East Mills Preschool Application...PO Box 209, 101 Central Street, Suite B-11, Glenwood, IA 51534 Ph: (712) 527-9699 Fax: (712) 527-4711 Dear Parent or Guardian: Mills County Public

East%Mills%Preschool%Application%!

Child’s!Full!Name!_____________________________________________________☐!Male!☐!Female!Child’s!Birth!Date_____________________________________________________!

Race!(Please!Circle)!!American!Indian=Alaska!Native!!!!!!!Asian!

Black=African!American!!!!Hawaiian/Pacific!Islander!!!!!!White!

Ethnicity!(please!Circle)!!!Hispanic/Latino!!Yes/No!!!!Primary!Language!_______________!

Parent(s)/Guardian(s)!!_____________________________________________________________________!

Street/Mailing!Address!_____________________________________________________________________!

City,!State,!Zip!________________________________________________________________________________!

Home!Telephone!Number!__________________________________________________________________!

Family!Email!_________________________________________________________________________________!

Mother!_______________________________________________________!!Cell!__________________________!

Work!Location!________________________________________!Work!#!_____________________________!

Father!________________________________________________________!Cell!___________________________!

Work!Location!________________________________________!Work!#!_____________________________!

Emergency!Contact!other!than!Parent/Guardian!_________________________________________!

Relationship!______________________________________!Phone!#!_________________________________!

Secondary!Emergency!Contact!other!than!Parent/Guardian!____________________________!

Relationship!______________________________________!Phone!#!_________________________________!

Are!you!a!resident!of!the!East!Mills!School!District?!!!!!!!☐!!!Yes!!!!!!☐!!!No!Will!your!student!ride!the!bus?!_____________________________________________________________!

Special!Health!Needs:!_______________________________________________________________________!

_________________________________________________________________________________________________

_________________________________________________________________________________________________!

Parent/Guardian!Signature:!_______________________________________________!Date:!__________!

For!Office!Use:!!State!ID!Number!_______________________________!!Meal!Account!___________!

Building!Number!0427!–!East!Mills!Elementary!

MILLS COUNTY PUBLIC HEALTH PO Box 209, 101 Central Street, Suite B-11, Glenwood, IA 51534 Ph: (712) 527-9699 Fax: (712) 527-4711 www.millscoia.us

Dear Parent or Guardian: Mills County Public Health will be offering free lead screenings to check your child for lead poisoning. This involves a finger stick to obtain a small amount of blood. The blood will then be sent to the State Hygienic Lab for the test to be completed. Because of this, we need your consent to perform this test on your child. This includes completing and signing the risk questionnaire. The recommendation is that most children be tested at least yearly through their 5th birthday. If your child has never been tested for lead poisoning before or if your child is due to be tested, we encourage you to take advantage of this free screening. Please Note: A law, House File 158, requires evidence of at least one blood lead test having been done before entry to Kindergarten. Although the recommended age for testing is at least yearly from age one through age five, it is now required that each child be tested at least once. Both you and your child’s physician will be notified of the lab results by Mills County Public Health. The Iowa Department of Public Health will work with the school to obtain your child’s lead results. If you have a younger child that needs lead testing, please let me know and I would be happy to do this for you. You may contact me with any questions or concerns. Thank you, Lorri Greiner, R.N. Coordinator Lead Poison Prevention Program

IOWADEPARTMENTOFPUBLICHEALTHCHILDHOODLEADPOISONINGRISKQUESTIONNAIRE

Child’sName:____________________________________ Date:___________________________________Address:________________________________________ Phone#:________________________________City,State,Zip:____________________________________DateofBirth:_____________________________________ Physician’sName:_________________________Father’sName:____________________________________ Dateoflastvisit:___________________________Mother’sName:___________________________________ Dentist’sName:____________________________Insurance/Medicaid:_______________________________ Dateoflastvisit:___________________________Ethnicity:NonHispanicHispanic(Pleasecircle) Dateoflastleadtest:________________________PrimaryLanguage:EnglishSpanishOther(pleasecircle) Immunizationscurrent:YES/NO(pleasecircle)Pleaseanswereachquestionsothatwemaydetermineifyourchildisathighriskorlowriskforleadpoisoning.

1. Hasyourchildeverlivedinorregularlyvisitedahousebuiltbefore1960? Yes No(Examples:home,day-carecenter,baby-sitter,relative’shome)

2. Haveyounoticedanypeelingorchippingpaintinoraroundthepre-1960 Yes Nohousethatyourchildhaslivedinorregularlyvisited?

3. Hasthepre-1960homethatyourchildhaslivedinorregularlyvisitedbeen Yes Noremodeledorrenovatedby:A. Stripping,sanding,orscrapingpaintontheinsideoroutsideofthehouse?B. Removingwallsand/ortearingoutlathandplaster?

4. Doesyourchildeatnon-fooditemssuchasdirt? Yes No5. Haveanyofyourotherchildrenortheirplaymateshadleadlevels>=15ug/dL? Yes No6. Doesyourchildlivewithorfrequentlycomeincontactwithanadultwho Yes No

workswithleadonthejoborinahobby?(Examples:painter,welder,foundryworker,oldhomerenovator,shootingrangeworker,batteryplantworker,batteryrecyclingworker,ceramicsworker,stainedglassworker,sheetmetalworker,scrapmetalworker,plumber.)

7. Doesyourchildlivenearabatteryplant,batteryrecyclingplant,orleadsmelter? Yes No8. Doyougiveyourchildanyhomeorfolkremedies?(ex:azarcon,greta,pay-loo-ah) Yes No9. DoesyourchildeatcandythatcomesfromMexicoorispurchasedfrom Yes No

aMexicangrocerystore?(Examples:picarindo,veropalerindas)10. HasyourchildeverlivedinMexico,CentralAmerica,SouthAmerica,Africa,Asia, Yes No

oreasternEurope,orvisitedoneoftheseareasforaperiodlongerthantwomonths?11.Doesyourchildhaveanydevelopmentaldelays? Yes No

TheParent/Guardianandthechild’physicianwillreceivetheresultsfromthisleadscreening.Thiswillindicateiftheleadscreeningis:

<10ug/dL normal10-14ug/dL slightlyelevated–receivenutritioncounseling,recheckin3months

>15ug/dL referredforvenousleadlevel

ThisinformationwillbesharedwithmyhealthcareproviderandtheIowaDepartmentofPublicHealth’sLeadPoisoningPreventionBureau.LeadPoisoningEducationProvided Yes No ClientConcerns________________________PamphletsProvided:HasYourChildBeenTested?HowToProtectIowaFamilies Other__________________Igivepermissionformychildtoreceiveacapillaryblooddrawtoobtainabloodleadlevel. ________________________________ PrintStaffName&Title ___________________________________________ ______________________________________________Parent/GuardianSignature Date StaffSignature

Iowa KidSight Consent Form

Date of Screening: ___________________ Is this child currently seeing an eye doctor? Ƒ No Ƒ Yes, name of eye doctor/clinic: ______________________________________________________ City _____________________________

If yes, the screening is not necessary and may not be conducted in order to use our limited resources for children whose vision problems have not been identified. Free vision screening will be offered to children by a local Lions Club. Screenings are in conjunction with Iowa KidSight, in the Department of Ophthalmology and Visual Sciences at University of Iowa Children’s Hospital. Vision screening produces images of a child’s eyes to determine the presence of eye disorders including far- and near-sightedness, astigmatism, anisometropia (unequal refractive power), strabismus, (misaligned eyes), and media opacities (e.g., cataracts). No physical contact is made with a child and no eye drops are used during the vision screening. This screening is approximately 85-90% effective in detecting problems that can cause reduced vision. Participation is voluntary. This screening is designed for pre-school-aged children. Children who are younger than 6-months old will not be screened. No child will be screened without a signed and completed consent form. Each individual child needs his/her own consent form. If you have questions, please contact: Iowa KidSight, 2431 Coral Court #5, Coralville, Iowa 52241, or 319-353-7616, or [email protected].

