PRESCHOOL STUDENT INFORMATION *To update information after enrolled, contact the teacher.
PARENT/GUARDIAN INFORMATION *To update information after enrolled, contact the teacher.
Parent/Guardian Last Name First Name Middle Name Phone
Relationship to child Address Alternate Phone
Parent/Guardian Last Name First Name Middle Name Phone
Relationship to child Address Alternate Phone
EMERGENCY CONTACT OTHER THAN PARENT *To update information after enrolled, contact the teacher.
Last Name First Name Middle Name Phone
Relationship to child Address Alternate Phone
Parent/Guardian Signature: _____________________________________________________________________________________ Date: _________________________ Preschool Staff Intake Signature: _________________________________________________________________________________ Date: ________________________
**Please turn over to the back of this form for income information**
**NOTE TO PRESCHOOL OFFICE STAFF: ONLY SEND THIS SIDE OF THE APPLICATION TO SCHOOL**
FOR OFFICE USE ONLY: IDENTITY AND HEALTH DOCUMENTATION
Correct Age
Yes
Birthdate:
Custody papers (if applic.) Yes - See PLP tab in IC and/or check with teacher for most current information.
N/A
Legal Identity Proof
Yes
Birth Certificate Affidavit (30 day date: )
Passport Immigration Docs
TB Skin Test (if applic.)
Yes N/A
Immunization Certificate
Yes
Exp. Date:
Physical Exam
Yes
Exam Date:
Eye Exam
Yes
Exam Date:
HS ONLY: Dental
HS ONLY: Lead Test
Initial: Copy for Health Dept HH Form Sent Stud. Health Sent Mid-Summer Letter Sent Placement Letter Sent Copy for teacher Child’s Last Name(s) (As listed on legal birth certificate) - First Name - Middle Name (if applicable) Date of Birth Child’s Gender
Male Female
Home Address City Zip
Is Transportation Needed?
Yes No
List special transportation devices, if applicable. Transportation Address (If pick-up/drop-off address is different than home)
Are there siblings currently attending a Fayette County Public Elementary School?
No Yes. If yes, what elementary school are they attending? Session Preference
AM PM
If left blank, we assume you have no preference.
Primary Language English Other: _________
If primary language is other than English, would you prefer initial teacher contact
be in primary language when possible? Yes No
Number of people in household # of Adults:_____ # of Children:_____ Ethnicity (Check all blocks that apply.)
American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Black/African American Asian White
Is the student Hispanic/Latino? No Yes Do you have concerns about your child’s development?
No Yes. If yes, please briefly explain here.
OFFICE USE ONLY: COMPLETED IN PRESCHOOL OFFICE HOUSEHOLD F. ___ STUDENT HEALTH F.___ SCANNED INTO IC ___
2017-2018
JOINT PRESCHOOL REGISTRATION FORM
FAYETTE COUNTY PRESCHOOL / COMMUNITY ACTION COUNCIL HEADSTART Return to: FCPS 701 E. Main St. Lexington, KY 40502 (physical location) or Mail to: FAYETTE PRESCHOOL 1126 Russell Cave Rd. Lexington, KY 40505
FAMILY INCOME INFORMATION
Do you or anyone in your household work? Yes No
Do you or anyone in your household receive government assistance such as food stamps? Yes No
What is your monthly combined family household income? $
You will be asked to show proof of income or government assistance award at registration WE THANK YOU FOR COMPLETING AND SUBMITTING THIS APPLICATION
FOR OFFICE USE ONLY: PROOF OF ADDRESS AND INCOME
Proof of Address Yes Lease/Deed OR Utility Bill OR Residency Affid. OR Printed PVA
YEARLY GROSS TOTAL INCOME: ______________ NUMBER OF PEOPLE IN HOUSEHOLD: _________
MAXIMUM GROSS YEARLY INCOME BY FAMILY OF:
APPROVED
2 - $25,984 6 - $52,736
3 - $32,672 7 - $59,424
OVER-INCOME
4 - $39,360 8 - $66,112
5 - $46,048
CALCULATED BY:
Do you need information about child care before or after Preschool? If yes, please read the information below.
***Head Start (Community Action Council) provides full day childcare for families who qualify based on availability. You must contact the Head Start office to determine your eligibility at 859-233-4600.
