AB ABCD BCD EA D EARL ARLY LE LY LEAR EARNING RNING G

 ABCD
D EARL
LY LEAR
RNING
AB
BCD EA
ARLY LE
EARNING
G APPLIICATION PACK
KET
Thhank you fo
or your inteerest in ou
ur Early Learning Proogram. Attaached is ouur applicatiion with
thee necessary
y forms needed to staart your chiild’s enrolllment. Pleaase take a few minuttes to fill
ouut the inform
mation below so we can
c help you with thee enrollmeent processs.
Today’s Date:
D
Name of child
nt:
Applican
Child’s date of
o Birth
Parrent/Guardiaan Name
Address
Phone #
OF
FFICE USE ONLY
Casseworker folllow-up:
1st contact: date:_
____________
___
(wiithin 2wks from
m app pick-up)) (REMIND PARENT TO
T COMPLE
ETE DENTA
AL/MAKE A
APPOINTM
MENT)
__
___________
__________
___________
___________
_______________________________________
__
___________
__________
___________
___________
________________________________________
No longer interestted
application incomp
plete /waiting oon documentattion
Application su
ubmitted
C
Continue follow
w-up
Apppt made
2nd contact: date: ____________
_
___
(if aapplicable, with
hin 2 wks of 1st contact)
__________
___________
__________
______________________
______________________
________
___
___
__________
___________
__________
______________________
______________________
________
No long
ger interested
applicatiion incompletee /waiting on doocumentation
pplication subm
mitted
Continue ffollow-up
Ap
Appt maade
ABCD
D EARL
LY LEAR
RNING
Deear Parent or Guardian,,
ABCD Inc.
Thank you so mucch your inteerest in the programs ooffered at A
I hhave encloseed the requiired applicaation packett for you to complete. I have also included a flyer that
proovides you with
w inform
mation abou
ut our Early Learning pprograms annd their locations. Pleaase bring
thee following items when
n you return
n the appliccation:
Birth verifiication (Birrth certificatte, Passportt, Hospital C
Certificate, etc..)
Social Secu
urity Numb
bers for the family

Child’s Me
edical Insurrance Card

Guardiansh
hip documeents (If appllicable)

Parent or Guardian’s
G
proof
p
of inccome

Most recen
nt monthly pay
p stubs

State Budg
get form (for one month
h of incomee)

Child’s Phy
ysical, Imm
munization and
a Dental form (or prroof of denttal appointm
ment)

Two emerg
gency namees and telep
phone numb
ber




pleted packeet to our Earrly Learninng Departmeent at ABC
CD Inc. 10700 Park
Yoou can returrn the comp
Avve or to the site of yourr choice. Fo
or more info
ormation caall ABCD aat 366-8241 Ext 221
Thhank you
dre / encargaado:
Esttimado Pad
Muchaas gracias po
or su interés en los pro
ogramas ofrrecidos por ABCD Inc. Adjunto
enccontraran lo
os formularrios requerid
dos para qu
ue usted pueeda complettar su aplicaación. Se inncluye
adeemás folleto
os que conttienen inforrmación aceerca de los pprogramas dde cuidado de niños y las
loccalizacioness de los missmos. Los siguientes do
ocumentos son requeriidos para pooder processar la
apllicación de su niño(a):
Verificació
ón de nacim
miento (Certtificado de nacimiento,
n
, pasaporte,, certificadoo de hospitaal, etc…)

Los número de Seguro
o Social de la familia

Tarjeta del seguro médico del niñ
ño

Prueba de Ingreso
I
Eco
onómico (P
Padre o Encaargado)

Deben ser talonarios
t
de
d pagos reccientes o caarta oficial ddel estado

Prueba de custodia
c

Examen fís
sico compleeto (debe in
ncluir las vaacunas)

Examen de
ental (o prueeba de cita con dentista)

