Fillable The Chickasaw Nation Head Start Parent Consent Form

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The Chickasaw Nation Head Start Parent Consent Form

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The The Chickasaw Nation Head Start Parent Consent Form form is 2 pages long and contains:

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The Chickasaw Nation Head Start
Parent Consent Form
Please initial the appropriate yes or no blank, then sign and date at the bottom. The form will be
notarized.
I, parent/guardian of ________________________ hereby give permission to the Chickasaw Nation
Head Start program:
To transport my child for any medical/dental care or treatment he/she might need, including
immunization, doctor appointments and for any emergency medical and/or dental care he/she might
need as a result of an accident Yes No
To transport my child to and from the Head Start center for field trips scheduled by the program
Yes No
To photograph and use my son/daughter and family’s photos in any publications of the Chickasaw
Nation
Yes No
To obtain information and records from the public school my child is or will be attending to observe
his/her progress in public school (it is a requirement of the Head Start Federal Performance Standards
that we track our students’ progress during their school years).
Yes No
To participate in several types of screenings regarding their general health and development (you will
be notified of the results of the screenings and of any follow-up treatment that may be needed)
Yes No
These screenings may include any or all of the following:
• General information screening
• Health history
• Physical examination by a doctor
• Height and weight measurement
• Blood pressure check
• Hearing screening
• Vision acuity
screening/strabismus
• Dental exam
• Nutrition screening/assessment
• Developmental
hematocrit/hemoglobin
• Lead
• Lift the Lip
• Screening/DIAL
• Speech/language screening
• Mental health
observations/screening
Page 1 of 2 Form no 04466PC CS-EDU Rev. 8/2015
In the event the Chickasaw Nation Education Division receives a dangerous weather notice, facility
employees will route children to the protected areas. The children will remain in those areas until the
Chickasaw Nation Education Division receives notice from the Lighthorse Police Department that it is
safe to leave the protected areas. It would be potentially hazardous to your children, other children and
facility employees to allow children to leave the protected areas during the course of dangerous
weather. Therefore, it is the policy of the Chickasaw Nation Education Division that children will not be
released to parents or guardians during periods of dangerous weather, if those children are already in
protected areas.
I UNDERSTAND THAT THE CHICKASAW NATION EDUCATION DIVISION WILL NOT RELEASE
CHILDREN FROM PROTECTED AREAS DURING PERIODS OF DANGEROUS WEATHER, AND I
FURTHER WAIVE THE RIGHT TO SUE FOR ANY SUCH CONDUCT.
Yes No

______________________________ __________________
Signature of parent or guardian Date
State of Oklahoma )
County of _________________)
Signed before me on ________________, 20___
By ____________________________________
Identification: ____________________________
My commission expires: ___________________
My commission no.: ______________________
__________________
Notary Public
Page 2 of 2 Form no 04466PC CS-EDU Rev. 8/2015
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The Chickasaw Nation Head Start Parent Consent Form

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Completed 31 January 2021

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