English Head Start Application - Family Development Services

Step 1 of 19 - Applicant Child

Applicant Child

Center Preference:(Required)

Second Option:(Required)

Program Preference(Required)

One Parent/Guardian must be working or in school or child has an IEP.

Head Start: 7 hour (M-F 9:00am - 3:00pm)

Head Start: 9 hour (M-F 8:30am - 4:30pm)

Child Full Name(Required)

Please enter child's full name.

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Race(Required)

Asian

American Indian/Alaskan Native

Black

Hawaiian/Pacific Islander

White

Multi-Racial/Bi-Racial

Other

Hispanic(Required)

Yes

English Proficiency(Required)

None

Little

Moderate

Proficient

Other Languages(Required)

Spanish

Burmese

Chin

Arabic

Other

Other Language Proficiency(Required)

None

Little

Moderate

Proficient

Primary Health Coverage(Required)

Medicaid

Private (through Individual/Employer)

No Insurance

Other

Medicaid Eligibility(Required)

Not Eligible

On Medicaid

Applied (Potentially)

Insurance/Medicaid #(Required)

Dental Coverage(Required)

Dental Coverage #(Required)

Dentist’s Office Name, Address, Phone #(Required)

Doctor’s Office Name, Address, Phone #(Required)

Does your child have a sibling currently attending Head Start/Early Head Start?(Required)

Yes

If yes, sibling name:(Required)

First Middle Last

Does your child have any disability, special health or developmental concerns?(Required)

(More information will be collected during interview).

Yes

Does your child have an Individualed Education Plan (IEP) or Individualized Family Service Plan (IFSP)?(Required)

(ex: Speech, Developmental, Occupational Therapy).

Yes

Primary Adult

Parental Status(Required)

One

Two

Primary Adult Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Race(Required)

Asian

American Indian/Alaskan Native

Black

Hawaiian/Pacific Islander

White

Multi-Racial/Bi-Racial

Other

Hispanic(Required)

Yes

English Proficiency(Required)

None

Little

Moderate

Proficient

Other Languages(Required)

Spanish

Burmese

Chin

Arabic

Other

Other Language Proficiency(Required)

None

Little

Moderate

Proficient

Highest Grade Completed(Required)

Employment Status(Required)

Child’s Relationship(Required)

Custody(Required)

Check all that apply for this adult(Required)

Lives with Family

Provides Financial Support

Teen Parent

Do you need an interpreter for your appointment?(Required)

Yes

If Yes, which language:

Email Address:(Required)

Primary Adult Contact Information

Primary Adult Living Address(Required)

Street Address Address Line 2 City State ZIP Code

Is mailing address different than living address?(Required)

Yes

Mailing Address (if different)(Required)

Street Address Address Line 2 City State ZIP Code

Is this the child’s legal address?(Required)

Yes

Phone Number(Required)

Type(Required)

Notes(Required)

(ext. or best time to call)

Text Message(Required)

Can we contact you via text message?

Yes

Secondary Adult

Secondary Adult Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Race(Required)

Asian

American Indian/Alaskan Native

Black

Hawaiian/Pacific Islander

White

Multi-Racial/Bi-Racial

Other

Hispanic(Required)

Yes

English Proficiency(Required)

None

Little

Moderate

Proficient

Other Languages(Required)

Spanish

Burmese

Chin

Arabic

Other

Other Language Proficiency(Required)

None

Little

Moderate

Proficient

Highest Grade Completed(Required)

Employment Status(Required)

Child’s Relationship(Required)

Custody(Required)

Check all that apply for this adult(Required)

Lives with Family

Provides Financial Support

Teen Parent

Email Address:(Required)

Secondary Adult Contact Information

Secondary Adult Living Address(Required)

Street Address Address Line 2 City State ZIP Code

Is mailing address different from living address?(Required)

Yes

Mailing Address (if different)(Required)

Street Address Address Line 2 City State ZIP Code

Is this the child’s legal address?(Required)

Yes

Phone Number(Required)

Type(Required)

Notes(Required)

(ext. or best time to call)

Text Message(Required)

Can we contact you via text message?

