Application Checklist for Parents

Transcription

Early Childhood Programs
APPLICATION CHECKLIST
Applications for the 2013-2014 school year are now being accepted! By applying for the CAP Tulsa early
childhood programs, you and your family are taking a step toward joining one of the top education and
development programs for young children in the nation. Because research tells us that children need multiple
years in educational settings to be ready for kindergarten, we want to make sure you and your child can continue
with us not only for this year, but until your child graduates to kindergarten.
So that we can assure your child’s opportunity to join our program, you must complete a full early childhood
programs application and return it along with the documentation listed below. All documents, including this
application, must be returned to the locations listed on the back of this checklist.
Children who participate in a regular, structured education program have been shown to be more successful
in kindergarten and beyond. We offer a year-round learning cycle in a nationally recognized education program
and want to make sure that you and your child fully participate throughout the year. Please be sure to carefully
review the Agency Expectations for Participation in our Programs. Active, full involvement in the program is a
requirement for continuing participation.
If you have any questions about this application, please don’t hesitate to ask one of our Client Services
Associates, or call (918) 585-3227.
Required Documents
When you turn in the application, you must bring the following documents with you, for every child you are
applying for. If you don’t have all required documents, your application will not be accepted. Documentation
should be for you and your child.
 Current Picture ID of parent or guardian completing the application
 Proof of Your Family’s Current Address
 Proof of Your Child’s Current Immunizations
 Your Child’s Birth Certificate
 Your Family’s Most Recent Income Tax Return
If both parents are employed or if custody is shared, include tax returns or income documentation for both parents.
Other Acceptable Proofs of Income – (You must include documentation for all income your family received in the
previous 12 months.)
Employment Income: W-2’s, paystubs from all employers in the previous 12 months, or if self-employed
bring your full income tax return or your accounting records for the last quarter.
Public Assistance: award letters for SSI, TANF or OKDHS Childcare (daycare) Subsidy.
Other Income: Social Security (SSA), unemployment, child support (the court order or if voluntary, a letter
from the parent providing support), letter of support from family member, friend or organization (letter
must include name, address, and phone number and be signed and dated), financial aid award letter
(college student).
 Foster Placement Papers or Reimbursement Letter (if the child you are applying for is a foster child)
 Documentation that your child has received a Current Well-Child Checkup (if available)
 Your Child’s Proof of Health Insurance (if available)
Application Forms
There are seven (7) forms for you to complete; you must answer every question and you must sign and date as
indicated.
 Client Intake Form (8 pages)
 Income Worksheet (2 pages)
 Family Application (2 pages)
 Child Application (3 pages – one Child Application per child applying)
 Authorizations and Releases Form (1 page – one form per child applying)
 Expectations for Participation in our Programs (1 page)
 CACFP Application (1 page – one CACFP Application per child applying)
(Please turn over. There is more information on the back of this checklist.)
Early Childhood Programs
APPLICATION CHECKLIST
Other Important Information
•
•
•
If you receive other public benefits such as SNAP or Section 8, please bring copies of your award letters.
If your child is disabled or requires special assistance, you must provide a copy of the IEP/IFSP. IEP/IFSP is an
individualized plan written by the public school or SoonerStart that assists your child to achieve goals and
objectives listed on the IEP/IFSP. If there is no IEP/IFSP, you must provide a copy of the medical record with
the diagnosis along with any formal evaluation(s) completed by the primary care physician or the medical
provider.
If there are custody arrangements regarding your child, you must provide a copy of the legal custody papers.
Once you have turned in your child’s complete application with all required documents, your child will be placed
on our waitlist. Immediate enrollment is not available for CAP Tulsa Early Childhood Programs.
Frequently Asked Questions
How can I provide proof of my current address?
Bring a copy of your driver’s license, a utility bill, rental agreement, or magazine mailing label. Anything official that has your name and current mailing address printed on it.
If you are currently living with someone and your name is not on the proof of address, please bring (1) the proof of address for that person and (2) a signed letter from the person you are living
with verifying your residency.
How can I get a copy of my child’s current immunization (shot) record?
Your doctor or clinic can provide a copy of your child’s current immunization record.
How to get your child’s birth certificate
If your child was born in Oklahoma, you can get a copy of your child’s birth certificate at the Tulsa Health Department at 5051 S. 129th; call 918-595-4529 if you have questions. If your child
was born in another state, contact that state’s Department of Vital Records for a copy of your child’s birth certificate.
How can I provide proof of receipt of SSI, TANF, or OKDHS Child Care Assistance?
Bring a copy of your award letter. If you cannot find this letter, contact your local OKDHS or Social Security office to ask for verification assistance. If you need assistance finding your local
office, call 211.
How can I get a well-child checkup (physical exam) for my child?
Ask your child’s doctor for a copy of the well-child checkup so that you can include it with your child’s application. You can get free or reduced-fee well-child checkups by contacting the Tulsa
Health Department 918-595-4529, Morton Clinic 918-587-2171, or the OSU Health Care Center 918-582-1980. For more information on well-child checkups you can also go to:
http://www.okhca.org/publications/pdflib/SGUENG%E2%80%93EPSDTG.pdf
How can I provide documentation of my child’s health insurance?
Bring a copy of your child’s Medicaid, SoonerCare, private insurance card or other proof of insurance. If your child doesn’t have health insurance, we can help you complete an application for
SoonerCare.
Applications are accepted at:
CAP Tulsa, 4606 S. Garnett in the
Exchange Center East building – 1st Floor.
We’re open Monday – Friday, 8:00 a.m. – 5:00 p.m.
Or at one of the following locations and times:
Sand Springs Early Childhood Education Center
1701 E. Park Rd (Exit 81st W. Ave)
1st Tuesday of each month, 3:30 – 5:30 p.m.
Frost Early Childhood Education Center
203 West 28th St. N. (Apache and Cincinnati)
2nd Tuesday of each month, 11:00 a.m. - 1:00 p.m.
Eugene Field Early Childhood Education Center
1120 W. 22nd St (21st St. and SW Blvd)
1st Thursday of each month, 2:00 – 4:00 p.m.
McClure Early Childhood Education Center
6150 S. Yorktown (61st between Lewis & Peoria)
2nd Thursday of each month, 3:30 – 5:30 p.m.
Rosa Parks Early Childhood Education Center
13804 E. 46th Pl (Off 145th E Ave b/w 41st and 51st)
4th Thursday of each month, 2:00 – 4:00 p.m.
Client Intake Form
Community Action Project of Tulsa County (CAP Tulsa) is one of the largest anti-poverty agencies in Oklahoma and a
nationally recognized provider of high-quality, research-based early childhood education programs for low-income
families with children ages birth through four. By combining early childhood education with programs that help
families learn new skills and achieve financial stability, CAP Tulsa creates opportunities for families to achieve
economic success.
1
What is today’s date?
Month
Day
6
Year
Would you like to receive e-mails from CAP Tulsa with
news and other information?

