PUF/MM/EAL APPLICATION FORM Child Name* First Middle Last Gender* Male Female Prefer not to say Date of Birth*YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM123456789101112DD12345678910111213141516171819202122232425262728293031Is your child currently receiving services from Foothills Creative Beginnings?* Yes No Attach Here One of the following documents: Birth Certificate, Canadian Passport or Alberta Health Card - required by Alberta Education (please send it in .pdf)*Accepted file types: pdf, jpg, Max. file size: 4 MB.*max file size - 4MB pdfIs your child born outside of Canada?* Yes No If your child was born outside of Canada, Alberta Education requires proof of Canadian residency (visa, permanent residence, citizenship docs)Attach Citizenship Status (please send it in .pdf)*Accepted file types: pdf, jpg, Max. file size: 4 MB.*max file size - 4MB pdf1. Parent / GuardianParent / Guardian Name* First Last Home Phone*Cell Phone*Email* Primary Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code 2. Parent / GuardianParent / Guardian Name First Last Home PhoneCell PhoneEmail Address Address (If different from Parent/Guardian 1) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency Contact InformationThis 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/guardian. This person needs to be local and able to pick up your child.Emergency Contact Name* First Last Main Phone*Alternative PhoneAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Relationship To Child Child's Medical Information***FCB will not administer medication without written authorization from the legal guardian. A special form is required.Alberta Health Care Number (FOIP) 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 My Child's Immunizations Are Up-To-Date Yes No Has your child had a recent hearing test?* Yes No Has your child had a recent vision test?* Yes No School Child Will Attend in 2023 / 2024 School YearSchool Name* School PhoneSchool Email Teacher Name Day and Time Attending* School Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Is your child attending any other school or preschool?* Yes No School Name* School PhoneSchool Email Teacher Name Day and Time Attending* School Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code I am requesting Foothills Creative Beginnings to apply for PUF or Mild/Moderate/EAL Funding* Yes No Signature* Reset signature Signature locked. Reset to sign again Date*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Program Unit Funding (PUF) and Mild/Moderate Funding (M/M) administered by Foothills Creative Beginnings (FCB) Policies ConfirmationI understand that Alberta Education requires that my child participates in 475 hours of teacher directed instruction for M/M or EAL funding and 300, 400 or 475 hours for PUF. (PUF hours are dependent on age)* I understandAttendance for children requiring 400 or 475 hours: My child must be registered and regularly attend an Early Learning program, at least 3 days per week, (minimum 9 hours per week) in order to receive this funding. Lack of attendance in an educational setting can jeopardize my child's funding. Attendance for children requiring 300 hours: My child must be registered and regularly attend an Early Learning program, at least 2 days per week, (minimum 6 hours per week) in order to receive this funding. Lack of attendance in an educational setting can jeopardize my child's funding.* I understandI understand we may be required to participate in additional early intervention programming that occurs outside of the time my child attends their community early learning program.* I understandI understand I will be required to attend Individual Program Plan (IPP) meetings during the school year.* I understandTo obtain PUF, M/M, EAL Funding I must sign the PUF, M/M or EAL application and provide a copy of my child's birth certificate. If my child was born outside of Canada, please provide Canadian residency or work permit.* I understandI give permission to Foothills Creative Beginnings Preschool and ECS Association to release records, assessments and therapy reports for my child to their receiving school.* I understandI will provide 24 hours notice to my therapist, if my child will miss their therapy session.* I understandI understand that by applying for this funding, my child will be registered with Alberta Education and be assigned an Alberta Student Number (ASN) and code. Assessments and IPP’s will become part of my child's student record.* I understandI understand that photo, film or video and name can be shared with FCB employees, contractors, and parents/guardians. For use in the following ways: Photographs demonstrating your child engaged in learning activities or tasks. Film or videos taken to demonstrate progress, show interactions or various methods of teaching used with your child.* I understandBy signing below I am agreeing with each of these policies which are expectations of PUF/MM/EAL funding as administered by: Foothills Creative Beginnings Preschool and ECS AssociationSignature Reset signature Signature locked. Reset to sign again Photo Use PermissionFCB will sometimes share images on our social media, website and/or in marketing materials. Do you give permission for your child’s photo to appear on FCB social media, website and/or in marking materials.* Yes No Photo use permissions are a voluntary decision. In the event you want to withdraw the authorization, send a written request to the executive director of FCB. By selecting “YES”, parents/guardians understand they have no rights to the photos and no payment will be made for any photos or materials. Signature* Reset signature Signature locked. Reset to sign again Date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f you have any questions or concerns please call 403.300.5543