Yes

Family Information

Primary Language at Home(Required)

Homeless Family(Required)

Yes

Active Military(Required)

Yes

Military Veteran(Required)

Yes

Referred by DCS(Required)

Yes

Receiving SNAP(Required)

Yes

WIC

Yes

Supplemental Security Income (SSI)(Required)

Yes

Temporary Assistance for Needy Families (TANF)(Required)

Yes

Other Non-Applicant Children in Family

Non-Applicant Children in Family

Full Name

Date of Birth

Relation to Child

Gender

Parent/Guardian Consent

Does your child have any fears?(Required)

Yes

If yes, please explain

Does your child easily form relationships with adults and/or peers?(Required)

Yes

If yes, please explain

Would you consider your child curious?(Required)

Yes

If yes, please explain

Does your child manage care of own needs appropriately?(Required)

Yes

If yes, please explain

PARENT/GUARDIAN CONSENT(Required)

I understand this is an application ONLY and does not guarantee enrollment in the program. All information is confidential. I also understand that I must keep Head Start informed of any changes of address or phone number. I am legally responsible for this child.

Signature(Required)

Application Date(Required)

MM slash DD slash YYYY

Income Verification Statement

First Last

, the parent/guardian of

First Last

state that I receive $

Income Amount(Required)

Per Week/Month/Year(Required)

The source of my income is

Source of Income(Required)

or I am being cared for by

Name of Caretaker

Comments

Please leave any comments in this section.

Consent(Required)

By signing, I certify that the information provided on this verification form is accurate and truthful to the best of my knowledge. I am also aware that I may be subject to termination from the program if the information verified causes me to become ineligible.

Signature of Parent/Guardian(Required)

Date(Required)

MM slash DD slash YYYY

Upload Income Documents

You may use the Notebloc app to format files to send to FDS

Max. file size: 256 MB.

Homeless Determination Checklist

If one or more of the following statements are checked, the child is considered to be homeless according to Family Development Services Early Head Start/Head Start standards.

Not applicable

Living “doubled up” with a friend, relative, or someone else due to the loss of their home or the family is having temporary financial problems;

Staying in a motel, hotel, or campground due to not having anywhere else to go;

Living in a shelter (such as an emergency or transitional shelter, domestic violence shelter, or runaway and homeless youth shelter);

Staying in substandard housing (Head Start staff must evaluate whether the child’s housing situation falls short of community standards or is of lower quality than the law prescribes. Staff should consider factors such as whether there are health and safety concerns related to the housing, the number of occupants per square foot, the age of the occupants, and whether the housing meets State and/or local building codes.);

If checked, please explain concern leading to substandard housing determination:

Living in a place not ordinarily used for sleeping (such as an automobile, park, public place, abandoned building, bus or train station);

Awaiting foster care placement;

Abandoned in a hospital.

Consent(Required)

The above information is a true representation of my current living arrangements.

Signature

Date

MM slash DD slash YYYY

Emergency Information & Authorization for Release Card

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Adult/Guardian(Required)

First Middle Last

Primary Phone #(Required)

Secondary Phone #

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Enter Email Confirm Email

Second Parent/Guardian(Required)

First Middle Last

Primary Phone #(Required)

Secondary Phone #

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Enter Email Confirm Email

Child's Allergies(Required)

Health Concerns/Accommodations(Required)

Daily Medications(Required)

In case of accident or emergency contact Doctor/Clinic:(Required)

Phone(Required)

In case of accident or emergency please take my child to (Hospital):(Required)

Consent(Required)

Family Development Services has my authorization to provide transportation and obtain medical treatment for my child in the event of a medical, health, or building emergency.

(Required)

I provide permission for my child to participate in extracurricular activities/events at the child care center on and off the premises.

Signature of Parent/Guardian(Required)

Date(Required)

MM slash DD slash YYYY

The following persons are authorized to pick up my child from the classroom. Please include parents/guardians on this pick up list. Photo Identification is required for release of child.(Required)

First & Last Name

Phone Number

Relationship to Child

Can this person seek Medical Care for my child?

Date of Removal from Pick-up List

Consent(Required)

I understand I am the only one who can make changes to this list, and any changes made must be by me and completed in person.

(Required)

I authorize anyone on this list who is a minor between the ages of 14-17 to receive my child from the classroom pending showing a valid photo I.D.

Signature of Parent/Guardian(Required)

Date(Required)

MM slash DD slash YYYY

Consent for Services

Child's Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

I give permission for my child to have all of the necessary services provided by Early Head Start/Head Start including:

Answer each line as: Accept-Yes or Refuse-No

Vision Screenings(Required)

Yes (Accept)

No (Refuse)

Blood Pressure(Required)

Yes (Accept)

No (Refuse)

Lead Screen (finger stick)(Required)

Yes (Accept)

No (Refuse)

Hemoglobin/Iron (finger stick)(Required)

Yes (Accept)

No (Refuse)

Height and Weight(Required)

Yes (Accept)

No (Refuse)

Behavioral Health Observation/Consultation(Required)

Yes (Accept)

No (Refuse)

Speech(Required)

Yes (Accept)

No (Refuse)

Hearing(Required)

Yes (Accept)

No (Refuse)

Other Permissions/Releases:

Obtain child’s immunization record (CHIRP)(Required)

Yes (Accept)

No (Refuse)

Dental Screening by licensed professional(Required)

Yes (Accept)

No (Refuse)

Well-Child Examination by nurse practitioner/physician(Required)

Yes (Accept)

No (Refuse)

Consent

I have been informed and understand the nature of the screenings offered and how they are completed. I do not want screened for the items answered "No" above.