***For help finding information about local child care provider opportunities, contact The Kentucky Partnership for Early Childhood Services toll-free at 1-877-316-3552 or visit their website at www.kentuckypartnership.org.
Qualifies for McKinney Vento Act on Resid. Affid.? Yes If yes, no income proof is required. **Note: Make sure to make a copy for the MCV Office.** Qualifies for SNAP/Food Stamp Assistance? Yes If yes, no other income proof besides current SNAP award letter is required.
SNAP valid through ________________________ OR Benefit Verification Letter date _____________________________
Paystub OR W-2
$
Weekly Biweekly Monthly Yearly Supplementary Income$
Weekly Biweekly Monthly Yearly Supplementary Income$
Weekly Biweekly Monthly YearlyForm Revised 10/01/2017
Pink 17-18 Registrar_____________ Date_________________
FAYETTE CO PUBLIC SCHOOLS HOUSEHOLD FORM (2017-18)
Household Address: ____________________________________________________________________ Apt # ________________ City: _____________________________________________ State: _______________________ Zip: ________________________ Household Phone Number: ( )_________________________________
STUDENT #1 - LIVING at this address with guardians listed below:
NAME Last: ___________________________________ First: _______________________________ Middle: __________________
Birthdate: ___________________ Gender:
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M Grade Level: ___________ School: ______________________________STUDENT #2 - LIVING at this address with guardians listed below:
NAME Last: ___________________________________ First: _______________________________ Middle: __________________
Birthdate: ___________________ Gender:
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M Grade Level: ___________ School: ______________________________STUDENT #3 - LIVING at this address with guardians listed below:
NAME Last: ___________________________________ First: _______________________________ Middle: __________________
Birthdate: ___________________ Gender:
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M Grade Level: ___________ School: ______________________________STUDENT #4 - LIVING at this address with guardians listed below:
NAME Last: ___________________________________ First: _______________________________ Middle: __________________
Birthdate: ___________________ Gender:
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F M Grade Level: _____________ School: ______________________________Please list parent(s)/guardian(s) NOT LIVING with student(s) on PAGE 2
PARENT/GUARDIAN – LIVING at this address with student(s):
NAME Last: ___________________________________ First: _______________________________ Middle: __________________
Gender:
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M Birthdate: ______________________ Email Address: ____________________________________________Cell Phone: _________________________ Other Phone: ________________________ Work Phone: ________________________
Relationship(s): Parent Step-Parent Foster Parent Legal Guardian – Specify relationship Parent Portal Access
Student # 1
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_______
Yes NoStudent # 2
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_______
Yes NoStudent # 3
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_______
Yes NoStudent # 4
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Yes NoPARENT/GUARDIAN – LIVING at this address with student(s):
NAME Last: ___________________________________ First: _______________________________ Middle: __________________
Gender:
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F□
M Birthdate: ______________________ Email Address: ____________________________________________Cell Phone: _________________________ Other Phone: ________________________ Work Phone: ________________________
Relationship(s): Parent Step-Parent Foster Parent Legal Guardian – Specify relationship Parent Portal Access
Student # 1
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Yes NoStudent # 2
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Yes NoStudent # 3
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Yes NoStudent # 4
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Yes NoI certify the information on this form is correct and understand that I must contact the school with any changes.
