Green Hills Head Start Child’s Name ______

Parent Authorization Location ______

for Services

Your signature on this agreement will allow your child to receive services during his/her enrollment in Head Start. Late enrollees have thirty days to complete the necessary services. FAILURE to comply with the standards of this agreement may result in your child NOT receiving the full Head Start experience. Please initial each item.

I understand the following should be completed
PRIOR to class attendance by Professional assessment…
Physical Examination, (as required by the MDOH) / Blood Pressure
Immunizations, as required by the MDOH / Dental Examination
Hematocrit/Hemoglobin & Lead Test (Finger stick) / Developmental Screening (by Head Start Staff)
I understand the following are assessed by a Head Start staff member
AFTER my child is enrolled…
Auditory Screening (Hearing) / Vision Screening
Tympanogram (Middle Ear) / Fluoride Varnish (2x year)
I understand the following will be the
PARENT’s RESPONSIBILITY to complete as needed and advised by Head Start staff…
Health Treatment (Includes follow-up for dental, hearing and vision conditions.)
Educational/Developmental Evaluation (Usually provided through local education agencies.)
AUTHORIZATION:
This document has been explained to me, I understand the conditions of participation in this program. Further…
1.  I authorize the completion of the above mentioned services and any emergency medical and/or dental treatment, if necessary, by Head Start staff or a qualified professional.
2.  I authorize the release of my child to persons as designated and documented in my child’s file.
3.  I have received information regarding this facility’s policies pertaining to the admission, care and discharge of children. This information can also be located on the website: www.greenhillsheadstart.org/parent_info.htm
4.  I have been informed that a copy of the Licensing Rules for Group Child Care Homes/ Licensing Rules for Child Child Care Centers in Missouri is available at this facility for review and at: http://www.sos.mo.gov/adrules/csr/current/19csr/19c30-62.pdf.
5.  The provider and I have agreed on a plan for continuing communication regarding my child’s development, behavior, and individual needs.
6.  When my child is ill, I understand and agree that s/he may not be accepted for care or remain in care. (See Illness Policy and Plan of Care in Parent Handbook.)
7.  Upon advance notification, I further grant permission for my child to participate in supervised field trips and travel by public/private transportation.
8.  I grant permission for my child to be photographed and/or videotaped for assessment purposes or use in communication media (newspaper, brochure, webpage, Facebook, etc.)
9.  I understand that this program does not provide transportation services.
10. I grant permission for my child to be observed by education/health professionals for evaluation purposes. Further, I authorize the sharing of education/health records used to facilitate education/health evaluations.

______

Signature (Parent/Guardian) Date Witness