Dos nombr
res de emerrgencia y nú
úmero de teeléfono


d
esttos formulaarios a ABC
CD Inc. 10770 Park Avee o algún dee los otros ccentros.
Ussted puede devolver
Parra más información llaame a ABCD
D al teléfon
no 366-824 1 Ext 221
Muucha Graciaas
ABCD
D EARL
LY LEAR
RNING
EA
ARLY LEAR
RNING APPL
LICATION
Applic
cant/Child Informatio
on
Child’s/A
Applicant’s Na
ame:
First:
Addresss:
House/ A
Apartment # & Street Nam
me:
City:
Mid
ddle:
Lasst:
Gender:
Sttate:
Te
elephone:
Pho
one #1:
Language(s)):
Phone #2:
Eng
glish Speakin
ng Ability:
Male:___
____ Female:_
_____
Primary:
Veryy Well:___ Well::___ Not Well:__
__ Not at all:___
_
Date of Birth:
Mode off Transportatio
on: Walk:__
___
Se
econdary:
Own car:____
Zip Code:
Frie
end’s/Family m
member car/rride:____
P
Public:____
Servicess Needed:
Full Day/
D
Full Yea
ar:______ Parrt Day/ Part Year:______
Y
H
Home Base:_
______ Transitioning from EHS/DC:___
____
Family
y/Household Informa
ation
Mother o
of child:
Live
es with child: yes____ no
o____
Father o
of child:
Live
es with child: yes____ no
o____
Guardian’s name:
Rellationship to cchild:
Names o
of other childrren in
the houssehold
Age
Relationship
R
to
o
ch
hild/applicant
Other ad
dult members in the
househo
old
(over 18yyrs of age)
A
Age
Relationship to
child/a
applicant
I certify tthat the inform
mation provided in this app
plication is accurate and tru
uthful to the b
best of my knowledge
Parent/G
Guardian Sign
nature:
I would llike refer an eligible
e
family to your progrram: Name:
Phone#:
Confiden
ntiality Statem
ment: All inforrmation share
ed with Early Learning
L
Stafff will be kept strictly confid
dential unlesss its release is
s
authorizzed in writing. These forms
s will be mainttained in locke
ed files.
For offfice use on
nly
Date recceived: Staff Signature:
S
Ap
pril 2016
ABCD
D EARL
LY LEAR
RNING
APLIC
CACIÓN DE
D EARLY
Y LEARNING
Inform
macion d el solicittante / ni no
Nombre del solicitantte/ niño :
Nombre:
Medio:
M
Direcció
ón:
Casa / a
apartamento # & nombre de la calle:
Ciudad:
Estado:
Te
eléfono:
Te
eléfono # 1:
Fecha de nacimiento:
Género:
Macho:___
____
Ap
pellido:
Idioma (s):
Hembra: ______
Primaria:
Secu
undaria:
Código posta
al:
T
Teléfono # 2:
Cap
pacidad de ha
ablar Ingles:
Muyy bien:____ Bien
n:____ Regular:_
____ No sabes:_
____
Modo de
e transporte: caminar:____
_ coche propio:____ amigo / familia mie
embros coche/paseo:____
_ público:_____
Servicios necesarios:
Todo día
a / todo año:_
____ Día parrte / parte año
o:____ Programa de Hom e Base;_____
_ Pasando de
e EHS/DC:__
_____
Inform
macion d e la fami lia/hogarr
Madre d
de niño:
Vive con niños: ssí no ____
Padre de
e niño:
Vive con niños: ssí no ____
Nombre del encargad
do:
Rellación al niño:
Nombres de otros niñ
ños en
el hogarr
Edad
Rellación con el niño
(solicitante)
adultos
Otross miembros a
en ell hogar
(máss de 18 años de edad)
E
Edad
Relacción con el niñ
ño
(solicitante)
Certifico
o que la inform
mación proveíída en esta aplicación es correcta
c
y verrdadera de accuerdo a mi m
mejor conocim
miento
Firma de
el padre/enca
argado:
Quiero rreferir a otra familia
f
a su prrograma: Nom
mbre:
Teléfono #:
Declaracción de confid
dencialidad: Toda
T
informac
ción compartiida será manttenida estricta
amente confid
dencial a men
nos que
usted lo autorices por escrito. Esto
os formularios
s serán mante
eniendo bajo llave.
Para uso de officina so lamente:
Date recceived: Staff Signature:
S
Ap
pril 2016
State of Connecticut Department of Education
Early Childhood Health Assessment Record
(For children ages birth – 5)
To Parent or Guardian: In order to provide the best experience, early childhood providers must understand your child’s health needs. This form
requests information from you (Part I) which will be helpful to the health care provider when he or she completes the health evaluation (Part II). State
