Child’s Name: ____________________________________ Date Received: _____________________

Date of Birth: ____________________ First Preference: ____________________________________

PLEASE NOTE:

• Age regulations for 2020 -2021 school year require children to be 4 years old by June 30, 2020!

According to state law policy 2419, all classrooms are inclusive.

• Transportation is not provided by Jefferson County Schools for Pre-K. However, the Head Start

Program has limited transportation available for qualifying families.

Your completed application (all components) must be turned in at the Head Start/Pre-K TA

Lowery site (the brick building located to the right of TA Lowery Elementary School) 221 Warm

Springs Rd., Shenandoah Junction, WV. After receipt of your application, if it is necessary to

schedule a face-to-face appointment, you will be contacted within 7 to 10 business days. The

EPIC Head Start office will be available to take phone calls on Tuesdays from 9:30 am to 2:30

pm at 304 724-9942.

___ Enrollment Form

___ Dental

___ Health Check

___ Immunizations

___ Birth Certificate

___ Preferences

___ JCS Home Language Survey

___ JCS Health Assessment

___ JCS Student Residency

JEFFERSON COUNTY SCHOOLS PRE-K APPLICATION PACKET

Jefferson County Schools Universal Pre-K Programs are a non-discriminatory collaboration between Jefferson

County Pre-K, Head Start, Child Care Centers and Office of Special Education.

JEFFERSON COUNTY SCHOOLS PRE-K/ HEAD START REGISTRATION PREFERENCES 2020-2021

221 Warm Springs Rd. Shenandoah Junction, WV 25442 phone – 304-724-9942 fax – 304-725-7511

Child’s Name: ____________________________ _Date of Birth: ________________ Gender: __________ _____

Child’s Social Security Number: _________________________Foster Care: (Y/N) ______TANF: (Y/N) __ Parent or Guardian’s name: __________________________ _ _ __________________

Street Address: ___________________________ _________________

City/Town/Zip: ____________________________ _________________

Main Phone number: _____________________________ Other phone: ____________________ __ ______________

Email address: ____________________________ _________________

Please indicate 3 sites that you would prefer by placing a #1, 2, or 3 on the line next to the site name. Sites that have transportation are the HS/Pre-K sites listed in the box on the right. Sites that offer before and after childcare say; “wrap around care,” next to the site name and they are listed in the box on your left. All sites are Full Day programs operating 5 to 6 hours per day depending on the location.

______ I do not have transportation. Please provide a reason for needing transportation (i.e. no car or one car family):

___________________________ __________________

Yearly: ________________ Monthly: ________________Weekly: ________________ SSI: (Y/N) ________________

Approximate gross family income (required for data collection)

Total number in family: ________________ # of Children under 4: ________________ Parent/Gaurdian Signature: __________________________ Date: __________________________

____ Blue Ridge Elementary Universal Pre-K ____ Children First (wrap around) Universal Pre-K ____ Driswood Elementary Universal Pre-K ____ North Jefferson Elementary Universal Pre-K ____ Page Jackson Elementary Universal Pre-K ____ Shepherdstown Daycare (wrap around) Universal Pre-K ____ TA Lowery Universal Universal Pre-K

Head Start Sites below may have limited transportation available for qualifying families. ____ Blue Ridge Elementary HS/Pre-K ____ Driswood Elementary HS/Pre-K ____ South Jefferson Elementary HS/Pre-K ____ TA Lowery Elementary HS/Pre-K

Reason for choice - check all that apply: 1._______ JCS Employee 2._______Childcare location 3. _______ Other: please list reason on line below. _____________________________________________________________________________________________

AK/2019

JEFFERSON COUNTY UNIVERSAL PRE-K/HEAD START

Jefferson County

Pre-K/Head Start CHILD - ORAL HEALTH 221 Warm Spring Ave. Shenandoah Junction, WV. 25442 Phone: 304-724-9942 Fax: 304-725-7511

Date exam completed: ___/___/___ Name: ______________________________________________

ORAL CONDITION UPPER

LOWER

Number of times per day child brushed teeth: l__l__l

Gum Condition:

□ Normal □ Swollen □ Bleeds Easily □ Infected

Dental Needs:

□ No Needs □ Treatment □ Cleaning

□ Fluoride Supplement □ Oral Hygiene Instruction

□ Other: Specify ______________________________

Comments/Follow-up

Follow-up/6 months check-up date __________________________

D.D.S. Signature: _________________________________________________ Date: _____________________

Stamp

phone #:

Address:

RIGHT

KEY X Missing Decayed

● Filled

LEFT

West Virginia Department of Health and Human Resources

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) HealthCheck Program Preventive Health Screen

Name________________________________________________________________________________________ DOB_____________________________________ Age_________________ Sex: M F

Weight _____________ Height______________ BMI______________ Pulse________________ BP______________ Resp_______________ Temp________________ Pulse Ox (optional)_______________

Allergies NKDA ___________________________________________________________________________________________________________________________________________________________

Current meds None________________________________________________________________________________________________________________________________________________________

Foster Child _______________________________ Child with special health care needs__________________________________ IEP/section 504 in place_________________________________________

Accompanied by Parent Grandparent Foster parent Foster organization________________________________________________ Other ____________________________________________

Oral Health

Date of last dental visit_____________________________________

Current oral health problems ________________________________

Water source Public Well Tested

Fluoride supplementation Yes No

Fluoride varnish applied (apply every 3 to 6 months)

Yes No ___________________________________________

Vision Acuity Screen:

R __________ L ___________ UTO (retest in 6 months)

Wears glasses? Yes No

Hearing Screen

20 db@ UTO (retest in 6 months) R ear _____ 500HZ R ear____ 1000HZ ____ 2000HZ ____ 4000HZ

L ear _____ 500HZ L ear____ 1000HZ ____ 2000HZ ____ 4000HZ

Wears hearing aids? Yes No

Medical History

Initial Screen Periodic Screen

Recent injuries, surgeries, illnesses, visits to other providers and/or

counselors and/or hospitalizations:____________________________

_______________________________________________________

_______________________________________________________

Family health history reviewed __________________________

_______________________________________________________

Concerns and/or questions_________________________________

_______________________________________________________

Social/Psychosocial History

What is your family living situation____________________________

_______________________________________________________

Family relationships Good Okay Poor

Do you have concerns about meeting basic family needs daily and/or

monthly (food, housing, heat, etc.)? Yes No _______________

_______________________________________________________

Are you and/or your partner working outside home? Yes No

Developmental

Developmental Surveillance (Check those that apply)

Child can enter bathroom and have a bowel movement by himself/

herself Child can brush his/her teeth Child can dress and

undress without much help Child can engage in well-developed

imaginative play Child can answer simple questions Child can

speak in words that are 100% understandable to strangers Child

can draw pictures that you recognize Child can follow simple rules

when playing games Child can tell you a story from a book

Child can skip on 1 foot Child can climb stairs, alternating feet,

without support Child can draw a person with at least 3 body parts

Child can draw a simple cross Child can unbutton and button

medium sized buttons Child can grasp pencil with thumb and

fingers instead of fist

Concerns about child’s behavior, speech, learning, social or motor

skills____________________________________________________

_______________________________________________________

Child care/after school care _________________________________

_______________________________________________________

How much stress are you and your family under now?

None Slight Moderate Severe

What kind of stress? ( Check those that apply)

Relationships (partner, family and/or friends) School/work

Child care Drugs Alcohol Violence/abuse (physical,

emotional and/or sexual) Family member incarcerated Lack of

support/help Financial/money Emotional loss Health

insurance Other_______________________________________

_______________________________________________________

Is your child in school? Yes No ________________________

Favorite thing about school_________________________________

Any problems?___________________________________________

Activities outside school____________________________________

Peer relationships/friends Good Okay Poor

Risk Indicators ( Check those that apply)

Child exposed to Cigarettes E-Cigarettes Alcohol

Screen Date_____________________ 4 Year Form

The information above this line is intended to be released to meet school entry requirements

Sch

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WVDHHR/BPH/OMCFH/HC 01-2018

Immunizations: Attach current immunization record

UTD Given, see immunization record Entered into WVSIIS

Referrals: Developmental

Mental/behavioral health/trauma- Help4WV.com/1-844-435-7498

Dental Vision Hearing

Other _______________________________________________

Children with Special HealthCare Needs (CSHCN)

1-800-642-9704

Women, Infants and Children (WIC) 1-304-558-0030

______________________________________________________

Please Print Name of Facility or Clinician

_______________________________________________________

Signature of Clinician/Title

Drugs (prescription or otherwise)__________________________

Access to firearm(s)/weapon(s) Has a firearm(s)/weapon(s)

Are the firearm(s)/weapon(s) secured? Yes No NA

Witnessed violence/abuse Threatened with violence/abuse

Scary experience that your child cannot forget_________________

________________________________________________________

Do you utilize a car/booster seat for your child? Yes No

Excessive television/video game/internet/cell phone use

General Health

Growth plotted on growth chart

BMI calculated and plotted on BMI chart

Continue on page 2

HCT/HGB ________

Lead Blood Score _______

Name________________________________________________________________________________________ DOB_____________________________________ Age_________________ Sex: M F

4 Year Form, Page 2 Screen Date_____________________

Plan of Care

Assessment Well Child Other Diagnosis

Labs

Hemoglobin/hematocrit (if high risk)