PLEASE LIST PARENT(S)/GUARDIAN(S) NOT LIVING WITH STUDENTS IN THIS SECTION
PARENT/GUARDIAN - NOT LIVING with student(s):
NAME Last: ________________________ First: ____________________________________ Middle: ______________________
Gender:
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F□
M Birthdate: ___________________ Household Phone Number: ___________________________________Address: ______________________________________________________________________ Apt # _______________________ City: ______________________________________State: ________________ Zip: _______________________________________ Email Address: ___________________________________________________
Cell Phone: _________________________ Other Phone: ________________________ Work Phone: ________________________
Relationship(s): Parent Step-Parent Foster Parent Legal Guardian – Specify relationship Parent Portal Access
Student # 1
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Yes NoStudent # 2
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Yes NoStudent # 3
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Yes NoStudent # 4
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Yes NoPARENT/GUARDIAN - NOT LIVING with student(s):
NAME Last: ________________________ First: ____________________________________ Middle: ______________________
Gender:
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F□
M Birthdate: ___________________ Household Phone Number: ___________________________________Address: ______________________________________________________________________ Apt # _______________________ City: ______________________________________State: ________________ Zip: _______________________________________ Email Address: ___________________________________________________
Cell Phone: _________________________ Other Phone: ________________________ Work Phone: ________________________
Relationship(s): Parent Step-Parent Foster Parent Legal Guardian – Specify relationship Parent Portal Access
Student # 1
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Yes NoStudent # 2
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Yes NoStudent # 3
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Yes NoStudent # 4
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Yes NoEMERGENCY CONTACTS - OTHER THAN GUARDIANS
Primary Contact Last Name First Name Middle Name Sex
F M
Relationship to Student
Cell Phone Other Phone Work Phone Home Address
Secondary Contact Last Name First Name Middle Name Sex
F M
Relationship to Student
Cell Phone Other Phone Work Phone Home Address
Third Contact Last Name First Name Middle Name Sex
F M
Relationship to Student
PH LHD-SH 650
Please Return Completed Form To School Nurse
LEXINGTON-FAYETTE COUNTY HEALTH DEPARTMENT (LFCHD)
SCHOOL HEALTH SERVICES DIVISION
650 Newtown Pike
Lexington, Kentucky 40508-1197
(859) 288-2314
(859) 288-2313 FAX
SCHOOL: __________________________________________________ SCHOOL YEAR: __________________
Last Name :
_______________________________
First Name :__________________________________
MI :____
( P l e a s e g i v e s t u d e n t ’ s c o m p le t e l e g a l n a m e . )
Student’s Social Security #
_________________________________
Birth Date:____________________________
Race: _______________________ Male Female
Home Room Teacher:
________________________________
Street Address___________________________________________ City_________________________ Zip ________________ Mother _______________________________ Hm Ph ________________ Wk Ph ________________ Cell Ph _____________ Father _______________________________ Hm Ph_________________ Wk Ph ________________ Cell Ph _____________ Legal Guardian _________________________ Hm Ph_________________ Wk Ph ________________ Cell Ph_____________
Emergency Contact Person OTHER than Guardian or Parent ___________________________________________________________
Relationship: ____________________________ Hm Ph ________________ Wk Ph ________________ Cell Ph ____________ STUDENT’S Medical Insurance
Does your student have a KY Medicaid or K-CHIP Card? Yes / No Number ______________________________ Does your student have other medical insurance? Yes / No Name of Company________________________________
STUDENT’S Medical History
1) Significant Medical History: _________________________________________________________________________ 2) Medication Allergies: ___________________________________ Food Allergies: ______________________________ 3) Other Allergies: ___________________________________________________________________________________ 4) Medications taken Daily: ____________________________________________________________________________ 5) * Prescription Medication to be given at School: _________________________________________________________ Student’s Health Care Provider: _____________________________________________ Phone: ____________________ * Must complete Medication Consent Forms prior to any prescription medications being brought to school to be administered.
Forms are available at school.
Does your student have any of the following life-threatening conditions that may require EMERGENCY treatment or medications to be given at school?
DIABETES (Glucagon)
ASTHMA (Rescue Inhaler)
SEIZURES (Diastat)
LIFE-THREATENING ALLERGY (Epi-Pen)
OTHER: _________________CONSENT FOR HEALTH SERVICES / ASSIGNMENT OF BENEFITS
All students will receive basic First Aid and emergency care. By signing this form, I consent to School Health services given to my student by Nurses or agents of the LFCHD while at school. I authorize the LFCHD to release medical information about my student to his/her Primary Care Provider. I also understand that the information obtained from the School Physical, including Immunization information, will be released to my student’s school. If I or my student has Medicaid or KCHIP, I authorize the LFCHD to release this information to Medicaid/KCHIP so that Medicaid/KCHIP can be billed for services provided by the School Nurse, at no cost to me.
I also understand that by signing this consent, I acknowledge that I have access to a copy of the Lexington-Fayette County Health Department’s Privacy Notice located at www.lexingtonhealthdepartment.org or I may request a copy by calling School Health Services at 288-2314. This form will remain in effect for your child through his/her 12th grade unless revoked in writing.