Child Name(Required)

First Last

(Required)

I understand that I must request screenings from my physician or retract this refusal at any time through the program year.

Parent/Guardian Signature(Required)

Date(Required)

MM slash DD slash YYYY

INDIANA UNIVERSITY SCHOOL OF OPTOMETRY VISION FOR THE FUTURE CONSENT TO TREAT MINOR PATIENT

This form provides authorization by a parent or legal guardian for the Indiana University School of Optometry (IUSO} to provide routine vision care to the minor listed at a Marion Head Start. IUSO provides full FREE comprehensive eye exams to students that did not pass the FREE vision screening for the purpose of providing access to vision care services to students

Child's Name(Required)

First Middle Last

Allergies:(Required)

Current Medications:

Chronic Conditions or Health Concerns(Required)

I authorize the Indiana University School of Optometry (IUSO} and Its personnel to deliver routine vision care and services, including a comprehensive eye exam and dilation, to the minor, when accompanied by an individual listed on this form. A comprehensive eye exam includes the use of eye drops to dilate the pupil to examine the lens, retina, and optic nerve inside the eye and to measure a prescription for glasses, as needed. I have read and understand information regarding the risks, benefits, and alternatives of dilation.

I authorize IUSO to share the results of the eye exam with the student's Head Start center.

I understand IUSO is an educational institution and I agree that student interns (in training to be optometry doctors) may assist in providing the services and the minor's optometry records may be used for the purposes of research, education and patient care.

I have been given the opportunity to review the IUSO Notice of Privacy Practices and I understand that I may request copy of this notice should I so choose.

I understand the services provided are paid for by the Nina Mason Pulliam Charitable Trust.

Name of Parent or Legal Guardian(Required)

First Middle Last

Phone Number(Required)

Signature of Parent or Legal Guardian(Required)

Date(Required)

MM slash DD slash YYYY

Date of Service(Required)

MM slash DD slash YYYY

List the individuals authorized to accompany the minor(Required)

First Name

Last Name

Relationship to Patient

INDIANA UNIVERSITY SCHOOL OF OPTOMETRY VISION FOR THE FUTURE DILATION INFORMATION

An important part of the eye/visual examination is a dilated fundus exam. Dilation uses eye drops to make the pupils larger. This makes it easier to look at the structures inside the eye, such as the lens, retina, and optic nerve and to measure the prescription for glasses. This component of the exam helps in the early detection of congenital eye problems including cataracts, glaucoma, and other retinal disorders. What are the benefits of dilating your eyes? • Dilation helps us find conditions such as cataracts, retinal disease and detachment, glaucoma, aging changes, and other conditions that may affect the Inside of your eye, but which may be hard to see without dilation. • Dilation allows us to measure the true glasses prescription. There are many times where in order to finalize the glasses prescription this step is necessary to ensure the proper glasses prescription will be provided. What are the risks of dilating your eyes? • After dilation, there may be sensitivity to light, and up-close vision may be blurry. Disposable sunglasses will be offered to help with the brightness. Both of these effects will usually last 3-6 hours, but may last longer (or shorter) depending on the individual and the type of drops used. • Be extra careful walking (especially on stairs) while the eyes are dilated. Are there other procedures that do the same thing? • No. While we can look Inside of the eye without dilating the pupils, we are limited in how much we can see. The bigger the pupil, the more that we can see inside the eye. If you are concerned once you. leave the clinic you may call (317) 321-1470, 24 hours a day, 7 days a week and talk to a doctor of optometry.