Yes
What is your preferred e-mail address?

No
Adult 1
7
Primary Phone
Your Primary Phone is the phone that CAP Tulsa will use to send important
notifications, such as weather closings.
Please tell us about yourself.
Note: Adult 1 must be the person who signs this application. If applying for CAP Tulsa Early
Childhood Programs, Adult 1 must also be a parent or guardian of the applying child(ren).
How would you like to receive notifications on this phone?
Phone call
2
Legal Name
Text message
Note: If you choose to receive notifications by text message, the phone you list below
must be capable of receiving text messages.
Last Name (Please print)
Area Code
First Name
3
Phone Type
Date of Birth
Month
+ Number
MI
Day
Home
Best Time to Call
Year
Work
Message
Cell
Morning
Afternoon
Evening
If this number is for a person who is not in your household, please provide the person’s
name and relationship:
4
Home Address
Address 1 (Number and street name)
8
Address 2 (Apartment/Unit Number, if applicable)
Phone 2
+ Number
Area Code
If the exact address is not known, please give a description of the location such as the
building name or the nearest street or intersection.
Phone Type
Apartment Complex Name
City
Home
Best Time to Call
State
Work
Message
Cell
Morning
Afternoon
Evening
Zip Code
County
9
Phone 3
Area Code
5
+ Number
Mailing Address (if different from the address given above)
-
Phone Type
Best Time to Call
Home
Work
Message
Cell
Morning
Afternoon
Evening
City
State
Zip Code
Page 1 of 8
8/9/2013 8:02 AM
Adult 1 (continued)
Please tell us more about yourself.
10
What is your gender?
Male
Female
11
Are you disabled?
Yes
No
12
Do you have health insurance?
Yes
No
13
Are you Hispanic or Latino?
Yes
No
14
What is your race? (Check all that apply.)
Asian
Black or African American
Native Hawaiian or
Other Pacific Islander
Other
What is your primary language? 
16
How well do you speak English?
Part Time
Full Time
Unemployed
Student/Training
Disability
Workers Compensation
Retired
Other

