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Staff Signature
Title
Date
Z:\PROGRAMS and SERVICES\APPLICATION & ENROLLMENT DOCUMENTS\2016-2017 Enrollment Forms 7-2016.doc
Child and Adult Care Food Program
Income Eligibility Form (IEF) 2016- 2017
Part 1 - List name and age of each child enrolled. Indicate each child’s race and ethnicity. If this information is left blank, the institution
representative may complete it based on visual identification. This information is for statistical reporting requirements and does not affect
eligibility. Note: A =Asian; AI/AN=American Indian or Alaskan Native; B/AA=Black or African American; H/PI=Native Hawaiian or other
Pacific Islander; W=White.
First Name
Last Name
Age
Ethnicity (select one) and Race (select one or more)
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Race:
 A  AI/AN  B/AA  H/PI  W
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Race:
 A  AI/AN  B/AA  H/PI  W
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Race:
 A  AI/AN  B/AA  H/PI  W
Participation in some programs allows automatic eligibility for free meals in the CACFP with required documentation. If applicable,
please check one of these boxes if one or more children listed above is:
 A foster child who is the responsibility of the State or was placed by the court.  An Early Head Start, or Head Start child or pregnant
mother or an Even Start enrolled child.  A homeless, migrant, or runaway child. Refer to the back of this page for required eligibility
documentation.
Please note: If you marked one of the boxes listed above and it applies to ALL children listed above, SKIP TO PART 5 – Signature.
Part 2 - Assistance Programs: Does anyone in your household receive benefits from any of the programs listed below? If no, go to Part 3.
If yes, please mark which assistance program (only one is required), write the case number, and SKIP TO PART 5 – Signature.
 Supplemental Nutrition Assistance Program (SNAP)
 Temporary Assistance for Needy Families (TANF)
CASE NUMBER
.
 Food Distribution Program on Indian Reservations (FDPIR)
(Quest Card or Social Security numbers are not acceptable)
Part 3 - Income to report: List the names of all household members who earn income, regardless of age. Write the amount of income received
by each household member for the current month, projected income for the first month of this application, or the month prior to this
application. Indicate if income is weekly (W), monthly (M), or annually (A). If you enter ‘0’ or leave any fields blank, you are stating there
is no income to report. Refer to the back of this page for definitions of income.
$
Gross Income/
Salary/Wages
W M A
$
W M A
TOTALS
Center Use Only
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
$
W M A
First and Last Name
Total number in Household
Other Income
Note: If necessary, convert multiple income schedules to annual
income. Multiply weekly income by 52, bi-weekly by 26,
monthly by 12.
Total Income:
Part 4 – Social Security Number (SSN): If the adult household member completing this form does not provide a TANF, SNAP, or FDPIR number in
Part 2, the person completing this form must provide the last four digits of his/her Social Security Number (SSN).
X
X
X
-
X
X
 Check if no SSN
-
Part 5 - Signature: I certify that all of the information on this form is true and correct and is given in connection with the receipt of Federal
Funds. Information may be verified. Deliberate misrepresentation may subject me to prosecution under applicable State and Federal
criminal statutes. Note: If the child is a foster child, an official of a court or other agency with responsibility for the child may sign this
form.
.
Signature of Adult Household Member
Printed Name
Date
.
.
Home Telephone
.
Street Address
City
.
State
Work Phone
J:\Institution Forms & Manuals\IEFs, Letters, HHGs, Rates Forms\FY 16\2016-2017 IEF English FINAL.doc
Zip Code
.
.
Gross Income/Salary/Wages includes, but is not limited to:
• Gross earned income or cash income before deductions.
• Monetary compensation for services, including wages, salary, tips, strike benefits, commissions, fees, withdrawals from savings,
investments, trust accounts, and other accounts.
• Net income from self-owned businesses and farms.
• Social Security, public assistance or Welfare payments (e.g. TANF, General Assistance/General Relief), alimony, child support payments,
and unemployment and worker’s compensation.
• Private pensions or annuities, retirement benefits, disability benefits, veteran’s benefits, dividends or interest, income from estates,
trusts or investments, net rental income, cash withdrawals from savings, and net royalties.
• Student financial assistance (grants or scholarships) not used to meet education expenses.
• Regular contributions from persons not living in the household or any other money that may be available to pay for child (ren)’s meals.
• Child’s income: The current earnings of a child or student grade 12 or below, regardless of age, who is a full-time or regular part-time
employee, or who receives income from other sources, such as SSI or social security. Infrequent earnings, such as income from
occasional baby-sitting or mowing lawns, are not counted as income and should not be listed on the application.