Please print or type the information below: Child’s Name _____________________________________________________________ (_____________)

First Middle Last Initials

Male _____ Female _____ Child’s Date of Birth ________/________/________ Child’s Age ___________ (MM/DD/YYYY)

Parent’s Name ___________________________________________________________________________

Address _________________________________________ City ____________________ Zip __________

Home Phone (______)_________________________ Work Phone (______)_________________________

Cell Phone (______)___________________________ E-mail address ______________________________

I, the undersigned, hereby give permission for my child, _______________________________________, to participate in the screening event. I understand the following regarding this program:

1. The information obtained from this screening is preliminary only and does not constitute a diagnosis of vision problems. 2. I will be contacted with the results of the screening through Iowa KidSight at University of Iowa Children’s Hospital, or through my

child care provider who aided in arranging the screening. I may be contacted regarding follow-up for vision referral by Iowa KidSight staff at University of Iowa Children’s Hospital.

3. This screening result may satisfy the requirement for vision screening upon entry to kindergarten, and may be recorded in the Iowa Immunization Registry.

4. I am responsible for arranging a full eye examination with a doctor of my choosing if my child has been referred as a result of the vision screening. Iowa KidSight recommends a dilated eye examination.

5. The results of your child’s eye examination will be shared with Iowa KidSight as a means to help evaluate the screening program’s effectiveness. 6. Iowa KidSight will maintain the confidentiality of all records and results. 7. I will not hold the Lions Club and its volunteers, Lions Clubs organizations, University of Iowa Children’s Hospital, or affiliates,

accountable for any errors of commission, omission or other misdiagnosis. There are no foreseeable risks to participating in the Iowa KidSight vision screening.

_______________________________________________________________ ____________________________ Signature of Parent or Guardian Date Revised 8-2015

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Ages & Stages Questionnaires®: Social-EmotionalA Parent-Completed, Child-Monitoring System for Social-Emotional Behaviors

By Jane Squires, Diane Bricker, & Elizabeth Twomblywith assistance from Suzanne Yockelson, Maura Schoen Davis, & Younghee Kim

Copyright © 2002 by Paul H. Brookes Publishing Co.

48 Month/4 YearQuestionnaire

(For children ages 42 through 53 months)

Important Points to Remember:! Please return this questionnaire by .! If you have any questions or concerns about your child or about this

questionnaire, please call: .! Thank you and please look forward to filling out another ASQ:SE

questionnaire in months.

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48 Month/4 Year ASQ:SEQuestionnaire

(For children ages 42 through 53 months)

Please provide the following information.

Child’s name:

Child’s date of birth:

Today’s date:

Person filling out this questionnaire:

What is your relationship to the child?

Your telephone:

Your mailing address:

City:

State: ZIP code:

List people assisting in questionnaire completion:

Administering program or provider:

Ages & Stages Questionnaires®: Social-EmotionalA Parent-Completed, Child-Monitoring System for Social-Emotional Behaviors

By Jane Squires, Diane Bricker, & Elizabeth Twomblywith assistance from Suzanne Yockelson, Maura Schoen Davis, & Younghee Kim

Copyright © 2002 by Paul H. Brookes Publishing Co.

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3Ages & Stages Questionnaires®: Social-Emotional, Squires et al.© 2002 Paul H. Brookes Publishing Co.

Please read each question carefully and1. Check the box ! that best describes your child’s behavior and2. Check the circle " if this behavior is a concern