law requires complete primary immunizations and a health assessment by a physician, an advanced practice registered nurse, a physician assistant, or a
legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to entering
an early childhood program in Connecticut.
Please print
Birth Date (mm/dd/yyyy)
❑ Male ❑ Female
Parent/Guardian Name (Last, First, Middle)
Home Phone
Cell Phone
Early Childhood Program (Name and Phone Number)
Race/Ethnicity
Primary Health Care Provider:
❑ American Indian/Alaskan Native ❑ Hispanic/Latino
❑ Black, not of Hispanic origin
❑ Asian/Pacific Islander
❑ White, not of Hispanic origin
❑ Other
Child’s Name (Last, First, Middle)
Address (Street, Town and ZIP code)
Name of Dentist:
Health Insurance Company/Number* or Medicaid/Number*
Does your child have health insurance?
Y
Does your child have dental insurance?
Y
Does your child have HUSKY insurance? Y
N
N
N
If your child does not have health insurance, call 1-877-CT-HUSKY
* If applicable
Part I — To be completed by parent/guardian.
Please answer these health history questions about your child before the physical examination.
Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.
Any health concerns
Y
N
Allergies to food, bee stings, insects
Allergies to medication
Any other allergies
Any daily/ongoing medications
Any problems with vision
Uses contacts or glasses
Any hearing concerns
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Frequent ear infections
Any speech issues
Any problems with teeth
Y
Y
Y
N
N
N
Has your child had a dental
examination in the last 6 months
Y
N
Very high or low activity level
Weight concerns
Y
Y
N
N
Problems breathing or coughing
Y
N
Y
Y
Y
Y
Y
N
N
N
N
N
Developmental — Any concern about your child’s:
1. Physical development
Y
N
5. Ability to communicate needs
6. Interaction with others
2. Movement from one place
to another
Y
N
7. Behavior
3. Social development
Y
N
8. Ability to understand
4. Emotional development
Y
N
9. Ability to use their hands
Asthma treatment
Seizure
Diabetes
Any heart problems
Emergency room visits
Any major illness or injury
Any operations/surgeries
Lead concerns/poisoning
Sleeping concerns
High blood pressure
Eating concerns
Toileting concerns
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
Birth to 3 services
Preschool Special Education
Y
Y
N
N
Explain all “yes” answers or provide any additional information:
Have you talked with your child’s primary health care provider about any of the above concerns? Y
N
Please list any medications your child
will need to take during program hours:
All medications taken in child care programs require a separate Medication Authorization Form signed by an authorized prescriber and parent/guardian.
I give my consent for my child’s health care provider and early
childhood provider or health/nurse consultant/coordinator to discuss
the information on this form for confidential use in meeting my
child’s health and educational needs in the early childhood program.
ED 191 REV. 8/2011
Signature of Parent/Guardian
C.G.S. Section 10-16q, 10-206, 19a.79(a), 19a-87b(c); P.H. Code Section 19a-79-5a(a)(2), 19a-87b-10b(2)
Date
ED 191 REV. 8/2011
Part II — Medical Evaluation
Health Care Provider must complete and sign the medical evaluation, physical examination and immunization record.
Child’s Name
Birth Date
❑ I have reviewed the health history information provided in Part I of this form
Date of Exam
(mm/dd/yyyy)
(mm/dd/yyyy)
Physical Exam
Note: *Mandated Screening/Test to be completed by provider.
*HT
in/cm
%
*Weight
lbs.
oz /
%
BMI
/
%
*HC
in/cm
%
*Blood Pressure
(Birth – 24 months)
/
(Annually at 3 – 5 years)
Screenings
*Vision Screening
*Hearing Screening
*Anemia: at 9 to 12 months and 2 years
