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About Siletz news / (Siletz, OR) 199?-current | View Entire Issue (May 1, 2007)
TRIBAL PROGRAM NEWS Siletz Tribal Head Start Health Summary This form must be completed and signed by a physician. Please do not defer any tests. Return this form to Siletz Tribal Head Start, P.O. Box 549, Siletz, OR 97380-0549. Sex: M Child’s Name: Parent/Guardian Name: DOB: -------------- Phone #: --------------------- - Vision: R L------------ Weight: Height: F Hearing: R L Blood Pressure. Immunizations Needed:------------------- --------------------------------------------------- Physical Examination Summary Date of Exam: Examiner’s Name: -------------------------------------- This is a Very Important Piece for Head Start: Het. or Hgb.:---------------- Siletz Tribal Head Start 2007-2008 Family Needs Assessment Siletz Tribal Head Start is conducting a survey to identify needs that exist in our community. This information is used to determine what programs and ser vices would be relevant for Head Start to offer in the future. Your assistance will help ensure that our program meets your needs. Your input and support are valuable. Thanks! Check One (Optional): Native American City -------------------------------------------- ------ County Where do you live: Family Data: Other Single-Parent Household Foster Parent/Grandparent NO NO YES YES Total Number of Household Members: Total Number of Children in Family: Age(s) of Primary Caregiver: Age(s) of Children:-------------------- Are any of your children disabled? YES NO Have any of your children been in Head Start? NO YES Economic Information: When recording results for the following, enter: N-normal, A-abnormal. NE-not evaluated General Appearance: __ Head:__ Skin:---- Abdomen: ---- Glands. ---- Nose/Mouth/Pharynx: __ Heart: Lungs: Muscular Coordination: ---- Bones/Joints/Muscles: __ Eyes: Ears: ------ Genitalia: -- 1. Does this child’s medical history and/or examination indicate any condition that would limit her/his participation in Head Start activities: NONE YES Parent(s) Employed:____ Full-time ____ Part-time In Training/School ------ Not Employed Gross Monthly Income: Highest Grade Completed by Caregiver:---- Does Family Receive: TANF ____ OHP Food Stamps WIC ----- SSI ------ GA Do you own or rent your home? Monthly Rent/House Payment---------- Transportation: Specify: Do you have reliable transportation? NO YES Do you have access to public transportation? NO YES Childcare: 2. Is any further medical treatment or specific health recommendation neces sary for this child? NONE YES Specify:__________________________________________________________ Do you have children in child care now? Clinic/Office Address:_____________________________________________ Telephone: _____________————————————— [ J CTSITeam Relay For Life Fund-raiser [ Car Wash May 18 • Noon to 4 p.m. I 1 I YES How much do you pay for care?__ __________ Is it easy to find and use childcare services? NO How would you rate your child care? Physician Signature:--------------------------------- ------------------------------------- NO Poor YES _ Good —Fair —Tremendous Please rate the following from highest to lowest priority of need; 1 = highest priority to 14 = lowest need. ____ Education _ Employment ____ Housing Recreation ____Dental Care Health Care ____ Parenting Childcare ____Alcohol & Drug Awareness ___ Preschool/Head Start Li teracy ____ Nutrition ___ Cultural Activities ____ Other Should Head Start Services be (circle one for each of the 3 questions): 1. Full-day 3. Classroom or Part-day or 2. Full-Year or Part-Year Home Based Should Head Start services serve children age 0 - 3 years? Behind the USDA warehouse next to the administration building in Siletz YES NO Any other comments?________________________________________________ We are asking for a donation of $5 for cars and $8 for big trucks. | Thank you for helping us raise money for the fight against cancer! May 2007 Siletz News 13