Name of
Employer
Month
Day
Year
Month
Day
Year
Name of
School
School
Start Date

15
What is your current employment status? (Check all that apply.)
Employment
Start Date
American Indian or Alaska Native
White
18
19
Very well
Well
During the past 12 months (52 weeks), how many weeks did you
work, even for a few hours, including paid vacation, paid sick
leave, and military service?
50-52 weeks
48-49 weeks
40-47 weeks
27-39 weeks
14-26 weeks
13 weeks or less
Did not work
Not well
Not at all
17
20
If you worked in the past 12 months, in the weeks worked, how
many hours did you usually work each week?
21
During the past 12 months (52 weeks), how many weeks did you
attend school or vocational training courses?
What is the highest grade you have completed?
8 or Less
9-12 — No Diploma
High School Graduate
GED
Some College
Occupational Certificate
44-52 weeks
33-43 weeks
Associates Degree
Bachelors
17-32 weeks
9-16 weeks
3-8 weeks
2 weeks or less
Masters or Higher
Did not attend school or vocational training courses
22
Page 2 of 8
If you attended school or vocational training courses in the past
12 months, in the weeks you attended, how many hours did you
attend each week?
8/9/2013 8:02 AM
Family Information
Please tell us about your family.
1
Which of the following best describes your type of family?
13
One Parent—Male
a. A parent is incarcerated.
Yes
No
Two Parents
Single Person
b. A parent/guardian is in the U.S. military.
Yes
No
Two Adults/No Children
Other
c. A grandparent or relative other than birth parent is
supporting and caring for children.
Yes
No

14
2
How many people in your immediate family live with you?
Count yourself, your spouse, your children, and
other dependents who live with you.
3
How many people do you live with at your current address?
Count yourself and anyone living with you that
you buy and share food with.
4
5
Do any of the following describe your family?
One Parent—Female
Type of Housing
House
Apartment
Mobile home/trailer
Homeless Shelter
Motel/Hotel
Other

Are you or is anyone living with you currently receiving any of
the following? (Check all that apply.)
a. OKDHS Childcare Subsidy
j. Indian Health Services
b. SSI
k. Insure Oklahoma
c. TANF
l. Lifeline Telephone Service
d. SNAP (Food Stamps)
m. LIHEAP (Utilities Assistance)
e. SoonerCare
n. Section 8/THA Housing Assistance
f. WIC
o. Social Security
g. FDPIR Food Assistance
p. Unemployment
h. Financial Aid (college student)
q. Other Public Benefit Program
i. First Time Homebuyers
Assistance
r. Private Assistance from family or
friends
Housing Payment Type
15
Rent
Rent + Subsidy
Free/No Rent
Rent to Own
Mortgage
Own Home (House is paid for)
Were you referred to CAP Tulsa by a social welfare agency?
Yes

Which?

No
6
7
Are you or your child homeless, living in a shelter, paying a
weekly rate for your housing, awaiting foster care placement, or
living in a car?
Yes
No
Are you or your child living at a friend’s or relative’s house
because you cannot afford or find affordable housing?
Yes
8
9
How many times have you moved in the last 12 months?
10
What is your family’s primary means of transportation?
Own a car
Friend/Relative
Bus/Public Transportation
Taxi
Walk
Other
Sibling currently enrolled at CAP
Sibling previously enrolled at CAP
Flyer
Mailer
CAP Tax Program
Walk-In
Sign at CAP site
KICK Packet—Health Department
Television:

Radio:

Newspaper:

Social Service Agency:

Friend/Family:

Public School:

CAPtain:

Other:

No

What is the primary language spoken by your family at home?
17
12
How did you hear about CAP Tulsa?
No
Does your current housing provide you and your family a nightly
place to sleep comfortably?
Yes
11
16
Would you be willing to share your experiences at CAP Tulsa with
others?
Yes
No
Maybe
Is anyone in your household pregnant?
Yes

Who?

