HARCATUS HEAD START - Change of Status Site

HARCATUS HEAD START - Change of Status Site:

Enter data into Child Plus as it is received. Staff Initials & Date Changes made on the appropriate forms in the Attendance Notebook and in the Bus Notebook. Complete a new section rather than a new form until a new form is needed. Child Name:______Parent Name(s):______Phone/Address Changes Family Status Child Release Information New Phone: □ Child New Name: (must provide □Add □Remove the following person ______documentation) from my child’s Family Agreement ______or Child Enrollment and Health New Message □ Parent New Name: Information form Phone:______Release New Cell: Parent Signature & Date: Person:______Phone: ______New Address: Address: ______Copy must be submitted to Bev Relationship: ______Statler in FA monthly report folder. Parent Signature & Date: ______Staff initials & date submitted: Staff Initials & Date ______Entered:______Staff Initials & Date Staff Initials & Date Entered:______Entered:______New Phone: ______New Message Phone:______□ Child New Name: (must provide □Add □Remove the following person New Cell: documentation) from my child’s Family Agreement ______and/or Child Enrollment and Health □ Parent New Name: New Address: Information form ______Release ______Parent Signature & Date: Person:______Phone: ______Staff Initials & Date Address: ______Entered:______Copy must be submitted to Bev Relationship: ______Statler in FA monthly report folder. Parent Signature & Date: New Phone: Staff initials & date submitted: ______Staff Initials & Date Staff Initials & Date New Message Entered:______Entered:______Phone:______New Cell: ______New Address: ______Staff Initials & Date Entered:______New Phone: Change in Custody (Attach copy of □Add □Remove the following person ______Custody Papers) from my child’s Family Agreement Name of New Custodian: and/or Child Enrollment and Health New Message ______Information form Phone:______Relationship: Release ______New Cell: Person:______Parent/Guardian Signature & Date: ______Phone: ______Address: ______New Address: Copy must be submitted to Bev ______Statler in FA monthly report folder. Relationship:______Staff initials & date submitted: _ Staff Initials & Date ______Parent Signature & Date: Entered:______Staff Initials & Date ______Entered:______Staff Initials & Date New Phone: Entered:______New Message Phone:______Change in Custody (Attach copy of □Add □Remove the following person New Cell: Custody Papers) from my child’s Family Agreement ______Name of New Custodian: and/or Child Enrollment and Health ______New Address: Information form Relationship: Release ______Person:______Parent/Guardian Signature & Date: Phone: ______Staff Initials & Date Address: ______Entered:______Copy must be submitted to Bev Statler in FA monthly report folder. Relationship: ______New Phone: Staff initials & date submitted: Parent Signature & Date: ______Staff Initials & Date Staff Initials & Date New Message Entered:______Entered:______Phone:______New Cell: ______New Address: ______Staff Initials & Date Entered:______HSFCP004 REV. 6/15