Authorization for Release and Receipt of Child Records

I hereby authorize

(Agency/Person/School releasing information)(Required)

to release or disclose to: Family Development Services Head Start/Early Head Start pertinent information in your files

that include any of the following reports for the student listed below, for the purpose of:

Enrollment

Special Needs

Child Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Reports(Required)

Testing Results

Diagnostic and Evaluation Reports

Individual Education Plans

Initialized Family Support Plan

Case Conference Reports

Copy of Birth Certificate

Immunization Records

Medical Files

OT Evaluation Report

PT Evaluation Report

Speech Evaluation Report

Physical/Well Child Exam

Oral Health History

Family contact information (address, phone, email)

Family Eligibility information (current family status and employment)

Signature of Parent/Guardian(Required)

Relationship to Child(Required)

Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address City State ZIP Code

Consent(Required)

I understand that my consent to this disclosure is entirely voluntary and may be revoked at any time. I also understand that if I revoke this consent, my revocation will not affect disclosures that have already been made. I understand that the confidentiality of any personally identifiable information will be maintained in accordance with both federal and state regulations. I understand that I may review the indicated information, and I may refuse to sign this authorization, this will not affect my eligibility for enrollment. This document is valid for one year from the date of the parent/guardian signature.

PHOTOGRAPHY/VIDEO PARENTIAL/GUARDIAN CONSENT FORM

Family Development Services (“FDS”) and the Center where your child is enrolled may take photographs or video during normal day-to-day activities, special events, or field trips. These images/videos may appear in scrapbooks, on center bulletin boards, in newsletters or publications, in presentations, or on our websites. These images may also be used in local media or for promotional purposes or shown to prospective and current clients. Photography of enrolled children and the use of images of enrolled children on an Early Head Start/Head Start Center require parental permission. If you prefer your child not be photographed or included in video or that images of your child not be used for certain purposes; please indicate this below. It is our policy to not photograph or video or use images of children for which we do not have parental consent.

Please answer the following questions about the use of photographs/videos of your child. Select YES or NO for each question.

May FDS and the Center photograph your child during normal day-to-day activities, special events, or field trips?(Required)

Yes

May FDS and the Center take video your child during normal day-to-day activities, special events, or field trips?(Required)

Yes

May images of your child be used in FDS and Center scrapbooks or on FDS and Center bulletin boards to be shown to current or prospective clients?(Required)

Yes

May videos of your child be used in promoting FDS and the Center to current or prospective clients?(Required)

Yes

May images of your child be used in FDS and Center newsletters or publications, or in video presentations that are NOT for promotional or advertisement purposes?(Required)

Yes

May images of your child be used on the FDS website, in local media publications, social media sites or in other promotional materials FOR promotional or advertisement purposes?(Required)

Yes

Please sign to indicate that you have read and understand the below statements:(Required)

I understand that it is my responsibility to update this form in the event that I no longer wish to authorize one or more of the above uses.

(Required)

I understand that this photography Consent Form will remain in effect during the term or my child’s enrollment at FDS. The consent will automatically expire after this time.

(Required)

Parent/Guardian Signature:(Required)

Date(Required)

MM slash DD slash YYYY

Conditions of use of images:

We will NOT include names, personal or e-mail addresses, or telephone numbers of any child or adult in an image.

We will only use images of children who are appropriately dressed.

We may use images of individual or groups of children with very general labels, such as “making a craft” or “lunch time”.

CACFP Enrollment Form

EngPolicy Instruction 05-03

Name of Institution:(Required)

IDOE/CACFP

Sponsor ID Number:

Child's Name(Required)

First Middle Last

Date(Required)

MM slash DD slash YYYY

Please indicate which session your child will be attending Head Start:(Required)

Full day session (Monday-Friday 8:30am-3:30pm) - he/she would receive breakfast, lunch and afternoon snack while attending Head Start.

Full day session (Monday-Friday 8:30am-5:30pm) - he/she would receive breakfast, lunch, and afternoon snack while attending Head Start.

This information is required by CACFP federal regulations at §226.15(e)(2) and (3) for each enrolled participant and must be updated annually.

Signature of Parent or Guardian(Required)

Parent/Guardian Name

First Middle Last

Phone Number(Required)

Date(Required)

MM slash DD slash YYYY

This institution is an equal opportunity provider.

Family Advocate:

Consent to Blood Lead Screening and Authorization to Share Information Form

Childhood Lead Poisoning Prevention Program 3838 N. Rural Street Indianapolis, IN 46205 317-221-2171 www.mchd.com

Child's Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Blood Lead Screening

I understand that a blood screening is necessary because lead poisoning can occur without symptoms. Screening requires a blood sample obtained by a fingerstick or venipuncture.

With a fingerstick, blood is taken from the child's finger. With a venipuncture, blood is taken from the child's arm.

If the fingerstick indicates that my child's blood levels are elevated, a representative from the Marion County Childhood Lead Poisoning Prevention Program will contact me to schedule a venipuncture. This test is necessary to confirm if my child has lead poisoning.

Sharing of Information

I understand that my child's test results are confidential medical information. Under Indiana law, the results of a blood lead test will be shared with other public agencies in a confidential matter. The agencies will take care to protect my and my child's privacy. Sharing information will help my child if lead poisoning is identified.

I understand if lead is present in my child's blood, Indiana Code 16-41-39.4-3 requires the laboratory that analyzes the blood to report the test result and all demographic information to the Indiana State Department of Health (ISDH).

I understand that lead-poisoned children need immediate medical attention. In order to provide this help, ISDH will share this information with other public agencies, which work to prevent and treat lead poisoning. The agencies include the Family and Social Services Administration, the Department of Health and Human Services, the Department of Housing and Urban Development and other housing agencies at the local, state and federal level.

Signature of Verification

By signing below I agree that I have read, understand and authorize the sharing of information regarding my child's blood lead screening and test results.

Parent/Legal guardian name(Required)

First Middle Last

Parent/Legal guardian signature(Required)

Date(Required)

MM slash DD slash YYYY

MARION COINTY PUBLIC HEALTH DEPARTMENT CLIENT REGISTRATION FORM

Please complete this form so we can provide the best care possible. The information you share with us is part of your confidential medical record. Some infectious diseases must be reported to the Indiana State Department of Health in accordance with Indiana state law (IC 16-41-2-1).

Birth Date(Required)

MM slash DD slash YYYY

Child's Name(Required)

First Middle Last

Nickname, other names used:(Required)

Maiden:(Required)

Address(Required)

Street Address City State ZIP Code

Phone Number(Required)

Email address(Required)

Sex/Gender(Required)

Male

Female

Trans (Male - Female)

Trans (Female - Male)

Marital Status(Required)

Single

Married

Divorced

Widowed

Separated

Primary Language(Required)

English

Spanish

Other

Is the patient of a multiple birth? (twin, triplet, etc.) Check the box if the answer is Yes

Yes

Please answer both questions: Please select all that apply. (This information is for statistical use only)

1. What is this person’s race?(Required)

African American or Black

American Indian or Alaskan Native

Asian Indian

Chinese

Filipino

Guamanian or Chamorro

Hawaiian Native

Japanese

Korean

Samoan

Vietnamese

White

Other

2. Is this client Hispanic/Latino?

No, not Spanish/Hispanic/Latino

Yes, Mexican, Mexican Am., Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, other Spanish/Hispanic/Latino

Insurance Information

Medicaid/Hoosier Health Wise ID#(Required)

Dental Insurance

Company(Required)

ID#(Required)

Subscriber#(Required)

Medicare ID#(Required)

Other Medical Insurance

Company:(Required)

Policy#(Required)

Smoking Status (Select one if over the age of 12)(Required)

Current Smoker

Former Smoker

Never Smoked

Parent or guardian information (if under age 18)

Name(Required)

First Middle Last

Date of birth:(Required)

MM slash DD slash YYYY

Relationship(Required)

Address(Required)

Street Address City State ZIP Code

Phone Number(Required)

In case of emergency, who should be contacted?(Required)

Phone Number(Required)

Acknowledgement of receipt of Notice of Privacy(Required)

I have received a copy of this office’s Notice of Privacy Practices. (You may refuse to sign this acknowledgement)

Authorization for Services(Required)

I hereby authorize the Marion County Public Health Department to examine, test or provide services to the patient listed above. Test results and treatment will be explained to me as part of my visit today. If follow-up is needed or any test/exam results or appointment reminders, I will be contacted by a staff member.

Patient/Parent/Guardian signature:

Date

MM slash DD slash YYYY

Name(Required)

First Middle Last

Date(Required)

MM slash DD slash YYYY

MCPHD#(Required)

Please check any of the following, which the patient has had or has currently:(Required)

ADHD/ADD

Alcoholism

Anemia

Arthritis

Artificial heart valve

Asthma or hay fever

Blood transfusions

Bruise easily

Cancer or tumor

Chemotherapy

Chest pains

Cold sores

Cortisone medication

Diabetes

Drug addiction

Emphysema

Epilepsy or seizures

Fainting or dizzy spells

Fever

Glaucoma

Heart attack or stroke

Heart condition

Heart murmur

Heart pacemaker

Heart surgery

Hemophilia

Hepatitis

Herpes

High blood pressure

Hip/joint replacement

HIV/AIDS

Kidney trouble

Liver disease

Lung disease

Night sweats

Osteoporosis

Pain in jaw joints

Psoriasis

Psychiatric treatment

Radiation therapy

Rheumatic fever

Shortness of breath

Sickle cell anemia

Sickle cell trait

Skin rashes or hives

Swelling of ankles

Thyroid disease

Tuberculosis (TB)