❑ EPSDT Subjective Screen Completed
(Birth to 3 yrs)
❑ EPSDT Annually at 3 yrs
(Early and Periodic Screening,
Diagnosis and Treatment)
❑ EPSDT Subjective Screen Completed
(Birth to 4 yrs)
❑ EPSDT Annually at 4 yrs
(Early and Periodic Screening,
Diagnosis and Treatment)
*Hgb/Hct:
Type:
Type:
Right
Left
With glasses
20/
20/
Without glasses
20/
20/
Test done:
❑ No
Left
❑ Pass
❑ Pass
❑ Fail
❑ Fail
❑ Yes
*Dental Concerns
❑ Yes
Date:
❑ Referral made to:
Results:
❑ No
❑ Yes
Has this child received dental care
in the last 6 months? ❑ No ❑ Yes
Treatment:
*Developmental Assessment: (Birth – 5 years)
❑ No
*Lead: at 1 and 2 years; if no result
screen between 25 – 72 months
❑ No
❑ Referral made to:
❑ No
*Date
Lead poisoning (≥ 10ug/dL)
❑ Unable to assess
❑ Unable to assess
❑ Referral made to:
*TB: High-risk group?
Right
❑ Yes
❑ Yes
*Result/Level:
*Date
Other:
Type:
Results:
*IMMUNIZATIONS
❑ Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED
*Chronic Disease Assessment:
Asthma
❑ No
❑ Yes: ❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent
If yes, please provide a copy of an Asthma Action Plan
❑ Rescue medication required in child care setting: ❑ No ❑ Yes
Allergies
❑ No
❑ Yes:
❑ No ❑ Yes
Epi Pen required:
History/risk of Anaphylaxis: ❑ No ❑ Yes:
❑ Food ❑ Insects ❑ Latex ❑ Medication ❑ Unknown source
If yes, please provide a copy of the Emergency Allergy Plan
Diabetes
Seizures
❑ No
❑ No
❑ Yes:
❑ Yes:
❑ Type I
Type:
❑ Type II
❑ Severe Persistent
❑ Exercise induced
Other Chronic Disease:
❑ This child has the following problems which may adversely affect his or her educational experience:
❑ Vision ❑ Auditory ❑ Speech/Language ❑ Physical ❑ Emotional/Social ❑ Behavior
❑ This child has a developmental delay/disability that may require intervention at the program.
❑ This child has a special health care need which may require intervention at the program, e.g., special diet, long-term/ongoing/daily/emergency
medication, history of contagious disease. Specify:
❑ No ❑ Yes This child has a medical or emotional illness/disorder that now poses a risk to other children or affects his/her ability to participate
safely in the program.
❑ No ❑ Yes Based on this comprehensive history and physical examination, this child has maintained his/her level of wellness.
❑ No ❑ Yes This child may fully participate in the program.
❑ No ❑ Yes This child may fully participate in the program with the following restrictions/adaptation: (Specify reason and restriction.)
❑ No ❑ Yes Is this the child’s medical home? ❑ I would like to discuss information in this report with the early childhood provider
and/or nurse/health consultant/coordinator.
Signature of health care provider MD / DO / APRN / PA
Date Signed
Printed/Stamped Provider Name and Phone Number
Child’s Name:
Birth Date:
REV. 8/2011
Immunization Record
To the Health Care Provider: Please complete and initial below.
Vaccine (Month/Day/Year)
Dose 1
Dose 2
Dose 3
Dose 4
Dose 5
DTP/DTaP/DT
IPV/OPV
MMR
Measles
Mumps
Rubella
Hib
Hepatitis A
Hepatitis B
Varicella
PCV* vaccine
Rotavirus
MCV**
Flu
Other
Dose 6
*Pneumococcal conjugate vaccine
**Meningococcal conjugate vaccine
Disease history for varicella (chickenpox)
(Date)
Exemption:
(Confirmed by)
Religious
Medical: Permanent
†Temporary
†Recertify Date
†Recertify Date
†Recertify Date
Date
Immunization Requirements for Connecticut Day Care, Family Day Care and Group Day Care Homes
Vaccines
Under 2
By 3
By 5
By 7
By 16
16–18
By 19
2-3 years of age 3-5 years of age
months of age months of age months of age months of age months of age months of age months of age (24-35 mos.) (36-59 mos.)
DTP/DTaP/
DT
None
1 dose
2 doses
3 doses
3 doses
3 doses
4 doses
4 doses
4 doses
Polio
None
1 dose
2 doses
2 doses
2 doses
2 doses
3 doses
3 doses
3 doses
MMR
None
None
None