No
Due Date
Month
Day
Year
Page 3 of 8
8/9/2013 8:02 AM
Adult 2
(Other Adult in Household Living with You)
If there is no other adult in your household, please continue to Person 3 on the next page.
1
What is Adult 2’s legal name?
Last Name
2
12
First Name
MI
What is Adult 2’s date of birth?
Month
Day
What is Adult 2’s current employment status? (Check all that apply.)
Part Time
Full Time
Unemployed
Student/Training
Disability
Workers Compensation
Retired
Other

Year
Name of
Employer
3
How is Adult 2 related to Adult 1?
Husband or wife
Son-in-law or daughter-in-law
Biological son or daughter
Other relative
Adopted son or daughter
Roomer or boarder
Stepson or stepdaughter
Housemate or roommate
Brother or sister
Unmarried partner
Father or mother
Foster child
Grandchild
Other nonrelative
13
What is Adult 2’s gender?
Male
Female
Is Adult 2 disabled?
Yes
No
6
Does Adult 2 have health insurance?
Yes
No
7
Is Adult 2 Hispanic or Latino?
Yes
No
8
What is Adult 2’s race? (Check all that apply.)
Month
Day
Year
During the past 12 months (52 weeks), how many weeks did Adult
2 work, even for a few hours, including paid vacation, paid sick
leave, and military service?
50-52 weeks
48-49 weeks
40-47 weeks
27-39 weeks
14-26 weeks
13 weeks or less
Did not work
14
If Adult 2 worked in the past 12 months, in the weeks worked,
how many hours did Adult 2 usually work each week?
15
During the past 12 months (52 weeks), how many weeks did Adult
2 attend school or vocational training courses?
44-52 weeks
33-43 weeks
Asian
17-32 weeks
9-16 weeks
Native Hawaiian or
3-8 weeks
2 weeks or less
White
Other
10
Year
School
Start Date
5
9
Day
Name of
School
Parent-in-law
4
Month
Employment
Start Date
Did not attend school or vocational training courses

16
If Adult 2 attended school or vocational training courses in the
past 12 months, in the weeks Adult 2 attended, how many hours
did Adult 2 attend each week?
17
Home Address (if different from address listed on first page)
What is Adult 2’s primary language?
How well does Adult 2 speak English?
Very well
Well
Not well
If the exact address is not known, give a description of the location such as the building
name or the nearest street or intersection.
Not at all
11
Apartment Complex Name
What is the highest grade Adult 2 has completed?
8 or Less
9-12 — No Diploma
GED
Some College
Associates Degree
Bachelors
City
State
Zip Code
County
Masters or Higher
Page 4 of 8
8/9/2013 8:02 AM
Person 3
Person 4
Please tell us about all of the children and other adults who live in your home.
1
What is Person 3’s legal name?
Last Name
2
First Name
MI
Day
Last Name
What is Person 3’s date of birth?
Month
3
1
2
Year
First Name
Month
How is Person 3 related to Adult 1?
3
MI
Day
Year
Husband or wife
Husband or wife
Other relative
Other relative
Roomer or boarder
Roomer or boarder
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
Parent-in-law
4
What is Person 3’s gender?
Male
Female
4
Male
Female
5
Is Person 3 disabled?
Yes
No
5
Yes
No
6
Does Person 3 have health insurance?
Yes
No
6
Yes
No
7
Is Person 3 Hispanic or Latino?
Yes
No
7
Yes
No
8
What is Person 3’s race? (Check all that apply.)
8
Asian
Asian
Native Hawaiian or
Native Hawaiian or
White
Other
9
White

Other
What is the highest grade Person 3 has completed?
9
8 or Less
9-12 — No Diploma
8 or Less
9-12 — No Diploma
GED
GED
Some College
Some College
Associates Degree
Bachelors
Associates Degree
Bachelors
Masters or Higher
10

Masters or Higher
Is Person 3 a child applying for CAP Early Childhood Programs?
Yes
10
No
Yes
Page 5 of 8
No
8/9/2013 8:02 AM
Person 5
1
Person 6
Last Name
2
First Name
MI
Day
Last Name
Month
3
1
2
Year
First Name
Month
3
MI
Day
Year
Husband or wife
Husband or wife
Other relative
Other relative
Roomer or boarder
Roomer or boarder
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
Parent-in-law
4
Male
Female
4
Male
Female
5
Yes
No
5
Yes
No
6
Yes
No
6
Yes
No
7
Yes
No
7
Yes
No
8
8
Asian
Asian
Native Hawaiian or
Native Hawaiian or
White
Other
9
White

Other
9
8 or Less
9-12 — No Diploma
8 or Less
9-12 — No Diploma
GED
GED
Some College
Some College
Associates Degree
Bachelors
Associates Degree
Bachelors
Masters or Higher
10