Venereal disease

Weight loss

Yellow jaundice

None

1. Have you ever received any health-related service from the Marion County Public Health Department?(Required)

Yes

2. Do you have any diseases, conditions or problems not listed above?(Required)

Yes

3. Are there any activities in gym class, athletics or other physical activities restricted in any way?(Required)

Yes

4. Are you presently taking any medicine or drugs?(Required)

Yes

5. List medication(s), dosage and directions(Required)

6. Are you now or have you been under the care of a physician during the last two years?(Required)

Yes

7. Have you ever been hospitalized or had surgery?(Required)

Yes

8. Are you allergic to latex?(Required)

Yes

9. Are you allergic to any medicine, drug or other substance?(Required)

Yes

If “yes”, please list:(Required)

10. Have you ever had a reaction to local anesthetic?(Required)

Yes

11. Have you ever had a prolonged or unusual bleeding?(Required)

Yes

12. Have you ever had complications or illness following dental treatment?(Required)

Yes

13. Have you ever had any injury or trauma to your face or jaw?(Required)

Yes

14. Do you smoke or use smokeless tobacco?(Required)

Yes

15. Are you nervous or concerned about having dental work done?(Required)

Yes

16. Women: Are you pregnant?(Required)

Yes

Women: Do you use birth control?(Required)

Yes

Women: Do you anticipate becoming pregnant?(Required)

Yes

Women: Have you had any complications or problems with previous pregnancies?(Required)

Yes

17. Do you presently have a dentist?(Required)

Yes

Dentist’s Name(Required)

Address(Required)

18. Are you having dental pain or discomfort at this time?(Required)

Yes

19. Why are you seeking dental treatment?(Required)

(Required)

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have a change in my health, or if my medicines change, I will inform the doctor at the next appointment. Specific dental procedures will be explained to me. I understand that I/my child may not be able to receive all of the desired services from the Marion County Public Health Department and my treatment may require the need for me to be referred to other dental practitioners due to the nature of my dental problem. I understand that all dental procedures have benefits as well as certain risks, including possible side effects from some medicines used in dentistry and that these risks include, but are not limited to allergic reactions, cuts/ abrasions, tenderness/bruising from injections, sensitive teeth, swallowing inhaling dental materials/prosthesis and infections or serious complications or conditions.

Patient/Parent/Guardian signature:(Required)

Date(Required)

MM slash DD slash YYYY

(Required)

I also authorize and agree that the Health and Hospital Corporation of Marion County may keep or compile health information in any manner and is hereby authorized to use any treatment records, x-rays or photography for teaching or research purposes, including scientific journals or government-related publications. Patient confidentiality will be protected. Patient’s name or other private identifying information will not be released.

(Required)

I hereby authorize insurance benefits to be paid directly to the dentist or their representative (Health and Hospital Corporation). I also authorize the dentist or other appropriate staff or representative to release information required to process claims and agree that a photocopy of this authorization is as valid as the original. I also agree that the Marion County Public Health Department may release a copy of my medical/dental record, or any portion thereof, or other information to the health professionals involved with my medical/dental care.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Child's Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Please list everyone that lives with you

Name

Birthday

Relationship

Gender

School

(Staff Use) MCPHD#

PATIENT CONTACT AUTHORIZATION

The Marion County Public Health Department allows you to request to receive communications regarding appointments, lab results, treatment and/or other health information. Please check all that apply:

I do not want any contact made.

Telephone Communication

Home Phone(Required)

(Required)

OK to leave a detailed voicemail message

Leave message with call back number only

Do not leave a message

Cell Phone(Required)

(Required)

OK to leave a detailed voicemail message

Leave message with call back number only

Do not leave a message

Work Phone(Required)

(Required)

OK to leave a detailed voicemail message

Leave message with call back number only

Do not leave a message

Other Phone

OK to leave a detailed voicemail message

Leave message with call back number only

Do not leave a message

Okay to leave a message with:

First Last

Relationship

Written Communication

You may contact me by mail using my home address

You may contact me by mail using my work/office address

If you have any other special request, please list:

Signature(Required)

Date(Required)

MM slash DD slash YYYY

If you change your mind after completing this authorization, you must submit a written cancellation of the authorization. This will not affect or undo any disclosure prior to this notification.

