Pre-K Counts/Headstart Program Enrollment

Little People’s Village

CHILD and FAMILY INFORMATION FORM

The information and documentation you provide will assist the Office of Early Childhood Education in determining your eligibility for The School District of Philadelphia's preschool program, You are obligated to provide accurate and complete information. Deliberate misrepresentation of your information may subject you to prosecution under applicable Federal and/or State laws. PLEASE PRINT CLEARLY and use BLUE or BLACK INK.

Section 1: CHILD

Mother Complete if child does not live with his/her mother

Father Complete if child does not live with his/her father

Little People’s Village

#1 CHILD and FAMILY INFORMATION FORM

Section 2: CHILD. continued

Child's Doctor

Child's Dentist

#1 CHILD and FAMILY INFORMATION FORM

Section 3: PRIMARY PARENT

The adult who is primarily responsible for the care and well-being of the child.

Employer Information Complete if you are Employed/Self-Employed

School/Job Training information Complete if you attend High School, College or a Job Training program

Section 4: SECONDARY PARENT

An adult who shares in the care of the child.

Employer Information Complete if you are Employed/Self-Employed

School/Job Training information Complete if you attend High School, College or a Job Training program

Section 5: FAMILY MEMBERS

List your name, the name(s) of your child(ren) and the names of all other adults and children who live with you in your home. Use additional paper if needed

Section 7: SIGNATURES

Read the following and sign where indicated.

l/We have completed all sections on my/our Child and Family Information Form and certify the information is correct. I/We understand that if any of my/our information is false, my/our participation in the preschool program may be terminated and l/we may be subject to legal action. l/We have attached a copy of my/our child's proof of date of birth, verification of my/our Philadelphia, PA address and copies of all income and monthly benefits that I/we and my/our children receive. l/We understand that this information is being given so that my/our eligibility can be determined for The School District of Philadelphia's preschool program. I/We understand that officials from The School District of Philadelphia, the Department of Health and Human Services and the Commonwealth of Pennsylvania will have access to and may verify the information and supporting documentation submitted with my/our Child and Family Information Form. l/We further understand that, if necessary, additional documents may be requested and I/we will comply with this request. l/We understand that my/our child's complete Preschool Application is confidential and will be held in strict confidence within The School District of Philadelphia and affiliated Community Nonprofit Partner Agencies that have been determined to be school officials under the Family Educational Rights and Privacy Act with legitimate educational interests as part of The School District of Philadelphia's preschool program.

#5: CHILD'S DIETARY or FOOD RESTRICTIONS FORM

Dear Parent/Guardian, The Child and Adult Care Food Program (CACFP) provides a daily nutritional breakfast, lunch and snack for your child at no cost to families. A monthly menu, posted in each location, lists the foods and beverages that your child is offered at each meal. The Office of Early Childhood Education recognizes the fact that certain foods, due to medical, religious or other reasons, are restricted from some children's diets. Please tell us about your child. This information will be shared with your child's nutritional, health and instructional staff. If your child has a non-disabling dietary restriction, efforts will be made to provide your child with an allowable substitution,

If your child has a food allergy or medical dietary concern that restricts his/her diet, the enclosed Medical Plan of Care Form for the Child ond Adult Care Food Program (Pages 33-34) must be completed by an appropriate health care professional and submitted with your child's Preschool Application. If your child has a food allergy which requires the administration of an EPI-PEN, Benadryl or other medication, please let us know immediately so that we can begin the process required to train the preschool staff.

The information on this form is true to the best of my knowledge. I will inform my child's teacher if any of this information changes.

#2: CHILD’S MEDICAL CONCERNS FORM

Dear Parent/Guardian, The Office of Early Childhood Education recognizes the fact that some children have a medical condition that requires prescribed medication. When the prescribed medication is to be administered during preschool hours, a representative from Early Childhood Health Services, with written permission, will train the staff at your child's preschool to administer the medication to your child. Written permission is given by submitting form MED-1: Request for Administration of Medication, completed by you and your child's health care provider for each medication. At no time will medication be given to your child without a completed MED-1.

The information on this form is true to the best of my knowledge. I understand that it is my responsibility to immediately inform my child's teacher or Early Childhood Health Services if there is a change to the information indicated above.

Part I: Place a check mark in the No or Yes Column next to each item. For all Yes responses, please explain in the Comments column

Little People’s Village

#8 VERIFICATION of INFORMATION FORM

Read the following statements and sign where indicated.

1. The information I/we have provided on all of the forms in my/our child's Preschool Application is accurate and complete. I/we have signed all application forms where indicated and have included copies of all required supporting documents. If any of my/our information is false, my/our participation in the preschool program may be terminated and I/we may be subject to legal action.
2. I/We understand that:
   1. The information contained in my/our child's Preschool Application will be held in strict confidence within The School District of Philadelphia and affiliated Community Nonprofit Partner Agencies that have been determined to be school officials under the Family Educational Rights and Privacy Act with legitimate educational interests as part of The School District of Philadelphia's preschool program.
   2. Completing and submitting a Preschool Application does not guarantee that my/our child will be accepted to a preschool program.
   3. Before my/our child's first day in preschool:
      1. I/We will attend an orientation meeting and an individual conference with my/our child's teacher and will receive a Parent Handbook.
      2. If my/our child's physical and/or dental exam dates are more than twelve (12) months old, I/We will be required to submit an up-to-date Child Health Assessment/Physical Exam Form, including a current immunization record and/or Child Dental Health/Dental Exam Form.
      3. I/We may be required to re-verify my/our Philadelphia, PA address, family income and/or monthly benefits.
      4. I/We will be notified if additional forms and/or documents are needed and will submit them as necessary.
3. During the time my/our child is enrolled in preschool:
   1. S/He will attend every school day, his/her health permitting.
   2. S/He will be escorted to and from school by an individual who is at least eighteen (18) years old.
   3. S/He will be able to use the toilet with minimal adult assistance
   4. I/We will abide by all program policies stated in the Parent Handbook and will adhere to the scheduled arrival and departure times for his/her location.
   5. I/We will keep my/our child's information current and inform his/her teacher and the Office of Early Childhood Education of any changes.
   6. I/We will always make sure my/our child's teacher has an active telephone number from within the Philadelphia calling area for me/us so that I/we can be contacted should the need arise.

2022-2023 PA Pre-K Counts Enrollment Form

(This information is confidential to the PA Pre-K Counts program)

• Parent of the child (biological or adoptive mother or father, stepmother or stepfather, caretaker or spouse)
• A biological, adoptive, unrelated or foster child or stepchild of the parent or caretaker who is under 18 years of age and not emancipated.
• A child who is 18 years of age or older but under 22 years of age who is enrolled in high school, a general educational development program, or a post-secondary program leading to a degree, diploma or certificate and who is wholly or partially dependent on the income of the parent or caretaker or spouse of the parent or caretaker.
• Others supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program. If counted toward family size, any applicable income of these persons must also be counted for eligibility purposes.