The following documentation is required for automatic eligibility:
• Documentation from the placement agency verifying the child is a foster child.
• One of the following documents from the Head Start program: 1) An approved Head Start or Even Start application; 2) A statement of
Head Start or Even Start enrollment; 3) A list of participants from the Even Start or Head Start official; 4) Documentation from the Even
Start official that confirms the child has not entered Kindergarten.
• Documentation verifying the status of a homeless, migrant or runaway child from the director of the homeless shelter, Migrant Education
Program Coordinator or an official of the Runaway and Homeless Youth program.
FOR CENTER STAFF USE ONLY
Income Category (check one):
 Free  Reduced  Paid (Ineligible for Free or Reduced Priced meals)
This form expires 12 months after the month in which the institution makes the determination. Example: If the determination is July 2016, the form is
valid from July 1, 2016 through July 31, 2017. The institution may use the date the parent/guardian signs the Income Eligibility Form, OR the date
the institution’s official makes the determination and signs the Income Eligibility Form. The same approval method selected must be used for all
forms approved by the institution.
Signature of Center’s Eligibility Official
Determination Date:
Month
Year
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its
Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based
on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g.
Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.
Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination,
complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed
form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence
Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal
opportunity provider.
J:\Institution Forms & Manuals\IEFs, Letters, HHGs, Rates Forms\FY 16\2016-2017 IEF English FINAL.doc
DENTAL SCREENING & EXAM PERMISSION FORM
Denver Health, a community partner, will be providing dental examinations
for children at Family Star. There will be NO CHARGE TO YOU for these services.
The dental examination will include:
1.
2.
3.
4.
A thorough clinical oral examination. No x-rays will be taken.
A fluoride varnish* application will be given.
Oral hygiene instructions
Dental needs will be identified to help parents prioritize need for further care and follow-up dental treatment.
Each parent/guardian will receive a report regarding the child’s dental needs.
* Fluoride varnish application helps to protect teeth from cavities. Your child’s teeth may feel sticky or look yellow after
the fluoride is put on but will not stay yellow.
RARE BUT POSSIBLE RISKS: Gagging or vomiting, injury from dental instruments
Child’s Name_______________________________________
Child’s Birthdate_________________________
Does your child have a history of allergic reactions?
Yes / No
If yes: To what? _____________________________________________________________________
Does your child have blood pressure problems, heart problems, rheumatic fever or a heart murmur?
Yes / No
Explain: ___________________________________________________________________________
I give permission for my child to receive the dental services mentioned above.
These services will be provided at Family Star Montessori School.
___________________________________________________________________
(Parent/Guardian signature)
(date)
________________________________________________________________________________________
(Home Address)
(City)
(Zip Code)
NOTE: If your child hasn’t been to a dentist in over 6 months and he/she has Medicaid or CHP+, Denver Health may bill them for
these services. Please complete below if you give permission for Medicaid or CHP+ to be billed without any cost to you. You may
take your child to another dentist anytime.
My child has Medicaid/CHP+: (Please circle one)
Yes / No
Child’s Medicaid/CHP+ number: ______________________________
Child’s Denver Health Hospital Card Number: ________________________
* If you wish to decline these services, please sign below: I decline the dental examination offered at no cost to me by Family Star
Montessori School:
___________________________________________________________________
(Parent/Guardian signature)
(Date)
Please note, dental exams are a requirement of Family Star’s program, if you decline you must provide documentation that your
child received a dental exam elsewhere.
ILLNESS POLICY - HOW SICK IS TOO SICK?
WHEN TO KEEP YOUR CHILD AT HOME
FROM SCHOOL OR CHILD CARE
There are three main reasons to keep sick children at home:
1. The child doesn’t feel well enough to take part in normal activities, (such as; overly tired, fussy or won’t stop
crying).
2. The child needs more care than teachers and staff can give, and still care for the other children.
3. The illness is on this list and staying home is recommended.
And remember, the best way to prevent the spread of infection is through good hand washing.
Children with the following symptoms or illness should be kept home (excluded) from school:
SYMPTOMS
Child Must Be at Home?
DIARRHEA
frequent, loose or watery stools compared to child’s
normal ones that are not caused by food or medicine
Yes - if child looks or acts sick; if child has diarrhea with fever and
isn’t acting normally; if child has diarrhea with vomiting; if child
has diarrhea that overflows the diaper or the toilet
FEVER with behavior change or other illness
A fever of 100°F or above in babies 4 months or
younger needs immediate medical attention.
