<p> ATCAA EARLY CHILDHOOD SERVICES Early Childhood Services/State Preschool</p><p>HEALTH PROCEDURE AGREEMENT</p><p>Child’s name: ______</p><p>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:</p><p>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)</p><p>2. Immunizations must be kept current. 3. A dental screening must be done within 90 days of entry.</p><p>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) ______</p><p>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.</p><p>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)</p><p>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.</p><p>______Parent/Legal Guardian signature Date Staff signature Date</p><p>7/04 White-file Yellow-parent D:\Docs\2018-05-03\0b168f5ab4bedbd375ec3ee36ba689f9.doc</p>