Blood lead (if not completed at 12 and/or 24 months or high risk)

(enter into WVSIIS)

TB skin test (if high risk)

Lipid profile (if high risk)

Other _________________________________________________

________________________________________________________

Referrals

See page 1, school requirements

Prior Authorizations

For treatment plans requiring authorization, please complete

page 3. Contact a HealthCheck Regional Program Specialist for

assistance at 1-800-642-9704 or www.dhhr.wv.gov/healthcheck

Follow Up/Next Visit 5 years of age

Other_________________________________________________

Screen has been reviewed and is complete

See page 1, school requirements for required signature

Nutrition/Physical Activity/Sleep

Normal eating habits? Yes No

Fruits/Vegetables/Lean protein per day_____________________

Vitamins___________________________________________

Normal elimination___________________________________

Physical activity/exercise an hour most days

Type of physical activity/exercise _________________________

Normal sleeping patterns? Yes No

Hours of sleep each night?______________________________

*See Periodicity Schedule for Risk Factors *Anemia Risk (Hemoglobin/Hematocrit) Low risk High risk *Lead Risk Low risk High risk *Tuberculosis Risk Low risk High risk *Dyslipidemia Risk Low risk High risk

Physical Examination (N=Normal, Abn=Abnormal) General Appearance N Abn ______________________

Skin N Abn ______________________

Neurological N Abn ______________________

Reflexes N Abn ______________________

Head N Abn ______________________

Neck N Abn ______________________

Eyes N Abn ______________________

Red Reflex N Abn ______________________

Ocular Alignment N Abn ______________________

Ears N Abn ______________________

Nose N Abn ______________________

Oral Cavity/Throat N Abn ______________________

Lung N Abn ______________________

Heart N Abn ______________________

Pulses N Abn ______________________

Abdomen N Abn ______________________

Genitalia N Abn ______________________

Back N Abn ______________________

Hips N Abn ______________________

Extremities N Abn ______________________

Possible Signs of Abuse Yes No

Concerns and/or questions______________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________

____________________________________________

Anticipatory Guidance

(Consult Bright Futures, Fourth Edition for further information

https://brightfutures.aap.org)

Social Determinants of Health

Living situation and food security

Tobacco, alcohol, and drugs

Intimate partner violence

Safety in the community

Engagement in the community

School Readiness

Language understanding and fluency

Feelings

Opportunities to socialize with other children

Readiness for structured learning experiences

Early childhood programs and preschool

Developing Healthy Nutrition and Personal Habits

Milk, water, and juice

Nutritious foods

Daily routines that promote health

Media Use

Limits on use

Promoting physical activity and safe play

Safety

Belt-positioning car booster seats

Outdoor safety

Water safety

Sun protection

Pets

Firearm safety

Other

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

WVDHHR/BPH/OMCFH/HC 01-2018

JEFFRSON COUNTY SCHOOLSHome Language Survey

JEFFERSON COUNTY SCHOOLS Student Residency

By completing this questionnaire, you help the county comply with the McKinney-Vento Act, Title X, Part C of the No Child Left Behind Act. Your

truthful and accurate answers help the county identify services that the student may be eligible to receive.

School:________________________________ Last School Attended:_______________________________

Student Name:__________________________ Male Female Age:_____ Grade:_____

Student WVEIS Number:__________________ Date of Birth:______________________

Parent(s)/Legal Guardian(s) Name:________________________________________________________________

Telephone: Work:________________ Home:_________________ Cell:________________________

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine the

services the student may be eligible to receive.

1. Is your current address a temporary living arrangement? ____ YES ____ NO

2. The student lives with: 1 parent 2 parents 1 parent & another adult a relative, friend(s), or other

3. Where is the student living now? (Check one box)

In a shelter In a motel/hotel In a car In a camper or campsite

With more than one family in a house or apartment

With friends or family members (other than parent/guardian)

A public or private place not ordinarily used as a regular sleeping accommodation.

None of the above

4. Do you need help obtaining any of the following records?

Birth Certificate Immunization/Medical Records Academic Records

Guardianship Records (If applicable) Evaluation for Special Services/Programs

5. Services received at “Last School Attended” (Check all that apply)

Title I Free Lunch Social Services Special Education

6. List the student’s siblings who also attending Jefferson County Schools below: (if applicable)

Sibling Name: ________________________ School Attending: ______________________

Sibling Name: ________________________ School Attending: ______________________

Sibling Name: ________________________ School Attending: ______________________

Parent/Legal Guardian’s Signature: _ _____________________________ Date: ____________________

Director of Attendance/Homeless Liaison

110 Mordington Avenue

Charles Town, WV 25414

Voice: 304-728-9249 Fax: 304-728-4574