Yes, when the child also has a rash, sore throat, vomiting,
diarrhea, behavior changes, stiff neck, difficulty breathing, etc.
“FLU-LIKE” SYMPTOMS
Fever over 100°F with a cough or sore throat. Other
flu symptoms can include tiredness, body aches,
vomiting and diarrhea
Yes - for at least 24 hours after the fever is gone, without the use
of medicine that reduces the fever
COUGHING
Note: Children with asthma may go to school with a
written health care plan and the school is allowed to
give them medicine and treatment
Yes - if severe, uncontrolled coughing or wheezing, rapid or
difficulty breathing and medical attention is necessary
Mild RESPIRATORY OR COLD SYMPTOMS
stuffy nose with clear drainage, sneezing, mild cough
No - may attend if able to take part in school activities
Keep home if symptoms are severe. This includes fever and the
child is not acting normally and/or has trouble breathing.
RASH WITH FEVER
Note: Body rash without fever or behavior changes
usually does not need to stay home from school, call
the doctor
Yes – call the doctor. Any rash that spreads quickly, has open,
weeping wounds and/or is not healing should be evaluated
VOMITING
Throwing up two or more times in the past 24 hrs
Yes - until vomiting stops or a doctor says it is not contagious. If
the child has a recent head injury watch for other signs of illness
and for dehydration
1
13123 E. 16th Avenue B 215, Aurora, Colorado 80045 • 303-281-2790
The School Health Program of Children’s Hospital Colorado provides school and child care health consultation and services in a variety of settings in Colorado. This document has been
reviewed and approved by designated staff of Children’s Colorado. It is intended to supplement, not replace, medical information provided by the healthcare provider, March 2014
ILLNESS POLICY - HOW SICK IS TOO SICK?
WHEN TO KEEP YOUR CHILD AT HOME
ILLNESS
Child Must Be at Home?
CHICKEN POX
Yes - until blisters have dried and crusted (usually 6 days)
CONJUNCTIVITIS (PINK EYE)
pink color of eye and thick yellow/green discharge
No (bacterial or viral) – children don’t need to stay home
unless the child has a fever or behavioral changes. Call
the doctor for diagnosis and possible treatment.
CROUP (SEE COUGHING)
Note: May not need to stay home unless child is not well
enough to take part in usual activities
Seek medical advice
FIFTH’S DISEASE
No - child is no longer contagious once rash appears
HAND FOOT AND MOUTH DISEASE (Coxsackie virus)
No - unless the child has mouth sores, is drooling and isn’t
able to take part in usual activities
HEAD LICE OR SCABIES
Yes - from end of the school day until after first treatment.
HEPATITIS A
Yes - until 1 week after the start of the illness and when
able to take part in usual activities
HERPES
No, unless - the child has open sores that cannot be
covered or is drooling uncontrollably
IMPETIGO
Yes - for 24 hours after starting antibiotics
RINGWORM
Yes - from end of school until after starting treatment
Keep area covered for the first 2 days
ROSEOLA
Yes – if the child has a fever and rash, call the doctor
RSV (Respiratory Syncytial Virus)
Staying home isn’t necessary, but is recommended when
a child in not well enough to take part in usual activities
and/or is experiencing acute respiratory symptoms. Call
the doctor. RSV spreads quickly through classrooms
STREP THROAT
Yes - for 24 hours after starting antibiotics and the child is
able to take part in usual activities
VACCINE PREVENTABLE DISEASES Measles, Mumps,
Rubella (German Measles), Pertussis (Whooping Cough)
Yes – the doctor says the child is no longer contagious
YEAST INFECTIONS
including thrush or Candida diaper rash
No - follow good hand washing and hygiene practices
References
 American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child
Care and Early Education. 2011. Caring for our children: National health and safety performance standards; Guidelines for
early care and education programs. 3rd edition. Elk Grove Village, IL.
 American Academy of Pediatrics, Managing Infectious Diseases in Child Care and Schools, 3rd Edition, Elk Grove Village, IL
2013.
 Colorado Department of Public Health and Environment, Communicable Disease Epidemiology Program, Infectious Disease in
Child Care Settings: Guidelines for Schools and Child Care Providers, Denver, CO, October 2013.
2
13123 E. 16th Avenue B 215, Aurora, Colorado 80045 • 303-281-2790
The School Health Program of Children’s Hospital Colorado provides school and child care health consultation and services in a variety of settings in Colorado.
