Student Name First Middle Last Date of Birth PRE-K ENROLLMENT APPLICATION 2017-18 Early Childhood Program Fill out this application if your student is applying to an Early Childhood School. Required Documents to Enroll: Proof of Birth Current Immunizations Proof of Parentage/Guardianship Parent/Guardian Photo ID Proof of Household Income 2 Proofs of Residency: 1) Lease, Mortgage, or Tax Receipt AND 2) Gas or Electricity Utility Bill* *Current utility bill only; disconnect/shut-off notices will not be accepted. www.kcpublicschools.org/earlylearning Admissions Phone: (816) 418-7505 Fax: (816) 418-7006 Admissions Office: 2901 Troost Ave. Kansas City, MO 64109 Email: admissions@kcpublicschools.org Notice of Non-Discrimination The Kansas City 33 School District does not discriminate on the basis of sex, race, religion, color, national origin, ancestry, age, disability, sexual orientation, gender identity, or any other factor prohibited by law in its programs and activities. If you believe you have been subject to discrimination or harassment, or if you have any inquiries regarding the District s non-discrimination policies, please contact the Anti-Discrimination and Harassment Coordinator at 2901 Troost Ave., Kansas City, Missouri 64109, or call (816) 418-7610.
Student Information Choose one ethnicity: Hispanic/Latino... Not Hispanic/Latino... Check all appropriate races (regardless of ethnicity): American Indian/Alaskan Native... Asian... Black/African American... White... Native Hawaiian/Other Pacific Islander... Does your child qualify for federal programs? To help determine whether your child qualifies for a federal program, please check Yes or No in response to the following questions. 1. Does the student speak a language other than English?... Yes No If YES, what language is spoken 2. Is there a language other than English spoken in the home?... Yes No 3. Are you sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason?... Yes No Explain if it is a similar reason: 4. Are you sharing or contributing to household expenses?... Yes No 5. Are you currently residing at a shelter, motel, hotel, in a car, or at a campsite because your home has been damaged or because of economic reasons?... Yes No 6. Are you currently living in or participating with a community based temporary housing arrangement?... Yes No 7. Does the parent/guardian work for the federal government?... Yes No 8. Has either parent, guardian, child or child s spouse been employed within the past three (3) years (or any of the aforementioned currently employed) in some form of temporary or seasonal agriculture work such as: planting or harvesting crops, transporting farm products to market, working on a dairy or catfish farm, feeding or processing poultry, beef or hogs, cutting firewood or logs to sell, gathering eggs or working in hatcheries?... Yes No 9. Is either parent or guardian on active duty or reserve military... Active Duty National Guard or Reserve Not Military Safe Schools Form Instructions: This form must be completed for all new students enrolling in the Kansas City Public Schools. Submitting false statements or information to a student s disciplinary history is defined as a Class B Misdemeanor. Students could face removal from school for submitting false statements and/or information regarding residency or disciplinary history. Please answer the following questions. An explanation must be provided if you answer yes to any of the questions below. 1. Is the student currently on long-term suspension (11-180 days) or expulsion from any in-state or out-of-state school (i.e. public, alternative, private, charter, or parochial school) previously attended?... Yes No If yes, please explain the reason(s) for suspension or expulsion: 2. Please list all schools your child has attended within the past (24) twenty-four months. Please include each school s name, city and state in which they are located: By signing and submitting this form in support of my child s enrollment in the Kansas City Public Schools, I understand that it is a criminal offense (class B Misdemeanor-Section 167.023 RSMo) to give false information concerning prior disciplinary actions taken against my child for an offense in violation of School Board policies relating to weapons, alcohol, drugs or the willful infliction of injury to another person. I acknowledge and accept responsibility for the consequences of submitting false statements or information for the purpose of enrollment. Parent/Guardian Signature: Date: / /
