Head Start Health Procedure Agreement

ATCAA EARLY CHILDHOOD SERVICES Early Childhood Services/State Preschool

HEALTH PROCEDURE AGREEMENT

Child’s name: ______

Dear Parent and Physician, Head Start Program Performance Standards and California Department of Social Services require that children who attend Early Childhood Services’ programs meet the following health requirements:

1. A completed physical exam within 30 days of entering the program. The physical exam shall include all of the following:  Health history and physical exam  Height and weight  Nutrition assessment  Blood pressure  Lead screening (if indicated)  Vision screening  Hearing screening  Hemoglobin or Hematocrit  Immunization assessment  TB test (needed only if risk factors present)

2. Immunizations must be kept current. 3. A dental screening must be done within 90 days of entry.

AGREEMENT I agree to the following: 1. To obtain any additional immunizations that might be required when they are due. I understand that if immunizations are not kept current my child will not be allowed to attend the program until their immunizations are brought up to date. 2. To have a completed physical exam (CHDP) done by: (date) ______3. To have a dental exam done by: (date) ______

I understand that if the CHDP (physical examination) is not complete, it is my responsibility to return to the doctor or clinic to complete all portions.

I give my consent to the Early Childhood Services Program to perform the following services as needed during the school year.  Vision screening  Hearing screening  Health Education (such as tooth brushing)  Developmental screening  Height and Weight  Other individual screening (motor development, social emotional development, and learning disabilities)

Early Childhood Services staff will keep me informed as each procedure takes place, and give me the results of all procedures and services my child receives.

______Parent/Legal Guardian signature Date Staff signature Date

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