This document has been reviewed and approved by designated staff of Children’s Colorado. It is intended to supplement, not replace, medical information
provided by the healthcare provider, March 2014
For Teaching Pedestrian Safety to Children
TIP SHEET
Tips for Parents and Other Adults
Walking is a fun and healthy way to spend time
with your children while teaching them skills that
can serve them well throughout life. The walk to
school is a great time to use these safety tips.
Be a walking role model
Children learn through experience. Walking with
parents or another caregiver is an important way for
children to practice crossing real streets and picking
safe places to walk. There is no magic age when
children are old enough to walk without an adult.
But, as a parent, you should decide when your child
has the skills and experience to deal with traffic safely
without you.
As you walk with your child, remember these safety tips:
• Wear bright-colored clothes, and carry flashlights
or wear reflective gear if it is dark or hard to see.
• Look for traffic at every driveway and intersection.
Be aware of drivers in parked cars that may be
getting ready to move.
• Obey all traffic signs and signals.
• Cross the street safely:
1. Stop at the curb or edge of the street.
2. Look left, right, left and behind you and in
front of you for traffic.
3. Wait until no traffic is coming and begin
crossing.
4. Keep looking for traffic until you have fi nished
crossing.
5. Walk, don’t run across the street.
Choose the safest route to school
Select a walking route with less traffic and
intersections.
• Pick places where there are sidewalks or paths
separated from traffic. If there are no sidewalks
or paths, walk as far from the motor vehicles as
possible and, if possible, on the side of the street
facing traffic.
• Limit the number of street crossings. When
available, cross at a location with an adult school
crossing guard.
• Avoid crossing busy or high-speed streets.
Understand your childs’ limitations
Children are not small adults. It will take time and practice for a child to develop the ability to deal with lots of traffic.
Over time, children develop the ability to accurately judge the speed and distance of oncoming traffic. Young children
may think that a car is able to stop, when in fact, it is not. Also, children may think that if they can see a driver, the
driver can see them. But, children are smaller and harder for drivers to see. Get down to a child’s height to experience
their perspective and see what they see.
For more resources and information on Safe Routes to School, please visit the National Center for Safe Routes to School Web site at www.saferoutesinfo.org.
www.walkbiketoschool.org
AYUDANDO A LOS NIÑOS A APRENDER HABILIDADES DE SEGURIDAD PEATONAL:
Visión general para padres y encargados de niños
El caminar es una manera divertida y saludable de pasar el tiempo con su hijo(a).
Usted es el ejemplo más importante para que su hijo(a) camine de manera
segura. Los niños aprenden observando a otros, así que su comportamiento
como peatón seguro es la mejor manera de enseñar estas valiosas lecciones.
Considere estos consejos cuando camine con su hijo:
1. Obedezca todas las señales de tráfico y los semáforos.
2. Escoja rutas que tengan espacios para caminar, la menor cantidad de tráfico
y las velocidades más bajas.
3. Observe el tráfico en todas las intersecciones.
4. Si es posible, cruce en una zona peatonal o en una intersección con
señalización peatonal.
5. Pare en la banqueta y observe si hay tráfico en todas direcciones (hacia la
izquierda, derecha, izquierda, frente y atrás). En una intersección es
importante mirar hacia adelante y atrás para ver si existen automóviles que
estén dando vuelta. La segunda mirada hacia la izquierda es para comprobar
que no haya tráfico a su alrededor.
6. Espere hasta que no haya tráfico a su alrededor y comience a cruzar; siga
observando el tráfico mientras cruce la calle.
7. No corra. Siempre cruce caminando.
8. Lleve equipo reflector si está oscuro o si la visibilidad es limitada como cuando
haya lluvia o nieve.
9. Mientras camine, hable con su hijo(a) acerca de lo que están haciendo y el
por qué lo están haciendo.
Cómo escoger la ruta más segura
1. Escoja la ruta con menos calles que cruzar.
2. Evite cruzar las calles más transitadas o de
velocidad alta.
Aunque sea seguro cruzar la calle o tomar otras decisiones mientras camina,
es posible que su hijo(a) no entienda el por qué sea seguro. Para ayudarle a
entender y a obtener experiencia caminando de una manera segura, camine con
su hijo(a) cada vez que pueda y explíquele sobre cómo caminar cerca y alrededor
del tráfico.
3. Escoja lugares que tengan aceras cuando sea
Como conductor, usted también puede darle ejemplo a sus hijos de cómo
comportarse de una manera segura. Respete a los peatones y mientras maneje,
ensénele a su hijo acerca de las señales, semáforos u otras reglas de tráfico.
Asegúrese de siempre seguir la misma ruta cuando
camine con su hijo hacia su destino.