X__________________________________________________ ____ / ____ / ____
(Signature of Parent / Legal Guardian / Emancipated Student) (Date signed)
THIS SECTION FOR SCHOOL USE ONLY
Care Plan(s) Date: __________________ Date: __________________ Sent Date: __________________ Date: __________________
Care Plan(s) Returned
Date: __________________ Date: __________________
Student Health Information
PH LHD-SH 650
Favor de entregar este formulario completado a la Enfermera de la Escuela
LEXINGTON FAYETTE DEPARTAMENTO DE SALUD (LFCHD) DIVISIÓN DE SERVICIOS DE SALUD DE ESCUELA
650 Newtown Pike Lexington, Kentucky 40508-1197 (859) 288-2314 Fax (859) 288-2313
ESCUELA: _______________________________________________ AÑO ESCOLAR: ________________________
Nombre Completo: _________________________________________________________________________________________ Seguro Social # del Estudiante: ____________________________ Fecha de Nacimiento: ___________________ Raza: ___________________ Masculino Femenina Inicio Sala de Maestros: ______________________
Domicilio: _____________________________________ Ciudad: _____________________ Código Postal: _________ Teléfono de Casa: Teléfono de Trabajo: Teléfono de Celular
Madre: __________________________________________ _________________ _________________ __________________
Padre: __________________________________________ _________________ _________________ __________________
Tutor Legal: ___________________________________ _________________ _________________ __________________
Contactado de Emergencia que no sea los Padres o Encargado: __________________________________________________________ Relación al Estudiante: __________________________________ Número Telefónico en caso de Emergencia: __________________
SEGURO MÉDICO DE ESTUDIANTE
¿Tiene su estudiante una tarjeta de Medicaid o KY K-CHIP? Si / No Número: _______________________________________ ¿Tiene su estudiante otro seguro médico? Nombre de Compañía: ____________________________________________________
HISTORIA CLÍNICA DE ESTUDIANTE
1) Historial Médica: ___________________________________________________________________________________________ 2) Alergias Médicas: _______________________________ Alergias de Comida: __________________________________________ 3) Otras Alergias: ____________________________________________________________________________________________ 4) Medicamentos de Administración Diaria: ________________________________________________________________________ 5) * Medicina con Receta que debe darse en la Escuela: ___________________________________________________________ Nombre del Proveedor de Atención Médica del Estudiante: ____________________________________ Teléfono: _______________
* Debe completar un Consentimiento para Medicina antes de traer cualquier medicina a la escuela para que se le administre a su estudiante. Los formularios de consentimiento están disponibles en la escuela.
¿Tiene su estudiante alguna de las condiciones siguientes que ponga en riesgo su vida que puedan requerir tratamiento de EMERGENCIA o que se le den medicinas en la escuela?
DIABETES
ASMA
LOS ATAQUES
ALERGIA DE VIDA-AMENAZANDO(Glucagon) (Inhalador de Rescate) (Diastat) (Epi-Pen)
OTRO _________________________________________________________________________________________________CONSENTIMIENTO DE SERVICIOS DE SALUD / ASIGNAMIENTO DE BENEFICIOS
Todos los estudiantes recibirán Primeros Auxilios básicos y atención de emergencia. Al firmar este formulario, autorizo que
Enfermeras de Salud Escolar o agentes de LFCHD le provean servicios a mi hijo mientras esté en la escuela. Yo autorizo que LFCHD le dé información médica de mi estudiante a su Proveedor Médico Primario. Yo también entiendo que información obtenida del Examen Físico Escolar, incluyendo información de inmunizaciones, se la entregarán a la escuela de mi estudiante. Si yo o mi estudiante tenemos Medicaid o KCHIP, yo autorizo que LFCHD entregue esta información a Medicaid/KCHIP para que le puedan mandar la cuenta a Medicaid/KCHIP por los servicios proveídos por la Enfermera de la Escuela, sin ningún costo para mí.
Yo también entiendo que al firmar esta hoja doy me consentimiento, yo reconozco que tengo acceso a una copia de la Notificación de
Privacidad del Departamento de Salud de Lexington Fayette ubicado en:www.lexingtonhealthdepartment.org o puedo llamar a los
Servicios de Salud de la Escuela al 288-2314. Este documento permanecerá vigente para su niño hasta su grado 12 a menos que ustedes lo revoquen en escrito
X __________________________________________________________________________ _____ / _____ / ___________ (Firma de Padre/Tutor Legal/Estudiante Emancipado) (Fecha cuando firmó)
Favor de entregar este documento completado a la Enfermera de la Escuela
