Head Start& Leaps and Bounds Collaboration - StanCOE.org

Head Start& Leaps and Bounds Collaboration - StanCOE.org

Head Start& Leaps and Bounds Collaboration Permission for Participation in Head Start Leaps &Bounds Collaboration (Hot Sheet) CF/MH-9 Revised 1/16 (Ma...

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Head Start& Leaps and Bounds Collaboration Permission for Participation in Head Start Leaps &Bounds Collaboration (Hot Sheet) CF/MH-9 Revised 1/16 (Mandatory RHS/EHS- Optional Migrant)

This form is used by Head Start Staff to document the Head Start parent’s written permission for the child to participate in the Early Childhood Consultation program that provides social emotional support in the classroom and community to children, families, and Head Start staff. The consultant services may include interaction with the child, child observation, behavioral education to parents and staff and case management with staff. 1. The Teacher, Home Visitor/Educator, Family Service Worker, Site Supervisor, Master Teacher will have the parent completely fill out the Head Start & Leaps and Bounds Collaboration Permission for Participation in Head Start Leaps &Bounds Collaboration form. 2. Child’s Name: Print the Head Start Child’s first and last name. 3. Child’s Date of Birth: Indicate the Head Start child’s date of birth 4. Child’s Age: Indicate the child’s age on the date that the form is being completed by the parent. 5. Parent/Guardian: Print the Parent/Guardian’s full name 6. Phone: Indicate the Parent/Guardian’s phone number that is most accessible 7. Address: Print the family’s address including City, State and Zip code. 8. Name of Head Start Center: Print the name of the Head Start Center including classroom Am/PM or Home base. 9. Phone: Indicate the Head Start Center’s phone number 10. Address: Print the Head Start Center’s phone number 11. The Head Start Teacher, Home Visitor/Educator, Family Service Worker, Site Supervisor, Master Teacher will review the narrative with the parent and explain the Leaps and Bounds service to the parent including #’s 1-3 on the form. 12. Signature of Parent/Legal Guardian: Parent/Legal Guardian will sign the form if they agree to participate in the Head Start &Leaps and Bounds Collaboration 13. Reviewed with Parent/Legal Guardian by: Head Start staff member will sign their name indicating that they reviewed the form with the Parent/Legal Guardian 14. Head Start staff will disperse the triplicate document to the following: White- Leaps and Bounds Consultant Yellow-Child’s file Pink- Parent/Legal Guardian