SafeRoutes
National Center for Safe Routes to School
posible. Si no existen, la camine lo más lejos del
tráfico que sea posible por su derecha, con vista
hacia el tráfico inminente.
Developed by the National Center for Safe Routes to School
of the University of North Carolina Highway Safety Research Center and funded by the U.S. Department of Transportation
Desarrollando las habilidades peatonales
La habilidad de los niños de entender y de tomar decisiones acerca de dónde caminar y cruzar la calle es diferente a diferentes edades.
Niños de cuatro a seis años
Niños de siete a nueve años
Niños mayores de diez años
1. Tienen experiencia muy limitada
1. Necesitan supervisión mientras
1. Necesitan instrucciones específicas y
lo cual hace difícil para ellos saber
dónde o cuándo es seguro cruzar la
calle.
2. No saben estimar la velocidad del
tráfico que se acerca.
3. Pueden perder la concentración
fácilmente.
4. Pueden tener dificultad para
mantenerse enfocados en una tarea,
así como cruzar la calle.
Caminen Juntos
Ya que los niños de cuatro a seis años
todavía están aprendiendo sobre lo
que significa ser seguro, ellos deben
estar acompañados de adultos quienes
harán de su seguridad, su prioridad.
La mejor manera para que los niños
aprendan sobre las habilidades
peatonales, es el caminar con un
adulto y repetir los ejercicios.
aprenden habilidades peatonales
más complicadas.
2. Pueden empezar a identificar sitios
seguros por dónde cruzar con ayuda
y práctica.
3. Pueden empezar a aprender cómo
identificar si hay tráfico y pueden
enfocarse en practicar a cruzar la
calle con ayuda.
Enseñe habilidades para toda la vida
Esta es la edad perfecta para enseñarle
a los niños lecciones para toda la vida
de cómo comportarse como peatones
seguros. Los niños de siete a nueve
años pueden empezar a aprender
lecciones más complicadas de seguridad
peatonal. Aunque sean mayores, los
niños siempre deben estar acompañados
de un adulto cuando caminen cerca o
alrededor del tráfico. La mejor manera
para que los niños aprendan sobre las
habilidades peatonales, es el caminar
con un adulto y repetir los ejercicios.
ejemplos mientras aprenden lecciones
seguridad peatonal más avanzadas.
2. Pueden identificar sitios seguros
donde cruzar con ayuda y práctica.
3. Con ayuda y práctica, pueden
identificar el tráfico y mantenerse
enfocados mientras crucen la calle.
Encuentre un balance entre ser
independiente y la supervisión
Los niños mayores de diez años pueden
gradualmente aprender lecciones de
seguridad peatonal más complicadas.
Aunque sean mayores, deben estar
acompañados de un adulto cuando
caminen cerca de o alrededor del
tráfico, hasta que demuestren
consistentemente buenas habilidades
de seguridad peatonal. La mejor
manera para que los niños aprendan
es practicar las lecciones de seguridad
peatonal con un adulto. A medida que
los niños crezcan, revise de nuevo estos
temas de seguridad con frecuencia
para asegurarse los niños conlleven un
comportamiento peatonal seguro.
¿Cómo puede ayudar?
Usted puede ayudarle a sus hijos hablando con ellos y demostrándoles cómo comportarse como un peatón seguro. Considere éstos consejos:
1. Camine con su hijo(a) para demostrarle buenos comportamientos de seguridad peatonal.
2. Camine con su hijo(a) para ayudarle a escoger el trayecto más seguro en las rutas más usuales (como el caminar hacia la escuela).
Explíquele la importancia de siempre seguir la misma ruta.
3. Pare en cada acera y hable con su hijo(a) acerca de la importancia de parar y mirar en todas direcciones antes de cruzar para comprobar
que no haya tráfico.
4. Explíquele a su hijo(a) sobre la importancia de esperar hasta que no haya tráfico en ninguna dirección antes de cruzar la calle juntos. Si
están en una intersección con una señal peatonal, explíquele el por qué debe esperar hasta que aparezca la señal de caminar, y antes de
cruzar, el por qué debe parar y mirar en todas direcciones para comprobar que no haya tráfico.
5. Mientras crucen, ayúdele a su hijo(a) a mantenerse enfocado en cruzar con seguridad tomándole de la mano y caminando directamente al
otro lado de la calle.
SafeRoutes
National Center for Safe Routes to School
Developed by the National Center for Safe Routes to School
of the University of North Carolina Highway Safety Research Center and funded by the U.S. Department of Transportation