LCAA Return Application 25-26

LCAA HS/EHS Return Application

School Year 2025-26
Child Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Application Date*

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Relationship*
Parent/Guardian(s) Email*
example@example.com
Parent/Guardian Cell Number*
Please enter a valid phone number.
Parent/Guardian Secondary Number
Please enter a valid phone number.
Center/Location*

Cottageville Head StartCottageville Early Head StartWhitaker Head StartLearn and Play Early HSEstill Head StartEstill Early Head StartVarnville Head StartHendersonville Head StartBells Elementary
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Is your Mailing Address different than your leaving address?*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Parent Signature*

Clear
Date

MonthDayYear
Date

Consent for Medical Dental Treatment

School Year 2024-25
Child Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Facility
Facility County
Facility Address
Facility City, State, Zip
I hereby give my consent for emergency Medical or Dental Treatment of my daughter and/or son (listed above) by a licensed physician or dentist while under the care of LCAA Head Start and for transporting of the student to and from the source of Emergency Treatment at the above Facility.

The Treatment may include examination and any test deemed necessary by the Physician or Dentist. Surgical operations without prior consent will not be administered of emergency, after several attempts have been made to contact me; until I become available.

This consent is valid for two years after the date signed.
Yes, I confirm that I have read and understand this form.*

By checking this box, I am electronically signing this form.

Student Information Emergency Transportation Card

School Year 2024-25
Child Name*

First NameLast Name
Bus #
Mother's Name*

First NameLast Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Father's Name

First NameLast Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Check any boxes below for any of the following items for which you give permission. Assure that each item is clearly explained and understood before giving consent.

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT: If required, hereby I authorize the Start staff to get medical aid for my child, From my physical, hospital emergency room staff, emergency medical technician, or center's physical if they are unable to contact me or other legal guardian. I authorize the emergency doctor (and whoever he/she my designate as his/her assistant) to perform necessary emergency treatment and/ or procedures as he / she deems necessary. I understand that Head Start will make every attempt to contact me in case of emergency and that when reached, my presence with my child is necessary.I authorize Head Start and Bus Drivers to administer basic first aid to my child in the classroom or in transit should injury occur.I give my permission for my child to be transported by Head Start for any parent authorized Health advance notification of date is given to parents.I give my child permission to take part in all Head Start field trips, picnics, etc. Advance notification of date is given to parents.Check this box if there are any Adults NOT allowed to sign out your child (List adults below).Check this box to List emergency contacts persons and /or authorized persons to receive the child from the center or bus stop. Please give working telephone number. (Person must be 18 yrs. or older.
Adults NOT allowed to sign out your child
1. Emergency/Authorized Contact*
1. Telephone*
2. Emergency/Authorized Contact*
2. Telephone*
3. Emergency/Authorized Contact
3. Telephone
4. Emergency/Authorized Contact
4. Telephone
5. Emergency/Authorized Contact
5. Telephone
Yes, I confirm that I have read and understand this form.*

By checking this box, I am electronically signing this form.

Statement of Child's Health

School Year 2024-25
Child Name*

First NameMiddle NameLast Name
1. Parent/Guardian's Name*

First NameLast Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
2. Parent/Guardian's Name

First NameLast Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
You must have two individuals who have the authority to obtain emergency medical treatment for the child.
1. Full Name

First NameLast Name
Relationship
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
2. Full Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Family Code Word(s)*
Health Insurance Provider
Additional Comments
Yes, I confirm that I have read and understand this form.*

By checking this box, I am electronically signing this form.

	Relative/Are they deceased?
Diabetes
Cancer
Heart Disease
Stroke
Tuberculosis
Seizures
Asthma
Allergies

	Yes	No
Rheumatic Fever or Rheumatic Heart Disease
Heart Valve Problems/Surgery
Heart Murmurs
Heart Problems/Congestive Heart Failure
Stroke
Jaundice
Kidney Disease
Prolonged Bleeding
ADD/ADHD
Autism
Down's Syndrome
Tuberculosis
Diabetes
Anemia
Seizures
Hepatitis
Eczema
Asthma
Medication/Inhaler
Chicken Pox
Ear Infection/frequent

LCAA HS/EHS Return Application

Consent for Medical Dental Treatment

Student Information Emergency Transportation Card

Parent Interview Sheet

Statement of Child's Health

Health Center Registration

Student Health Information