please list yourself as the primary caregiver and then list those who will be consistently signing your child on and off the bus. We do understand that there may be extenuating circumstances where someone other than those listed below may have to sign for your child (with prior notification and photo ID)

Primary Caregiver #1 Full Name

Primary Caregiver #2 Full Name

Primary Caregiver #3 Full Name

Primary Caregiver #4 Full Name

If your child will be attending a child minding program, please complete the following section:

Daycare / Day home Name

Daycare / Day home Address

Daycare / Day home Phone

Transportation Procedures

The amiskwaciy Cultural Society provides the Aboriginal Head Start Program with four 24 passenger school busses and access to the program's spare bus if needed. These vehicles are used to transport those children who are registered in our program and who live within the designated boundaries set forth by the Aboriginal Head Start Program.

Estimated hours for pick up: Between 8:00am - 9:00am for both our Kihew Group (Tuesday/Thursday classes) and our Muskwa Group (Wednesday/Friday classes). Estimated hours for drop of:. Between 3:00pm - 4:00pm for both our Kihew Group (Tuesday/Thursday classes) and our Muskwa Group (Wednesday/Friday classes)

The bus will pick up/drop off your child at home or/at the designated child care facility.

Parents/Guardians are required to bring the child to the bus upon pick up and meet the bus upon drop off. The bus drivers are not allowed to leave the bus at any time

The bus will stop at each home for exactly 3 minutes. Please have your child dressed and ready for the bus. If your child is not ready to go or no one attempts to signal the driver, she/he will carry on with the route and there will be no reattempt at any later time.

Drop off – If no one is home at time of drop off, the driver will attempt to call parent/guardian. The bus driver will then make a second attempt at the end of the route. If still no one is available to receive the child, the Family Support Worker will attempt to contact emergency phone numbers and if still no one is available, they will then contact the Children's Services Crisis Line.

A transportation permission form must be signed for all children who ride the bus.

If a parent/guardian has an alternate caregiver receiving their child upon drop off or pick up from school, teachers MUST be informed verbally and in written form. Individuals will be required to show proper identification.

If your child will not be riding the bus on any given day, the bus driver MUST be notified the night before or at least half an hour before s/he arrives at your residence.

If your child is sick or away from school and will not be riding the bus for any number of days, the drivers MUST be contacted in order to resume bus riding for his/her child

Transportation Permission

Parent / Caregiver Full Name

Date

Child Full Name

Date of Birth

Signature: _______________________________(to be signed in person)

Field Trip Blanket Permission

The following form is a Blanket Permission Form which will allow your child to attend and be transported by the Aboriginal Head Start bus to ANY and ALL field trips in and around the Edmonton City limits. Regularly scheduled field trips and activities will be listed on your child's monthly classroom calendar that is handed out at the beginning of each month, and this form will grant permission for your child to attend.

I do understand the above and hereby give my permission for my child to attend ANY and ALL program planned field trips and activities during the Academic School Year.

With warmer weather throughout the spring, summer and fall months, protecting our skin from the sun and insects becomes an important part of enjoying the outdoor wonders Mother Earth gives us. Our program is happy to supply and apply sunscreen and bug spray to your child as needed on our many adventures. If you wish to provide your own sunscreen and/or bug spray for your child, please notify the program staff and we will collect these items from you, label them with your child's name and use only on your child. If you give permission for your child to use the sunscreen and bug spray provided by our program or yourself and apply as needed, please sign below:

I do authorize the Aboriginal Head Start program staff to obtain emergency medical treatment for my child in cases of emergency.

I also understand that I WILL NOT hold the Aboriginal Head Start program liable for injury to my child during ANY or ALL of these planned field trips and activities without just cause.

Parent/Caregiver Full Name

Date

Child Full Name

Date of Birth

Signature: __________________________(to be signed in person)

Audio / Visual Recording Consent

I, the Parent/Primary Caregiver of the child listed below, do hereby acknowledge that the Aboriginal Head Start and the amiskwaciy Cultural Society may use, reproduce or distribute any photographs, slides, video or other similar material associated with the program and related events and activities for promotional and archival purposes. There is no time limit to this consent; however, the consent can be revoked at any time with written notice to the Program Manager. Audio and visual recordings will be securely stored at the amiskwaciy Cultural Society office

PLEASE NOTE: Children in care will need written consent from their Social Worker

I Consent

Yes

Parent / Guardian Full Name

Date

Child Full Name

Date of Birth

Waiver

As the Parent/Primary Caregiver, I hereby understand that the Aboriginal Head Start Program, and the amiskwaciy Cultural Society will not be responsible for the following:

*Lost or stolen and/or Damage of personal items.