2017-2018 Health History Form Student Name: Date of Birth: / / Grade: Student ID: School: Age: Sex: M F Parent/Guardian Name: Home Phone: Cell Phone: Work Phone: Please attach a copy of current immunizations from the Physician or Clinic. Students will NOT be permitted to enroll without proof of state required immunizations. Medication: Does your student take medications? Yes No Diagnosis/Reason Medication Dose Time(s) Health Information: Physician s Name Phone: Date of Last Visit: Dentist s Name: Phone: Date of Last Visit: Hospital Preference Has your child had or does your child have any of the following illnesses or diseases? Age Date Age Date Chicken Pox... Yes No Mononucleosis... Yes No Fifth s Disease... Yes No Scarlet Fever... Yes No Hepatitis... Yes No Strep Infection... Yes No Meningitis... Yes No Other Contagious Disease... Yes No Allergies (food, medications, environment, animals, etc.)... Yes No Injuries/Accidents... Yes No Asthma... Yes No Mental/Emotional Problems... Yes No Attention Deficit/Hyperactive Disorder... Yes No Physical Limitations... Yes No Behavior Problems... Yes No Pneumonia... Yes No Bladder Problems... Yes No Rash/Birthmark/Scar... Yes No Bowel Problems... Yes No Seizure Disorder... Yes No Broken Bones... Yes No Speech Problems... Yes No Dental Problems... Yes No Surgery... Yes No Diabetes... Yes No Sutures/Stitches... Yes No Frequent Ear Infections... Yes No Tube Feeding... Yes No Head Injury/Concussion... Yes No Tubes in Ears... Yes No Hearing Problems... Yes No Vision Problems... Yes No Heart Problems/Murmur... Yes No Wears Glasses/Contacts... Yes No Hospitalizations (other than newborn)... Yes No Wheel Chair... Yes No Please explain yes answers here:
2017-2018 Health History Form (Cont.) Student Concerns: Do you have any concerns about your student s: Vision... Yes No Hearing... Yes No Attention Span... Yes No Emotional Development... Yes No Speech... Yes No Behavior... Yes No Ability to Learn... Yes No Physical Development... Yes No Please explain yes answers here: In Case of Emergency and Parent/Guardian cannot be reached: Contact #1 Name: Phone No.: Relationship: Contact #2 Name: Phone No.: Relationship: Verification: In case of illness or injury of my student, I understand the school will attempt to contact parents or guardians first. Then they will contact other persons I have listed - who are authorized to receive information, make certain medical decisions, and have my student released to their custody. If none is available, the school is authorized to make whatever arrangements are deemed necessary to maintain my student s health including, but not limited to, emergency medical treatment. I am the legal Parent/Guardian of this student: Yes No Initials: If you are not the legal Parent/Guardian of this student, state your relationship to this student: I verify that the information provided on this form is accurate and current. SIGNATURE of Parent/Guardian/Other PRINTED Name of Parent/Guardian/Other Date
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION / BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE CHILD CARE ENROLLMENT FORM FACILITY/PROVIDER NAME ADMISSION DATE DISCHARGE DATE CHILD S NAME GENDER BIRTHDATE ADDRESS (STREET, CITY, STATE, ZIP CODE) IDENTIFYING INFORMATION MOTHER S/GUARDIAN S NAME ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE HOME TELEPHONE NUMBER CELL PHONE NUMBER E-MAIL ADDRESS EMPLOYER OR SCHOOL ATTEND EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE) FATHER S/GUARDIAN S NAME ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE WORK/SCHOOL SCHEDULE WORK TELEPHONE NUMBER HOME TELEPHONE NUMBER CELL PHONE NUMBER E-MAIL ADDRESS EMPLOYER OR SCHOOL ATTEND EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE) WORK/SCHOOL SCHEDULE WORK TELEPHONE NUMBER EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY (OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED. NAME RELATIONSHIP TO CHILD TELEPHONE NUMBERS (CELL, WORK, HOME) ADDRESS (STREET, CITY, STATE, ZIP CODE) NAME RELATIONSHIP TO CHILD TELEPHONE NUMBERS (CELL, WORK, HOME) ADDRESS (STREET, CITY, STATE, ZIP CODE) COMMENTS ON CHILD S DEVELOPMENT (PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, & INDIVIDUAL NEEDS) CACFP REQUIREMENT RELATED CHILD YES NO HOW IS CHILD RELATED TO CHILD CARE PROVIDER? CHILD S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED CHECK HERE WHAT DAYS THE CHILD WILL ATTEND. WILL CHILD ATTEND: FULL TIME OR PART TIME WHAT TIME DOES YOUR CHILD USUALLY ARRIVE EACH DAY? CIRCLE AM OR PM WHAT TIME DOES YOUR CHILD USUALLY LEAVE EACH DAY? CIRCLE AM OR PM WRITE ANY COMMENTS, CHANGES OR VARIATIONS IN USUAL ATTENDANCE IN THIS SECTION INCLUDING SHIFT CHANGES. MONDAY AM PM AM PM TUESDAY AM PM AM PM WEDNESDAY AM PM AM PM THURSDAY AM PM AM PM FRIDAY AM PM AM PM SATURDAY AM PM AM PM SUNDAY AM PM AM PM MO 580-2994 (11-15) PLEASE ALSO COMPLETE PAGE 2 SCCR/CACFP PAGE 1
CACFP REQUIREMENT CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY BREAKFAST MORNING SNACK LUNCH AFTERNOON SNACK SUPPER EVENING SNACK NONE CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY NEW YEARS S DAY (JANUARY) MEMORIAL DAY (MAY) VETERANS DAY (NOVEMBER) MARTIN LUTHER KING JR. S BIRTHDAY (JANUARY) INDEPENDENCE DAY (JULY) ELECTION DAY (NOVEMBER) PRESIDENT S DAY (FEBRUARY) LABOR DAY (SEPTEMBER) THANKSGIVING (NOVEMBER) EASTER (MARCH/APRIL) COLUMBUS DAY (OCTOBER) CHRISTMAS DAY (DECEMBER) AUTHORIZATION FOR EMERGENCY MEDICAL CARE I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGEMENTS FOR MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE. IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE TO CONTACT THE FOLLOWING: NAME NAME DAY CARE PROVIDER OR HOME PROVIDER PHYSICIAN OR CLINIC PREFERRED HOSPITAL TELEPHONE NUMBER TELEPHONE NUMBER ACKNOWLEDGEMENTS I HAVE RECEIVED A COPY OF THIS FACILITY S POLICIES PERTAINING TO THE A ADMISSION, CARE AND DISCHARGE OF CHILDREN. I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE B HOMES OR THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS FACILITY FOR REVIEW. THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING C COMMUNICATION REGARDING MY CHILD S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS. WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE D ACCEPTED FOR CARE OR REMAIN IN CARE. I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I E WILL PROVIDE PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS. I DO F DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS. I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED. I DO G DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD. I HAVE BEEN INFORMED AND HAVE RECEIVED A COPY OF THE FACILITY S SAFE H SLEEP POLICY WHEN ENROLLING A CHILD LESS THAN ONE (1) YEAR OF AGE. I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED I IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED. PARENT S/GUARDIAN S SIGNATURE DATE CACFP REQUIREMENT FIRST ANNUAL UPDATE PARENT/GUARDIAN SIGNATURE DATE SECOND ANNUAL UPDATE PARENT/GUARDIAN SIGNATURE DATE THIRD ANNUAL UPDATE PARENT/GUARDIAN SIGNATURE DATE MO 580-2994 (11-15) SCCR/CACFP PAGE 2
2016-2017 KCPS EDUCATIONAL SERVICES SUBSIDY APPLICATION COMPLETE ONE APPLICATION PER HOUSEHOLD PART 1. FOOD STAMP/TEMPORARY ASSISTANCE BENEFITS If any member of your household receives Food Stamps or Temporary Assistance, provide the name and case number for the person who receives the benefits below. Also complete Part 2, numbers 1, 2, and 3 for all students in the household. If no one receives benefits, fill out Part 2 completely. Name: Case Number: 0 0 PART 2. HOUSEHOLD INFORMATION 3. Name of school building Name of school building for each 2. Student child/student or ID (if indicate N/A if 1. Name list everyone in household applicable) not in school 4. Grade PART 3. HOMELESS, MIGRANT, OR RUNAWAY STUDENT 5. Check if a foster child legal responsibility of welfare agency or court 6. Gross income and how often it was received (weekly, every 2 weeks, 2x per month, monthly, yearly) Earnings from work before deductions Welfare, child support, alimony Pensions, retirement, social security, SSI, and VA benefits All other income Income How often Income How often Income How often Income How often If any student you are applying for is homeless, migrant, or a runaway contact the KCPS Homeless Liaison/Migrant Coordinator at 816-418- 8679. 