DEC Application · 2025-2026

EMERGENCY MEDICAL CONSENT

This form is taken on field trips and kept in the child’s classroom and the bus
Child's Full Name
In case of an emergency, I hereby consent to diagnosis and/or treatment (diagnostic procedures, surgical and medical treatment, and blood transfusion) by authorized members of the hospital staff which in their professional judgment is deemed necessary.

I hereby acknowledge that no guarantees have been made to me as to the effect of such examination or treatment of the child’s condition.

I hereby give my consent for the child named above to be transported for emergency medical procedures or emergency dental care necessary to preserve the health and life of my child for program year: 2025-2026. I acknowledge that I am responsible for all reasonable charges in connection with such emergency care and treatment.
Parent / Guardian's Name
Family Doctor / Pediatrician
Family Doctor / Pediatrician
Child's Dentist
Home Phone
Cell / Message Phone
Current Medications
Does your child have medical insurance?

YesNo
Private Insurance Name & Policy or Group Number
Medicaid Number
Does your child have any significant or chronic health problem? i.e. asthma, severe food allergy, heart condition, etc
Special Care Plan required?

YesNo
Previous Surgeries
Parent / Guardian Signature

Clear
Today's Date

MonthDayYear
Child’s Name
Date of Birth

MonthDayYear

PERMISSION FORMS
PERMISSION TO PHOTOGRAPH AND/OR VIDEO RECORDING

Program Year 2025-2026
Child's Name
Permission for my child to have his/her photograph taken by the staff of the Division of Early Childhood. I understand that these photographs are for the promotion of self-esteem, self-identity, and for tracking each child’s developmental progress and other classroom use.

YES, I grant permission.NO, I deny permission.
I understand that this permission form is valid for program year: 2024-2025
Parent / Guardian Signature

Clear
Today's Date

MonthDayYear
PERMISSION TO POST PICTURES OF CHILD ON FACEBOOK and/or LDOE WEBPAGE

Program Year 2025-2026
Permission to post pictures of my child on the LDOE Facebook page and/or the Laguna Department of Education website(s)

YES, I grant permission.NO, I deny permission.
Parent / Guardian Signature

Clear
Date

MonthDayYear
PERMISSION TO POST PICTURES OF CHILD IN NEWSLETTER

Program Year 20245-2026
Permission to post pictures of my child on the LDOE Facebook page and/or the Laguna Department of Education website(s)

YES, I grant permission.NO, I deny permission.
Parent / Guardian Signature

Clear
Date

MonthDayYear
PERMISSION TO INCLUDE PICTURES OF CHILD ON BULLETIN BOARDS

Program Year 2024-2025
Permission to post pictures of my child on DEC bulletin boards and newsletters

YES, I grant permission.NO, I deny permission.
Parent / Guardian Signature

Clear
Date

MonthDayYear

CONSENT FOR SCREENING/ASSESSMENT

Division of Early Childhood • Program Year 2025-2026
Child's Name
I understand that for Program Year 2024-2025 my child is to have screenings and assessments completed in order to gain information about his/her development and progress. I understand the office of Head Start requires child and family data for reporting purposes, including required reporting from the office of Head Start. All information will be kept confidential.
Statement to Parents/Guardians:
1. Health and developmental screenings noted in the paragraph above are part of Head Start requirements.
2. You will be informed of the results and may request copies of any screenings and assessments and other records.
3. All screening, assessment, and other records in your child’s name will be kept confidential.
4. I understand that Head Start programs are required to conduct developmental screenings and have evidence of completion of a physical examination and health screenings within 45 days of the child’s enrollment.
I approve the use of my child's/family records for program improvement and Head Start grant-related purposes, including reporting. All information will be kept confidential.
Parent / Guardian's Signature

Clear
Date:

MonthDayYear

Administer Topical Solution

Division of Early Childhood • Program Year 2025-2026
The Preschool Head Start Program is requesting permission to administer topical solutions to your child during DEC program hours. Topical solutions are sprays, ointments, or creams that can be applied directly to skin. Please check the topical solution(s) of which you give permission to be used for your child while in the program.
Parent / Guardian’s Name:
Child’s Name:
Date of Birth

MonthDayYear
I authorize the DEC staff to use the following on my child when needed:

Insect Repellent with DEETLotionSunscreen
Signature

Clear
Today's Date:

MonthDayYear

School Screening, Fluoride Varnish, Dental Sealant Consent

Note: All procedures rendered at these visits are billable to Medicaid and third party insurance as authorized in the Indian Health Care Improvement Act
Indian Health Service Dental Program will be offering free dental screenings, fluoride varnish and sealants at your child's school.