None
Hep B
None
1 dose
2 doses
2 doses
HIB
None
1 dose
2 doses
Varicella
None
None
None
None
None
None
Pneumococcal
Conjugate
None
1 dose
2 doses
3 doses
1 dose after
1st birthday
1 dose after
1st birthday
1 dose after
1st birthday
Hepatitis A
None
None
None
None
1 dose after
1st birthday5
1 dose after
1st birthday5
1 dose after
1st birthday5
Influenza
None
None
1 or 2 doses
1 or 2 doses
1 or 2 doses6
1 or 2 doses6
1 or 2 doses6
1 dose after 1st 1 dose after 1st 1 dose after 1st 1 dose after 1st 1 dose after 1st
birthday1
birthday1
birthday1
birthday1
birthday1
2 doses
2 doses
3 doses
3 doses
3 doses
2 or 3 doses 1 booster dose 1 booster dose 1 booster dose 1 booster dose 1 booster dose
depending on
after 1st
after 1st
after 1st
after 1st
after 1st
vaccine given3
birthday4
birthday4
birthday4
birthday4
birthday4
Vaccine (PCV)
1 dose after
1 dose after
1 dose after
1st birthday or 1st birthday or 1st birthday
prior history of prior history of or prior history
disease1,2
disease1,2
of disease1,2
1 dose after
1st birthday
1 dose after
1st birthday
2 doses given 2 doses given
6 months apart5 6 months apart5
1 or 2 doses6
1 or 2 doses6
1. Laboratory confirmed immunity also acceptable
2. Physician diagnosis of disease
3. A complete primary series is 2 doses of PRP-OMP (PedvaxHIB) or 3 doses of HbOC (ActHib or Pentacel)
4. As a final booster dose if the child completed the primary series before age 12 months. Children who receive the first dose of Hib on or after 12 months of age and before 15 months of age are
required to have 2 doses. Children who received the first dose of Hib vaccine on or after 15 months of age are required to have only one dose
5. Hepatitis A is required for all children born after January 1, 2009
6. Two doses in the same flu season are required for children who have not previously received an influenza vaccination, with a single dose required during subsequent seasons
Initial/Signature of health care provider
MD / DO / APRN / PA
Date Signed
Printed/Stamped Provider Name and Phone Number
ABCD
D EARL
LY LEAR
RNING
nt,
Deear Paren
Taake the Dental Exaam Form to the Deentist. It iss very im
mportant thhat your cchild
haas a dental exam beefore he/sshe is enrrolled in th
the Child Care Proogram at A
ABCD
Incc.
Yoour child’’s doctor cannot co
omplete this
t form.
If you do not have a dentist leet us know
w. We wiill help yoou to locaate a denttist.
p
, Esstimados padres
Toomar estaa forma dee Examen
n Dental al
a Dentistta. Es muuy importaante que ssu hijo
tennga un ex
xamen den
ntal antess de que él
é o ella eestá inscriito en el pprograma en
AB
BCD Inc.. Ell pediatra no puedee complettar este fo
ormularioo. Si usted no tiene un dentista nos
n dejó saber.
s
Tee ayudarem
mos a loccalizar a uun
deentista. D
ABCD
EARL
LY LEAR
RNING
Den
ntal Form
F
Name of
o the Child
d : _______
__________
________________________
Date of Birth:
_______
__________
________________________
___________
________________________
Date of Dentist Viisit: ______
REAS
SON FOR D
DENTAL V
VISIT
UPPER
C
B
E F
G
H
I
LINGUAL
L
A
LEFT
D
J
14
3
30
T
19
K
LINGUAL
L
S
M
R
Q
N
P O
LO
OWER
RIGHT
1 □
ORAL E
EXAMINAT
TION
2 □
PREVE
ENTIVE CA
ARE
□
□
□
C
Cleaning
F
Flouride Ap
pplication
S
Sealant Application
3 □ TREATMMENT
□ Exxtraction
□ Reestorationn
□ Puulp Therappy
w –up or work
w
is needed please provide appointme
ent date:
If Follow
Date: __________
_
___________
_________
d for
Follow-up needed
□ Cleaningg
□ XX-rays □ Treatmeent
DENTIS
ST NAME & SIGNATU
URE & DAT
TE
Revised January 2016 a b d c The mission of ABCD’s Early
Learning Division is to
empower families so that they
may overcome the impact of
poverty and improve the
quality of life for all family
members. To that end, ABCD
is committed to a comprehensive
program consisting of:

