Funding Application Form

Child's Name*

First Middle Last

Sex*

Male
Female

Date of Birth*

Attach Birth Certificate*

*max file size - 2MB

Parent / Guardian One

Parent / Guardian Name*

First Last

Home Phone*

Cell Phone*

Email Address*

Primary Address*

Street Address City Province Postal Code

Parent / Guardian Two

Parent / Guardian Name

First Last

Home Phone

Cell Phone

Email Address

Address (If different from Parent/Guardian 1)

Street Address City Province 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

Main Phone*

Alternative Phone

Address*

Street Address City Province Postal Code

Relationship To Child

Any Other Persons Who Have Permission To Take/Pick-Up Your Child From Preschool

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

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

School Child Will Attend in 2018 / 2019 School Year

School Name*

School Phone

Teacher Name

Day & Time Attending*

Referring Therapist

Address*

Street Address City Province Postal Code

I am requesting Foothills Creative Beginnings to apply for PUF or Mild/Moderate Funding*

Yes
No

Has your child had a recent vision test?*

Yes
No

Has your child had a recent hearing test?*

Yes
No

Signature*

Date*

If you have any questions or concerns please call 403.851.5534

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.

Signature*

Date*

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

To 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 agree

Attendance: 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 agree

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

I will notify my child's PUF / M/M Coordinator if my child's therapist did not show to the scheduled therapy time.*

I agree

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

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

I agree

I 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 agree

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

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

PUF 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 agree

PUF 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 agree

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.*

I agree

Signature*

Date*

Parent / Guardian One

Parent / Guardian Two

Emergency Contact Information

Child's Medical Information

Immunizations

School Child Will Attend in 2018 / 2019 School Year

If you have any questions or concerns please call 403.851.5534

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

HOURS

CONTACT

LINKS

RESOURCES