*Any occurrence, after program hours where a child has been dropped off at specified childcare location. (i.e.: Home, daycare, babysitter)

*Restricting contact without legal documentation on file. (Both office and school files)

Parent / Guardian Full Name

Date

Child Full Name

Date of Birth

Signature:___________________(to be signed in person)

Parent / Primary Caregiver Participation Agreement

Parent participation plays a major role for the success of the Aboriginal Head Start Program. Your participation as a parent/primary caregiver will benefit the Program as well as yourself and your child. The parent/primary caregiver portion of the Program requires you to become involved. We attempt to be flexible in order to accommodate your hours available. Parent participation is crucial for the continued success of our Head Start program.

I, the Parent/Primary Caregiver, do agree to fulfill my parental/primary caregiver obligation to the Aboriginal Head Start Program. I understand that my participation in the Program will benefit my child and myself as a parent/primary caregiver. This participation may include in person or virtual via program media platforms. I will become involved in the following ways:

I will attend parent/primary caregiver gatherings/functions subject to program policies and procedures.

I will ensure my child attends Head Start on a regular basis

I will contact the bus driver when my child will not be taking the Head Start Bus.

I will permit home-visits by Head Start staff regarding my child to access community services subject to program policies and procedures

I will volunteer a minimum of 9 hours in the Head Start Program. This could include participation in online meetings, classroom participation, fieldtrips, making play-dough, material preparation or any of the listed below.

I am willing to contribute to the program by sharing my skills, talents and knowledge in (check as many as apply to you)

Traditional foods

Storytelling

Drumming

Crafts

Singing

Personal Career

Other

Parent / Caregiver Full Name

Date

Signature:_______________(to be signed in person)

Orientation Agreement

This is to verify I that have had the opportunity to go over all the information shared in the Aboriginal Head Start program with a family support worker. I fully understand all information shared and have asked the necessary questions for me to understand what it takes to have my child participate in the Head Start program. I have been informed and completed the following:

Overview of the application form

Provided the program with a copy of:

the child's Alberta Health Care Card

the child's Birth Certificate

the Delegation of Powers (if required)

the child's Treaty Status Card (optional)

Documents Pending

the child's Alberta Health Care Card

the child's Birth Certificate

the Delegation of Powers (if required)

Medication:

child requires an inhaler and it has been provided

child requires an inhaler, but it is not available

child requires an epi pen and it has been provided

child requires an epi pen, but it is not available

Signing of all Parental Consent forms

I understand all Program Policies and Procedures and was given an opportunity to ask questions

I understand the 9 hours commitment for volunteering in the program

I will inform the Aboriginal Head Start program of any changes to parent/caregiver or emergency contact information as soon as they occur

I understand that the program is obligated by law to report to the appropriate authorities should they suspect any form of abuse

I understand that I must inform Aboriginal Head Start if my child has been exposed to anyone with a positive result to any outbreak, epidemic or pandemic that is currently occurring within our city

I understand that if my child is experiencing any new symptoms to a current outbreak, epidemic or pandemic that a staff member may put a mask or other required PPE (personal protective equipment)

I understand that this is a "fluid" document and changes may be makde to the intake procedures at any time

If I should have any further questions or concerns relating to my child or the progrma in any way, I will contact my Family Support Worker directly.

If I should have any further questions or concerns relating to my child or the program in any way, I will contact my site family support worker to discuss matters directly.

Parent / Guardian Full Name

Date

Signature: __________________________

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CHILD AND FAMILY INFORMATION

Child Information

Primary Caregiver Information

Aboriginal Learner Data Collection Initiative

*It is mandatory that this quesiton is included on registration forms, however answering the question is optional

Alternate pickup / Emergency Contact Information

*Please note - A Parent living in the home is not considered an alternate pick up, and the emergency contacts must live within the Edmonton City Limits and have a working phone number

Contact #1

Contact #2

Signature: _______________________________________________________________________________________________ (to be signed in person)

Income Declaration

Health Information

*Please note that you have said yes to your child having asthma and/or needing an EpiPen then a rescue inhaler and/or an EpiPen will need to be provided (and kept at school) prior to your child starting the program

Community Resources and Services

Children Services Worker:

Social Worker:

Family Support Worker

Personal and Social Development

Caregiver Survey: Help us to get to know your child

As the caregiver, you know your child the best, therefore your input and involvement into your child's education is very important. Please fill out the following. What 3 words best describe your child?