Dear Parent or Guardian: The Marion County Public Health Department (MCPHD) Smile Mobile will be visiting your child’s school soon. The Smile Mobile is a forty foot, fully equipped dental office that comes complete with a reception/education area, a two chair dental treatment area, and a complete lab/ sterilization area. The Smile Mobile provides a mobile dental office for all children ages 18 and younger. Our goal is to provide a positive dental experience and an opportunity for better oral and overall health for your child. The MCPHD Smile Mobile is staffed by a highly qualified, professional and friendly dental team from the Marion County Public Health Department. The safety of your child is assured by ethical standards of practice by staff and dental services that are provided in a safe, sterile and pleasant environment. All dental instruments are sterilized or disposed of after each patient. The MCPHD Smile Mobile provides dental examinations, x-rays, cleanings, fluoride treatments and dental education during your child’s visit. If time allows, dental sealants are also provided. Your child will be encouraged to brush and floss daily to maintain a healthy smile and teeth. After the visit, a dental report from the dentist will be sent home with your child. The report will inform you on what treatment was provided and what further treatment is recommended. You will also receive a MCPHD Dental Services brochure listing MCPHD dental clinics where your child can receive further recommended treatment or you may seek treatment at a dental office of your choice. The dentist will contact you immediately regarding any urgent or emergency recommended treatment. There is an administration fee of $20 for your child’s dental visit. Medicaid and personal insurance reimbursement are also accepted as payment. Please be sure to include your child’s Medicaid or your personal insurance information with the attached registration and treatment consent form. If you do not have Medicaid or personal insurance for your child, a mail-in payment request for the $20 fee and a blue, self-addressed, return envelope will be sent home with your child. Money will not be collected at the visit. If you would like for your child to receive dental services from the MCPHD Smile Mobile, please fill out, in full, the attached form regarding your child’s medical history, family physician and a telephone number where you (or other adult family member) can be reached during the school day. Please sign the form and return it to your child’s school immediately. Please do not send money with the form or your child. We look forward to serving your child’s dental health needs! Sincerely, The MCPHD Smile Mobile Dental Team * In order for your child to receive services, please answer all questions in ink and return this completed form to your child’s school.

Dental Consent Form

School(Required)

County(Required)

Grade(Required)

Teacher(Required)

Parents/Guardian Consent(Required)

DENTAL SAFARI COMPANY, a fully licensed, professional corporation, will be at your child’s school. By signing this consent form, your child will receive a visual exam (no x-rays) by a licensed dentist, a cleaning, Fluoride, and sealants as needed.

Parent/Guardian Name(Required)

First Middle Last

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Child's Legal Name(Required)

First Middle Last

Gender(Required)

Male

Female

Birth Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

OK to text?(Required)

Yes

Cell Phone(Required)

Email(Required)

Is Child Eligible for Free or Reduced Lunch?(Required)

Yes

Medicaid / Hoosier Healthwise RECIPIENT ID#(Required)

Does Your Child have PRIVATE Dental Insurance?(Required)

Yes

Primary Card Holder Name(Required)

First Middle Last

Phone(Required)

Employer(Required)

Primary’s Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary’s Birth Date(Required)

MM slash DD slash YYYY

DENTAL Insurance Company(Required)

Insurance Company Phone(Required)

Members ID#(Required)

Group #:(Required)

Does child need PreMedication with antibiotics for dental treatment?(Required)

Yes

IF YES – Please call our office: (618) 993-8333

HEALTH HISTORY

PLEASE FILL OUT COMPLETELY

Has your child had any history of the following?(Required)

Check ALL that apply

AD/HD

Allergies (seasonal)

Asthma

Autism

Blood Disorders

Cancer

Cerebral Palsy

Chronic Sinusitis

Diabetes

Ear Aches

Growth Problems

Hearing

Heart

Heart Murmur

Pregnancy

Seizures

Speech Difficulties

Surgeries

Tobacco / Drug Use

Other

Please Describe:

Is child allergic to ANY medication?(Required)

Yes

If YES, please list(Required)

Is child taking ANY medications at this time?(Required)

Yes

if YES, please list(Required)

Has your child ever suffered injuries to the mouth, head, or teeth?(Required)

Yes

If YES, please list(Required)

Does child’s home have well water?(Required)

Yes

IMPORTANT: PARENT / GUARDIAN SIGNATURE REQUIRED(Required)

I am a custodial parent or legal guardian of the minor child named above. I authorize and consent to this child receiving the dental treatment described, and allow the school nurse/school representative and dental provider access to child’s dental record.