Family & Child Services for all
family members
ABCD / INNER CITY
CHILDREN’S CENTER
1070 Park Ave
Bridgeport, CT
LUCILLE E. JOHNSON
CENTER
816 Fairfield Ave
Bridgeport, CT
203-366-8241-X 273
203-331-4541
ABCD at HOLY NAME
OF JESUS CENTER
1950 Barnum Ave
Stratford, CT
ABCD at GEORGE E.
PIPKIN CENTER
52 George Pipkins Way
Bridgeport, CT
203-385-1127
203-576-9960 x 231
TRUMBULL GARDENS
CENTER
715 Trumbull Ave
Bridgeport, CT
CESAR BATALLA CTR
927 Grand Street
Bridgeport, CT
203-336-2153
203-371-5117

Inclusive of parents in the
implementation & development
of programs and policies
BULLS HEAD
HOLLOW HEADSTART
108 Sanford Ave
Bridgeport, CT
CHARLES B TISDALE
CENTER
1795 Stratford Ave
Bridgeport, CT

Advocacy and support for
families and children
203-338-9640
203-330-0166

An enhanced collaboration
between and among family &
child services agencies to
improve the knowledge and
responsiveness of these
agencies to the needs of
children and their families
The fulfillment of this mission
will create a collaborative
consisting of parent, agency, and
community of opportunity for all
families and their children.
JAMIE A. HULLEY CTR
460 Lafayette St
Bridgeport, CT
WEST END CENTER
361 Bird Street
Bridgeport, CT
203-367-6801
203-335-0553
TENDER LOVING CARE:
THERAPEUTIC PROGRAM (TLCC) ABCD
1070 Park Ave
Bridgeport, CT
FULL & PART YEAR
TRUMBULL / MONROE
REGIONAL HEAD START
240 Middlebrooks Ave
Trumbull, CT
203-366-8241 x 244
203-452-4423
PART DAY/PART YEAR:
BULLARDS HAVEN
500 Palisade Ave
Bridgeport, CT
PART DAY/PART YEAR:
ABCD at STRATFORD
SOUTHEND COMMUNITY
CTR 19 Bates Street
Stratford, CT
203-377-4721
203-579-6333 x 6611
ACTION FOR
BRIDGEPORT
COMMUNITY
DEVELOPMENT
1070 PARK AVE
BRIDGEPORT, CT
www.abcd.org
The first five years of
childhood are the most
important in development
and learning. Our
educational curriculum is
designed to help children
reach their fullest potential.
At ABCD we have set the
standard for the highest quality of
preschool programs in the Greater Bridgeport area.
Our programs feature fun, age-appropriate lessons and
activities which help develop the whole child: physically,
intellectually, emotionally and socially. Each child is
encouraged to explore and discover at his or her own pace.
Not only do we provide services for the children, we also help
families with their needs. Our social service team is ready to
assist families with referrals to community agencies or other
ABCD programs.
Most families qualify for our sliding scale fee or free
programs.
Our curriculum has been developed in accordance with CT
Department of Education Early Learning standards as well
as the Head Start’s Creative Curriculum program with the
goal of School Readiness.
In addition our Early Head Start Home Based program
option supports children and their families through
home visits and group socialization experiences.
ABCD welcomes all children. We greatly appreciate the
cultures of all our families and staff and provide a
multicultural environment. We assist in providing
translation services. Our qualified staff are also trained
for children with disabilities. With on-site support from
mental health, education and disabilities specialists all
children are assured to receive the required services.
Assistance with referrals for children are also available.
We provide free nutritional meals daily. The meals are
planned by the staff nutritionist with the parents, staff,
and the caterer. We also have health professionals on
staff who assist with children’s health concerns at the
centers.
We have an open door policy and parents are always
welcome. Parents have the opportunity to volunteer in
their child’s classroom and also become active members
of many different parent groups.