7. Check if no Income PART 4. SIGNATURE (ADULT MUST SIGN) An adult household member must sign the application. If Part 2 is completed, the adult signing the application must also list his or her last four digits of their social security number or mark the I do not have a social security number box. (See Privacy Act Statement.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school may be eligible for certain federal funds based on the information I give. I understand that the school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose benefits, and I may be prosecuted. Sign here: Print name: Date: Address: City: Zip code: Phone number: Last 4 digits of social security number: * * * - * * - I do not have a social security number Privacy Act Statement. You do not have to provide the information on this form, but if you do not, we cannot determine your child s eligibility for additional benefits under state and federal programs. We will hold the information you provide as private and confidential to the extent required by law. However, we will share your information with various state and federal programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. Regardless of whether you provide the information on this form, all KCPS students will receive meals at no charge. Non- discrimination Statement. KCPS is committed to maintaining an educational environment that is free from discrimination and harassment in admission or access to, or treatment or employment in, its programs, services, activities and facilities. KCPS prohibits discrimination and harassment against employees, students or others on the basis of sex, race, religion, color, national origin, ancestry, age, disability or any other factor prohibited by law. Inquiries regarding the nondiscrimination policies should be directed to Kansas City Public Schools, Attention: Chief Legal Counsel, 1211 McGee, Kansas City, Missouri 64106; 816-418- 7610. DO NOT FILL OUT THIS SECTION. THIS IS FOR SCHOOL USE ONLY. ANNUAL INCOME CONVERSION: WEEKLY X 52, EVERY 2 WEEKS X 26, TWICE A MONTH X 24, MONTHLY X 12 (USE ONLY IF MULTIPLE FREQUENCY) Food Stamps/Temporary Assistance Household size: Total income: Per: Week Every 2 Weeks Twice a Month Month Year Eligibility: Qualifies Does not Qualify Reason: Date withdrawn: Determining Official s Signature: Date Approved/Denied: Confirming Official s Signature (For verification purposes only): Date:
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION CHILD MEDICAL EXAMINATION REPORT (INFANT/TODDLER/PRE-SCHOOL) IDENTIFYING INFORMATION CHILD S NAME BIRTHDATE CURRENT STATE OF HEALTH Based on my assessment of this child s medical history, current state of health and my physical examination of the child on / /, this child can participate in a child care program. This child has no special care needs unless specified below. (Date of medical examination must be within the last 12 months.) PHYSICIAN S INSTRUCTIONS FOR SPECIALIZED CARE Complete this section only if child requires special care at a child care facility, e.g. special diets, allergies, ear infections, convulsions, diabetes, asthma, behavior problems, hearing or visual impairment, etc. (Attach additional pages as needed.) SIGNATURE OF PHYSICIAN OR REGISTERED NURSE UNDER THE SUPERVISION OF A PHYSICIAN DATE PHYSICIAN S OR NURSE S NAME (PLEASE PRINT) NAME AND ADDRESS OF CLINIC, GROUP, PRACTICE OR OTHER (MAY USE STAMP.) IF NURSE IS SUPERVISED BY A PHYSICIAN, INDICATE PHYSICIAN S NAME (PLEASE PRINT.) TELEPHONE NUMBER MO 580-1878 (6-14) TO BE FILED IN CHILD S RECORD AT CHILD CARE FACILITY BCC-6A