Signature(Required)

Relation to Child(Required)

Date(Required)

MM slash DD slash YYYY

Dentist’s Initials

Free Well-Child Examination Consent Form

Please complete the following information:

First Middle Last

, give permission for a physician or nurse practitioner licensed in Indiana, to conduct a well-child examination on my child.

First Middle Last

Center Enrolled:(Required)

Parents Signature(Required)

Date(Required)

MM slash DD slash YYYY

Finding Your ACE Score

We have been asked to implement the ACE questionnaire at intake to be used as a data collection tool. ACE stands for Adverse Childhood Experiences. Studies have shown that 70% of the general population have experienced at least one of the ten events addressed in this survey. Nationwide efforts are being made to become more “trauma informed” and develop systems of care that address resulting needs. FDS is joining this movement to increase our quality of services. We realize that the questions in this survey are sensitive in nature and want to assure you that your score is confidential. This is an optional questionnaire....if you choose to answer the 10 questions… I ask that you score your questionnaire and include the score below. Thank you for partnering with us in this effort to meet the needs of our families.

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt?

2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? Or attempt or actually have oral, anal, or vaginal intercourse with you?

4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? Or your family didn’t look out for each other, feel close to each other, or support each other?

5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Were your parents ever separated or divorced?

7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or smetimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit at least a few minutes or threatened with a gun or knife?

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

10. Did a household member go to prison?

Now add up your “Yes” answers:(Required)

This is your ACE Score.

Asthma Screening Tool

Is your child at risk? Ask yourself the following questions:

1.When the seasons change, does your child require medication and/or a breathing treatment?

2. Has albuterol been used to treat your child for a medical condition in the past six months?(For example: Bronchitis or respiratory infection, croup, whooping cough)

3. Has your child been diagnosed with asthma or reactive airway disease by a medical provider?

4.Has your child been prescribed an albuterol medication such an inhaler or albuterol sulfate nebulizer solution to use ongoing as needed?

An asthma attack is generally defined as shortness of breath that interrupts your well being, requiring either medication or some other form of treatment, such as a nebulizer, to allow you to breathe normally again.

If you suspect that your child is suffering from asthma, you must visit a doctor as soon as possible. Asthma can be a life-threatening illness if not properly controlled.

If you suspect that your child may be even slightly asthmatic, take him/her to the doctor for advice as soon as possible. Please do not ignore any symptoms and dismiss it as a “onetime” event; the next one could be more serious.

Often young children cannot perform a lung test, but a doctor is usually able to tell if a child has asthma from either the symptoms that are present or by giving a trial of asthma treatment to see if the problem is reduced.

In infants and children, asthma may appear as cough, rapid or noisy breathing, or chest congestion.

If you answered “yes” to any of the above questions your child may be at risk for asthma or their asthma may not be well managed. Call your doctor and schedule a check-up for your child.

Asthma Screening Confirmation Sheet

I, parent/guardian of

Child's Name(Required)

First Middle Last

State that my child(Required)

does not have asthma.

does have asthma.

(Required)

I understand that I am required to provide an asthma action plan and current medication before my child can enroll in school.

Parent/Guardian Signature:(Required)

Date(Required)

MM slash DD slash YYYY

Comments:

This field is for validation purposes and should be left unchanged.

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Contact us

317-803-3803

Attendance Hotline

317-217-1415

Applicant Child

Primary Adult

Primary Adult Contact Information

Secondary Adult

Secondary Adult Contact Information

Family Information

Other Non-Applicant Children in Family

Parent/Guardian Consent

Income Verification Statement

Homeless Determination Checklist

Emergency Information & Authorization for Release Card

Consent for Services

INDIANA UNIVERSITY SCHOOL OF OPTOMETRY VISION FOR THE FUTURE CONSENT TO TREAT MINOR PATIENT

INDIANA UNIVERSITY SCHOOL OF OPTOMETRY VISION FOR THE FUTURE DILATION INFORMATION

Authorization for Release and Receipt of Child Records

PHOTOGRAPHY/VIDEO PARENTIAL/GUARDIAN CONSENT FORM

CACFP Enrollment Form

Consent to Blood Lead Screening and Authorization to Share Information Form

Blood Lead Screening

Sharing of Information

Signature of Verification

MARION COINTY PUBLIC HEALTH DEPARTMENT CLIENT REGISTRATION FORM

PATIENT CONTACT AUTHORIZATION

Dental Consent Form

HEALTH HISTORY

Free Well-Child Examination Consent Form

Finding Your ACE Score

Asthma Screening Tool

Asthma Screening Confirmation Sheet

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