FUNDING APPLICATION FORM Child's Name* First Middle Last Gender*MaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Age on Sept. 1, 2018*Attach Birth Certificate*max file size - 2MB jpg or pdfParent / Guardian OneParent / Guardian Name* First Last Home Phone*Cell Phone*Email* Primary Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Parent / Guardian TwoParent / Guardian Name First Last Home PhoneCell PhoneEmail Address Address (If different from Parent/Guardian 1) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & 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.Emergency Contact Name* First Last Main Phone*Alternative PhoneAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Relationship To ChildAny Other Persons Who Have Permission To Take/Pick-Up Your Child From PreschoolChild'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 RestrictionsMedications 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 ConcernsImmunizationsPlease 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-DateYesNoSchool Child Will Attend in 2018 / 2019 School YearSchool Name*School PhoneTeacher NameDay & Time Attending*Referring TherapistAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code I am requesting Foothills Creative Beginnings to apply for PUF or Mild/Moderate Funding*YesNoHas your child had a recent vision test?*YesNoHas your child had a recent hearing test?*YesNoSignature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If you have any questions or concerns please call 403.851.5534I give permission to Foothills Creative Beginnings Preschool and ECS Association to release records, assessments and therapy reports for my child to their receiving school.Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Program Unit Funding (PUF) and Mild/Moderate Funding (M/M) administered by Foothills Creative Beginnings (FCB) Policies ConfirmationTo obtain PUF or M/M Funding I must sign the PUF / M/M 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 agreeNoAttendance: My child must be registered and regularly attend a preschool or kindergarten program in order to receive this funding. Lack of attendance in an educational setting can jeopardize my child's funding.*I agreeNoI 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 agreeNoI will notify my child's PUF / M/M Coordinator if my child's therapist did not show to the scheduled therapy time.*I agreeNoI 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 agreeNoI will provide one month's notice if I decide to withdraw my child from a therapy program (PUF or M/M Service).*I agreeNoI understand that extended conversations with my child's therapist could result in a reduction of therapy hours. A therapy session consists of 45 minutes of direct therapy with 15 minutes for communicating/debriefing. Additional interaction may be considered consultative in nature and may be billed, thus reducing your child's therapy hours*I agreeNoI 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 agreeNoFor 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 agreeNoPUF ONLY: I want my child's PUF Coordinator to provide a minimum of 4 (90 minute) Family Orientated Programming sessions (FOPS). I agree to have a parent or a dedicated caregiver (who will fully communicate the contents of the sessions to the parents) present for these sessions.*I agreeNoPUF ONLY: I will attend 3 - 1 hour Individual Program Plan (IPP) meetings during the year. Time for the meeting will be limited to one hour per meeting.*I agreeNoI 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 agreeNoSignature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHA
