Common use of MDHHS Clause in Contracts

MDHHS. BCAL 3305 (formerly OCAL 3305/BRS-3305) Rev. July 2015 I, , give permission to Little Treasures Early Childhood Center to charge my card for the following services. My payment details will be stored in my profile and will be used for the services provided. My payment will also be used for auto pay when payment is due based on the information below. There will be a 3% fee for credit/debit cards or a $1.00 fee for ACH bank accounts that is charged by the billing company for each transaction. You may choose to have your card and bank account on file or just a card on file. It is required to have a card on file. If payment is declined, the payment will be reprocessed. MasterCard Discover VISA American Express Other ACH Information Bank Name: Routing Number: Billing Address: Name On Account: Account Number: Card Will Be Charged Every: Week Month Charges Will Be Made On: For The Amount Of: I have thoroughly read through the tuition contract and agreement provided and understand the terms of agreement. Customer Signature: Date: Primary Phone Number* Family Name* Address* Apartment/Unit # City* State* Zip Code* Date Received*: Referral Source* Agency Parent Guardian Other Initial Contact Method Email Phone Walk In Other: How did you learn about us? Authorization to Share (please read this statement in full)*: Part of Oakland Schools is to support your family, which means we may refer you to another program or organization. Do you give permission to Oakland Schools to share the information you’ve given me today with affiliate/community organizations in order to best support your family? Information may also include the results of the Ages and Stages Questionnaire. This will remain in effect until the youngest child in the family turns five or your family requests, either verbally or in writing, that information sharing be stopped. Parent/Guardian Signature* For which year are you hoping to have your child enrolled or be considered for services? 2023-2024 2024-2025 Desired Program Schedule Part Day School Day - 4 days per week School Day - 5 days per week Child’s Legal First Name Middle Name Child’s Legal Last Name Suffix Date of Birth (Month, date, year) Gender Is Hispanic or Latino Yes No Race/Ethnicity * Select the one that you most identify with. American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Do you need transportation? (transportation is not available in all areas) Yes No The questions contained in this document are sensitive for families. Now that enrollment prioritization is based on income level, and eligibility factors determine prioritization within the income levels, it is not as necessary to gather this information at the start of the school year. This information: Can be gathered throughout the year and reported in April on the Child Information and Staff Report (CISR) that is submitted to Oakland Schools and then to MDE. Is more easily gathered once a collaborative relationship with the family has been established. Can be gathered informally through confidential chats at drop-off or pick-up or at more formal conversations like the home visit and conferences. The following questions are designed to find more information while being aware of how sensitive these areas are for families. This document can be used to take notes on information gathered from families and kept in the child file as evidence that the program seeks eligibility factor information with the goal of providing support to the child and family. Eligibility Factor Sample Questions Check the IEP / IFSP box in MiECC if any of the following are marked Yes: Does your child have an individualized education program (IEP)? Yes No Did you child have an individualized family service plan (IFSP) with a transition referral at age 3? Yes No Yes No Does your child have a chronic illness (example: asthma)? If yes ,please explain: Do you, a doctor ,or other professional have any concerns regarding your child’s development? Yes No If yes, please explain: Check the Severe or Challenging Behavior Box in MiECC if any of the following are marked Yes: Has your child’s behavior prevented participation in another group setting? Yes No Is your child in counseling or therapy? Yes No Has your child been expelled from preschool/ child care center/ other setting? Yes No Check the Primary Home Language Other than English Box in MiECC if any of the following are markedYes: If yes, what language? What is your child’s primary language? Check the Parent or Guardian with Low Educational Attainment Box in MiECC if any of the following are Less than High School or Evidence of Parent Literacy Need: What is the highest level of education for the parents of the child? Parent 1 (check all that apply): LessthanHighSchool GED Highschool College Parent 2(check all that apply): LessthanHighSchool GED Highschool College Are there any literacy resources, either for the child or parent, the family would be interested in? Who reads to the child in the home? Check the Abuse / Neglect of Child or Parent Box in MiECC if any of the following are Yes: Have you or your child ever felt unsafe in your home? Yes No Has anyone in your home been a victim of physical, sexual, or emotional abuse or neglect? Yes No Is there a history of substance abuse in the home (alcohol, drugs, prescription drugs)? Yes No Does anyone in the home have a violent or destructive temper? Yes No Check the Environmental Risk Box in MiECC if any of the following are Yes: Has any of the following occurred for the child? Divorce Parental: Yes No Yes No Military Leave Incarceration Chronic illness Yes No Yes No Yes No Living elsewhere due to school or work Yes No Grandparents raising child Yes No ▇▇▇▇▇▇ child Yes No Frequent changes in custody Yes No Single parent Yes No Teen parent at the time the first child was born Sibling with: Yes No Chronic illness Yes No Challenging behavior Yes No Disability Death Yes No Yes No Do you consider yourself homeless? Yes No Did your family unexpectedly relocate in the last 6 months? Yes No How many times have you moved in the past 2 years? Are you residing with anyone other than your immediate family members? Yes No Residing in a neighborhood with: High poverty High crime Yes No Yes No Limited access to critical community services Yes No es Yes Ye No High death rat Violence Daily exposure to: s No Lead Yes No Rodents Yes No Insect infestations Yes No Violence Yes No Injury Drug use Yes No Yes No Crowded housing Lack of utilities Yes No Yes No No space for children’s play Yes No Prenatal or postnatal exposure to toxic substances known to cause learning or developmental delays Yes No Fetal Alcohol Syndrome Yes No Born addicted Yes No Environmentally-induced respiratory problems Other: Yes No Other Parent/Guardians in the household (dependent on the household income) Last Name Relationship to Child Last Name Relationship to Child Siblings/other children in the household Last Name Date of Birth (Month, date, year) Gender Last Name Date of Birth (Month, date, year) Gender Last Name Date of Birth (Month, date, year) Gender Last Name Date of Birth (Month, date, year) Gender Last Name Date of Birth (Month, date, year) Gender Last Name Date of Birth (Month, date, year) Gender Last Name Date of Birth (Month, date, year) Gender Last Name Date of Birth (Month, date, year) Gender Notes: Tell us more about your child to help us support the transition into school. Enrollment is not determined based on responses to these questions. Please circle the interest areas in our classroom that you think your child will enjoy the most: BlockArea HouseArea ToyArea WoodworkingArea ReadingandWritingArea Movement&MusicArea SandandWaterArea ComputerArea Outdoor Area What language(s) does your family speak? How much experience (exposure) has your child had with the(se) languages? Is your child growing up with two languages? If so, what are the languages? Can you tell me about your child’s use of English (if at all)? What are some of the ways your child plays at home? Does your child play with children from other households? If yes, how? Has your child ever used: scissors? Glue? Crayons? Paint? Pencil? What other school-type experience has your child had? Approximately how many hours does your child spend daily watching TV? Approximately how many hours does your child spend daily playing video games? Approximately how many hours does your child spend daily on the computer or a tablet?