Fluoride Varnish
- Procedure: Fluoride varnish is applied directly onto the teeth.
- Benefits: Fluoride Varnish coats the outside of the tooth and makes it resistant to a cavity.
- Risks: Used in the proper amount, fluoride varnish is safe and effective.
Dental Sealants
- Procedure: A Plastic coating is applied on the chewing surface of the back teeth.
- Benefits: Sealants help prevent cavity-causing germs from getting stuck in the deep groves in the back teeth.
- Risks: There are no known commonly occurring adverse effects or hazards associated with dental sealants.
Preventive Services provided by Indian Health Service at your Child's school DO NOT replace a regular dental checkup. We will send a notice home with your child of all retreatment they received in school.
Below, please check if you DO NOT WANT YOUR CHILD TO PARTICIPATE in all or part of the prevention services:

I DO NOT want my child to participate in the program.I DO NOT want my child to have a fluoride varnish application.I DO NOT want my child to have sealants placed.
Please list any medical conditions that the school should be aware of (asthma, allergies, chronic illness, etc.):
Student's Full Name
Student's Date of Birth

MonthDayYear
DOB
Student's Grade & Teacher
Parent or Guardian's Name & Phone Number
Parent or Guardian's Signature

Clear
Date

MonthDayYear
Today's Date

Afternoon Child Care

School Hours & Child Care hours have Changed for SY25-26
For program year 2025-2026, the Laguna Division of Early Childhood school hours have changed:
- Early Head Start school hours will be 7:30 a.m. – 3:00 p.m.
- Preschool Head Start school hours will be Mon-Thu: 8:00 a.m. – 2:00 p.m. and Friday: 8:00 a.m. - 12:00 p.m.
Childcare hours will be:
- Early Head Start (EHS) 3:00 p.m. – 5:00 p.m. (Monday-Thursday) and 12:00 a.m. – 4:30 p.m. (on Fridays)
- Preschool Head Start (PHS) 2:00 p.m. - 5:00 p.m. (Monday – Thursday) and 12:00 p.m. – 4:30 p.m.(on Fridays)
In order to qualify for child care services, parents must be working and/or in school. Please provide:
- 2 current check stubs and/or class schedule (if taking classes) and
- DEC child care application. Childcare rates are based on family’s income/family size.
Please indicate which childcare services you will need:

Afternoon Childcare · EHSAfternoon Childcare · PHS
Child/Children's Name(s)

Upload Required Documents
- Parent’s income (W-2 or 1040 tax form for 2024)
- Immunization record
- Birth certificate
- Well child check-up (for current age at time of enrollment)
- Legal guardian MUST provide current legal documentation (i.e., court order verifying custody of the child being enrolled)
File Upload

Cancelof
Should be Empty:

Pueblo of Laguna • Division of Early Childhood

Child's Name

Address

Phone Numbers of Parents/Guardian

General

Parent/Legal Guardian 1

Address

Parent/Legal Guardian 2

Address

EMERGENCY CONTACTS/RELEASE FORM

Emergency Contacts / Program Check-outs / Head Start Bus Check-outs

EMERGENCY MEDICAL CONSENT

PERMISSION FORMS

PERMISSION TO PHOTOGRAPH AND/OR VIDEO RECORDING

PERMISSION TO POST PICTURES OF CHILD ON FACEBOOK and/or LDOE WEBPAGE

PERMISSION TO POST PICTURES OF CHILD IN NEWSLETTER

PERMISSION TO INCLUDE PICTURES OF CHILD ON BULLETIN BOARDS

CONSENT FOR SCREENING/ASSESSMENT

Administer Topical Solution

Authorization to Release or Receive Information

Physical Residency Questionnaire

Section 1

Section 2

School Screening, Fluoride Varnish, Dental Sealant Consent

Afternoon Child Care

Upload Required Documents