TOTAL POINTS ON PAGE

1. Does your child look at you when you talk tohim? ! Z ! V ! X "

2. Does your child cling to you more than youexpect? ! X ! V ! Z "

3. Does your child talk and/or play with adultsshe knows well? ! Z ! V ! X "

4. When upset, can your child calm down within15 minutes? ! Z ! V ! X "

5. Does your child like to be hugged or cuddled? ! Z ! V ! X "

6. Does your child seem too friendly withstrangers? ! X ! V ! Z "

7. Can your child settle himself down afterperiods of exciting activity? ! Z ! V ! X "

8. Does your child cry, scream, or have tantrumsfor long periods of time? ! X ! V ! Z "

9. Is your child interested in things around her,such as people, toys, and foods? ! Z ! V ! X "

MOSTOF THE

TIME SOMETIMES

RARELYOR

NEVER

CHECK IFTHIS IS A

CONCERN

48 months/4 yearsTM

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TOTAL POINTS ON PAGE

10. Does your child stay dry during the day? ! Z ! V ! X "

11. Does your child have eating problems, such asstuffing foods, vomiting, eating nonfood items, or _______________________ ?(You may write in another problem.) ! X ! V ! Z "

12. Do you and your child enjoy mealtimes together? ! Z ! V ! X "

13. Does your child do what you ask her to do? ! Z ! V ! X "

14. Does your child seem happy? ! Z ! V ! X "

15. Does your child sleep at least 8 hours in a24-hour period? ! Z ! V ! X "

16. Does your child seem more active than otherchildren his age? ! X ! V ! Z "

17. Does your child use words to tell you whatshe wants or needs? ! Z ! V ! X "

18. Can your child stay with activities he enjoys forat least 10 minutes (not including watchingtelevision)? ! Z ! V ! X "

MOSTOF THE

TIME SOMETIMES

RARELYOR

NEVER

CHECK IFTHIS IS A

CONCERN

Ages & Stages Questionnaires®: Social-Emotional, Squires et al.© 2002 Paul H. Brookes Publishing Co. 48 months/4 years

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TOTAL POINTS ON PAGE

19. Does your child use words to describe herfeelings and the feelings of others, such as,“I’m happy,” “I don’t like that,” or “She’s sad”? ! Z ! V ! X "

20. Can your child move from one activity to thenext with little difficulty, such as from playtimeto mealtime? ! Z ! V ! X "

21. Does your child explore new places, such as apark or a friend’s home? ! Z ! V ! X "

22. Does your child do things over and over and can’t seem to stop? Examples are rocking, hand flapping, spinning, or _______________________ . ! X ! V ! Z "(You may write in something else.)

23. Does your child hurt himself on purpose? ! X ! V ! Z "

24. Does your child follow rules (at home, at childcare)? ! Z ! V ! X "

25. Does your child destroy or damage things onpurpose? ! X ! V ! Z "

26. Does your child stay away from dangerousthings, such as fire and moving cars? ! Z ! V ! X "

MOSTOF THE

TIME SOMETIMES

RARELYOR

NEVER

CHECK IFTHIS IS A

CONCERN

Ages & Stages Questionnaires®: Social-Emotional, Squires et al.© 2002 Paul H. Brookes Publishing Co. 48 months/4 years

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TOTAL POINTS ON PAGE

27. Can your child name a friend? ! Z ! V ! X "

28. Does your child show concern for other people’s feelings? For example, does she look sad when someone is hurt? ! Z ! V ! X "

29. Do other children like to play with your child? ! Z ! V ! X "

30. Does your child like to play with other children? ! Z ! V ! X "

31. Does your child try to hurt other children,adults, or animals (for example, by kickingor biting)? ! X ! V ! Z "

32. Does your child show an interest or knowledgeof adult sexual language and activity? ! X ! V ! Z "

33. Has anyone expressed concerns about yourchild’s behaviors? If you checked “sometimes”or “most of the time,” please explain: ! X ! V ! Z "

MOSTOF THE

TIME SOMETIMES

RARELYOR

NEVER

CHECK IFTHIS IS A

CONCERN

Ages & Stages Questionnaires®: Social-Emotional, Squires et al.© 2002 Paul H. Brookes Publishing Co.

48 months/4 yearsTM

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34. Do you have concerns about your child’s eating, sleeping, or toileting habits? If so, please explain:

35. Is there anything that worries you about your child? If so, please explain:

36. What things do you enjoy most about your child?

Ages & Stages Questionnaires®: Social-Emotional, Squires et al.© 2002 Paul H. Brookes Publishing Co. 48 months/4 years

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