Partnership Childcare Emergency Card

La Crèche Early Childhood Centers, Inc.

1800 Olson Memorial Hwy
Minneapolis, MN 55411
(612) 377-1786

CHILD EMERGENCY CARD

CHILD'S NAME(Required)
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Gender

PICK UP AND DROP OFF ADDRESS IF DIFFERENT FROM THE HOME ADDRESS

IN CASE OF EMERGENCY

THE FOLLOWING ADULTS ARE AUTHORIZED CONTACTS AND MY CHILD MAYBERELEASED TO THESE PEOPLE. In the event of an emergency, we will make every effort to contact you or one of the emergency contacts. Your child will NOT be released to anyone other than those adults listed on this form. Please allow 48 hours for changes to go into effect.

In the case of a medical or dental emergency I hereby authorize Parents In Community Action, Inc. (PICA) staff to take my child to a health facility for treatment. I also authorize any licensed medical practitioner to provide whatever treatment is deemed necessary. I accept responsibility for any costs arising from such treatment that are not covered by insurance and/or Medical Assistance.
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Partnership Allergy Form

La Crèche Early Childhood Centers, Inc.

1800 Olson Memorial Highway Minneapolis, MN 55411 612-377-1786
1120 Oliver Avenue North Minneapolis, MN 55411 612-521-4384
www.lacrechekids.org         [email protected]

ALLERGY FORM

SITE = La Crèche / North II (Circle One)

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An Individualized Child Care Plan for Allergies listed, must be completed by the child's physician before childcare can begin.

Mobile Infant Napping Form

La Crèche Early Childhood Centers, Inc.

1800 Olson Memorial Highway Minneapolis, MN 55411 612-377-1786
1120 Oliver Ave. N Minneapolis, MN55411
www.lacrechekids.org         [email protected]

Mobile Infant Napping Form (12months -15months)

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I give permission for my child to nap om a toddler-sized cot while in programming at La Crèche Early Childhood Centers, Inc. - Oliver II
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An Individualized Child Care Plan for Allergies listed, must be completed by the child's physician before childcare can begin.

Individual Childcare-Dental Exam-Asthma Plan

La Crèche Early Childhood Centers, Inc.
1800 Olson Memorial Hwy
Minneapolis, MN 55411
(612) 377-1786

INDIVIDUAL CHILD CARE PLAN

Please send the Asthma Action Plan OR Anaphylaxis Plan, if applicable
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HEALTH CARE PROVIDER TREATING THE CHILD'S CONDITION:

Address

1. Diagnosed Medical Condition:

Is it an ongoing health issue?

2. Treatment and Medications (Complete MEDICATION PERMISSION form)

Child's Knowledge (to be completed by parent):

c) Can your child tell the teacher when treatment or medication is needed?
d) Does your child cooperate with treatment and medication?
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(not needed for eczema)
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DENTAL EXAM & TREATMENT REPORT

Child's Name
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Gender
Home Address
Dear Parent or Guardian: To ensure good oral health, every child one year and older must have a dental examination within the last six months, or no later than 90 days after the child starts school. If your child does not have a regular dentist, you may choose to have your child seen at PICA through Children's Dental Services.
If your child does have a dental provider, please have them complete the section below and bring it with you to registration.

DENTAL REPORT

This child received the following treatment in my office:
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Asthma Action Plan

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Green Zone "Go All Clear!"


Peak Flow Range
(80%-100% of personal best)
- Breathing is easy
- Can play, work and sleep
To

Yellow Zone "Caution..."


Peak Flow Range
(50%-80% of personal best)
- Wake up at night
- Cough or wheeze
- Chest is tight
To
The Yellow Zone means keep taking your Green Zone controller medicine(s) every day and add the following medicine(s) to help keep the asthma symptoms from getting worse.
Use Quick Reliever 2-4 puffs, every 20 minutes for up to 1 hour or use nebulizer once. If your symptoms are not better or you do not return to the GREEN ZONE after 1 hour follow RED ZÓNE instructions. If you are in the Yellow Zone for more than 12-24 hours, call your provider. If your breathing symptoms get worse, call your provider.

Red Zone "STOP!" "Medical Alert!"


Peak Flow Range (50%-80% of personal best)
-Medicine is not helping
-Nose opens wide to breathe
-Breathing is hard and fast
-Trouble walking
-Trouble talking
-Ribs show
To
The Red Zone means start taking your Red Zone medicine(s) and to call your doctor NOW! Take these medicines until you talk with your doctor. If your symptoms do not get better and you can't reach your doctor, go to the emergency room or call 911 immediately.
I give my permission for this asthma action plan to be used by the following, and for them to share information with each other about my child's asthma on year beginning today, so that they can work together to help my child manage his/her asthma.
This plan, when signed and dated, may replace or supplement the school's/daycare's consent to administer medication form, and allows my child's medicine to be administered at school/daycare.
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Headstart Income Verification Form

Head Start Income Verification

To be completed by personnel only

Child & Family

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Address
New Enrollee
Returnee
Select Head Start program
Residence Verified

Child & Family

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Complete ONLY ONE of the following sections:

A. Categorically Eligible
B. New Enrollee or Transitioning from EHS to Head Start
Number of adults and children in family:
Documents Received:
I certify that I have reviewed documentation and that the above named applicant meets Head Start eligibility requirements for the program year(s).
NOTE TO STAFF: If family has all of the required documents and has met age, residency and income requirements, send form with family to records clerk. If any of the above required documents are missing, the family member must attain the necessary items and return at another time to complete the

Head Start Eligibility Verification Form

La Crèche Early Childhood Centers, Inc.

1800 Olson Memorial Highway Minneapolis, MN 55411 612-377-1786
1120 Oliver Avenue North Minneapolis, MN 55411 612-521-4384
www.lacrechekids.org         [email protected]
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3. Is this child eligible to participate in the program?
4. Type of eligibility interview conducted:
5. Indicate the applicable eligibility criterion for this child:
6. What documentation was used to determine eligibility and is included as part of the eligibility determination record?
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