Funding Application Form – Foothills Creative Beginnings

Child Name*

First Middle Last

Date of Birth*

Gender*

Male
Female

Alberta Health Care Number

Attach Birth Certificate

*max file size - 20MB jpg or pdf

Parent / Guardian

Parent / Guardian Name*

First Last

Home Phone*

Cell Phone*

Email*

Primary Address*

Where child resides

Street Address City Province Postal Code

Address

If different than child's address

Street Address City State / Province / Region ZIP / Postal Code

Emergency Contact Information

This is a person who could come to pick up your child in the case of illness or emergency if the school is unable to reach the parent.

Emergency Contact Name*

First Last

Relationship to Child*

Main Phone*

Alternative Phone

Address*

Street Address City Province Postal Code

Child's Medical Information

***FCB will not administer medication without written authorization from the legal guardian. A special form is required.

Has your child had a recent vision test?*

Yes
No

Has your child had a recent hearing test?*

Yes
No

Allergies or Diet Restrictions

Medications Your Child Would Need In An Emergency (epi-pen, inhaler, etc.)

Medications Your Child Takes On A Regular Basis (insulin, inhaler, etc.)

Any Areas of Your Child's Development About Which You Have Concerns

Immunizations

Please Check the Immunizations That Your Child Has Received

*routine immunizations 2mo – 18 mo
*routine immunizations 4-6 yrs.

My Child's Immunizations Are Up-To-Date

Yes
No

Early Learning Program Child Will Attend September 2021 - June 2022

Name of Early Learning Program (daycare/preschool/kindergarten)*

Teacher Name (if known)

School Phone*

Day and Time Attending*

School Address*

Street Address City Province Postal Code

Is your child registered with any other school or preschool program?*

Yes
No

If yes, name of Early Learning Program

I authorize Foothills Creative Beginnings to apply for and administer Program Unit Funding, Mild/Moderate or English Language Learner funding:*

Yes
No

I give permission to Foothills Creative Beginnings Preschool and ECS Association to release records, assessments and therapy reports form my child to their receiving school.*

Yes
No

Signature*

Date*

If you have any questions or concerns please call 403.478.8618

I give permission to Foothills Creative Beginnings Preschool and ECS Association to release records, assessments and therapy reports for my child to their receiving school.

Program Unit Funding (PUF) and Mild/Moderate Funding (M/M) administered by Foothills Creative Beginnings (FCB) Policies Confirmation

I understand that Alberta Education requires that my child participates in 475 hours of teacher director instruction for M/M or ELL funding and 400 hours for PUF.*

I agree
No

Attendance: My child must be registered and regularly attend an Early Learning program, at least 3 days per week, (minimum 3 hours, per session) in order to receive this funding. Lack of attendance in an educational setting can jeopardize my child's funding.*

I agree
No

I understand that to achieve these hours I will be required to participate in home based programming, community programming and therapy.*

I agree
No

I understand that I will be required to attend Individual Program Plan (IPP) meetings during the school year.*

I agree
No

To obtain PUF, M/M, ELL Funding I must sign the PUF, M/M or ELL application and provide a copy of my child's birth certificate (and documentation that supports my ability to work in Canada, if my child was not born in Canada).*

I agree
No

I will provide 24 hours notice to my therapist, if my child will miss their therapy session. I must let my therapists know if my child will be unable to attend a session. I will be allowed one no-show appointment; all others, I may be required to pay a $50 short notice cancellation fee if FCB incurs a charge due to the short notice cancellation/no show.*

I agree
No

I will notify my child's FCB Early Learning Coordinator if my child's therapist did not show to the scheduled therapy time.*

I agree
No

I will let my child's teaching assistant and teachers know if my child will be absent at preschool or kindergarten on any given day.*

I agree
No

I will provide one month's notice if I decide to withdraw my child from a therapy program (PUF, M/M or ELL Service) which alternatives will be discussed.*

I agree
No

I understand that extended conversations with my child's therapist could result in a reduction of therapy hours. Additional interaction may be considered consultative in nature and may be billed, thus reducing your child's therapy hours.*

I agree
No

I understand that if I am not on time for my therapy session, my session time will be reduced accordingly. (Therapy time will not be extended).*

I agree
No

For serious illness, I will provide a signed report from my child's doctor. It will be kept in a private file, and will be available to staff only, in case of any related emergency requiring staff assistance.

I agree
No

I understand that by applying for this funding, my child will be registered with Alberta Education and be assigned Alberta Student Number (ASN). Assessments and IPP’s will become part of my child's student record.

I agree
No

Signature*

Date*

CAPTCHA

ELECTRONIC FUNDING APPLICATION FORM - PUF/MM/ELL

Parent / Guardian

Emergency Contact Information

Child's Medical Information

Immunizations

Early Learning Program Child Will Attend September 2021 - June 2022

If you have any questions or concerns please call 403.478.8618

Program Unit Funding (PUF) and Mild/Moderate Funding (M/M) administered by Foothills Creative Beginnings (FCB) Policies Confirmation

If you have any questions or concerns please call 403.478.8618