Parent / Caregiver Delegation of Power and Duty

Delegation of Powers in case of Emergency

Child's Legal Name:

Parent / Caregiver

Signature: ___________________________________(to be signed in person)

Online and Virtual Learning

By signing below, you show understanding of the above statement and agree to participate in the programming provided, either through the secondary online program or through the primary direct teaching in the classroom.

Parent / Caregiver

Child

Signature: _______________________________(to be signed in person)

Health Promotion and Assessment Permission

I, the Parent/Primary Caregiver, hereby authorize the following agencies to observe my child in the Head Start program and provide necessary documentation and consultation to Aboriginal Head Start staff in order to enhance my child's learning in the classroom.

I understand that as part of the services provided by Head Start, these services and screenings may be completed with and/or provided for my child.

Intials: _________________ ( in person)

Parent / Caregiver

Child

Signature: ____________________________ (to be signed in person)

Collection and Release of Information

I understand that the Head Start may release the following information on my child to Early Education Programs and/or institutions and may collect the following information from previous Early Education Programs and/or institutions that will support my child's educational programming:

*Individual Program Plan

*Speech and Language Report, if applicable

*Occupational Therapist Report, if applicable *Physical Therapist Report, if applicable

Intials: ______________ (in person)

I understand that the Head Start may collect the following information from previous Early Education Programs and/or institutions that will support my child's educational programming:

*Individual Program Plan

*Speech and Language Report, if applicable

*Occupational Therapist Report, if applicable

*Physical Therapist Report, if applicable

Initials: _________________(in person)

I understand that the information collected by Head Start will be kept confidential.

Parent / Caregiver

Child

Signature: ________________________(to be signed in person)

Transportation

PLEASE NOTE: Child's residence and/or child care provider must be located in the bus boundaries to receive bus services.

If your child will be attending a child minding program, please complete the following section:

Transportation Procedures

The bus will pick up/drop off your child at home or/at the designated child care facility.

Parents/Guardians are required to bring the child to the bus upon pick up and meet the bus upon drop off. The bus drivers are not allowed to leave the bus at any time

The bus will stop at each home for exactly 3 minutes. Please have your child dressed and ready for the bus. If your child is not ready to go or no one attempts to signal the driver, she/he will carry on with the route and there will be no reattempt at any later time.

A transportation permission form must be signed for all children who ride the bus.

If a parent/guardian has an alternate caregiver receiving their child upon drop off or pick up from school, teachers MUST be informed verbally and in written form. Individuals will be required to show proper identification.

If your child will not be riding the bus on any given day, the bus driver MUST be notified the night before or at least half an hour before s/he arrives at your residence.

If your child is sick or away from school and will not be riding the bus for any number of days, the drivers MUST be contacted in order to resume bus riding for his/her child

Transportation Permission

Signature: _______________________________(to be signed in person)

Field Trip Blanket Permission

I do understand the above and hereby give my permission for my child to attend ANY and ALL program planned field trips and activities during the Academic School Year.

I do authorize the Aboriginal Head Start program staff to obtain emergency medical treatment for my child in cases of emergency.

I also understand that I WILL NOT hold the Aboriginal Head Start program liable for injury to my child during ANY or ALL of these planned field trips and activities without just cause.

Signature: __________________________(to be signed in person)

Audio / Visual Recording Consent

PLEASE NOTE: Children in care will need written consent from their Social Worker

Waiver

As the Parent/Primary Caregiver, I hereby understand that the Aboriginal Head Start Program, and the amiskwaciy Cultural Society will not be responsible for the following:

*Lost or stolen and/or Damage of personal items.

*Any occurrence, after program hours where a child has been dropped off at specified childcare location. (i.e.: Home, daycare, babysitter)

*Restricting contact without legal documentation on file. (Both office and school files)

Occupational Therapist Report, if applicable Physical Therapist Report, if applicable