Masters or Higher
Yes
10
No
Yes
Page 6 of 8
No
8/9/2013 8:02 AM
Person 7
1
Person 8
Last Name
2
First Name
MI
Day
Last Name
Month
3
1
2
Year
First Name
Month
3
MI
Day
Year
Husband or wife
Husband or wife
Other relative
Other relative
Roomer or boarder
Roomer or boarder
Brother or sister
Unmarried partner
Brother or sister
Unmarried partner
Father or mother
Foster child
Father or mother
Foster child
Grandchild
Other nonrelative
Grandchild
Other nonrelative
Parent-in-law
Parent-in-law
4
Male
Female
4
Male
Female
5
Yes
No
5
Yes
No
6
Yes
No
6
Yes
No
7
Yes
No
7
Yes
No
8
8
Asian
Asian
Native Hawaiian or
Native Hawaiian or
White
Other
9
White

Other
9
8 or Less
9-12 — No Diploma
8 or Less
9-12 — No Diploma
GED
GED
Some College
Some College
Associates Degree
Bachelors
Associates Degree
Bachelors
Masters or Higher
10

Masters or Higher
Yes
10
No
Yes
Page 7 of 8
No
8/9/2013 8:02 AM
Disability Status
1
Non-Discrimination Policy
Is anyone in your household deaf, or does anyone have serious
difficulty hearing?
Yes
2
No
Is anyone blind, or does anyone have serious difficulty seeing,
even when wearing glasses?
Yes
3
No
Because of a physical, mental, or emotional condition, does
anyone have serious difficulty concentrating, remembering, or
making decisions?
Yes
4
5
6
Our mission is to help families in need achieve economic self-sufficiency. We believe
that this is best fulfilled by embracing diversity as a core value and as an embedded
practice. Achieving diversity requires a long-term dedication to inclusion that must
permeate our organizational culture, values, norms, and behaviors. Throughout our
work with clients, volunteers, vendors, partners and employees, we support diversity in
all of its forms, encompassing but not limited to race, gender, marital status, color,
religion, national origin, economic circumstance, ethnicity, sexual orientation or disability. We are committed to fostering an organizational climate which is welcoming to and
respectful of all people, and celebrate the diversity of thought and background which
makes us stronger.
No
Does anyone have serious difficulty walking or climbing stairs?
Yes
No
Yes
No
Does anyone have difficulty dressing or bathing?
Because of a physical, mental, or emotional condition, does
anyone 15 years old or older have difficulty doing errands alone
such as visiting a doctor’s office or shopping?
Yes
No
Certification
I certify that the information provided in this application is true and correct to the best
of my knowledge. I understand that the information provided may be reviewed by
representatives of the State of Oklahoma, the Federal Government, independent
auditors, or others as necessary for the administration of CAP Tulsa programs and
services. I understand that deliberately providing false, inaccurate or incomplete
information can result in being removed from consideration for service or termination
of any or all services being provided through CAP Tulsa.

 Adult 1 Signature
Month
Day
Year

 Adult 1 Legal Name
First Name
MI
Page 8 of 8
8/9/2013 8:02 AM
Family Information Form
for CAP Tulsa Early Childhood Programs
Complete one Family Information Form for your family. You will complete a separate Child Information Form for each child applying.
Adult 2
Adult 1
1
2
First Name
Day
2
Year
Does Adult 1 live with the child applying?
3
5
Year
Does Adult 2 live with the child applying?
5
Hamilton
Disney
Eugene Field
McClure
Skelly
Sand Springs
Yes
No
Yes
No
Yes
No
May CAP Tulsa contact Adult 2 in case of emergency?
Short Answer Questions
1
Why do you want to enroll your child in CAP Tulsa’s Early
Childhood Program?
2
What do you want for your child’s future, and how are you
preparing your child for kindergarten?
3
How interested are you in participating in programs that will help
you get a better job, improve your education, health or parenting
skills? What programs might you be interested in?
None of the above
2
No
Can Adult 2 pick up the child applying?
Family Information
7
Yes
Is Adult 2 a CAP Tulsa employee?
No
Do you have a child currently enrolled at any of the following
elementary schools? (Check all that apply.)
No
Does Adult 2 provide financial support for the child applying?
No
6
1
MI
Yes
4
Is Adult 1 a CAP Tulsa employee?
Yes
Day
No
Does Adult 1 provide financial support for the child applying?
Yes
First Name
Month
Yes
4
Last Name
MI
Month
3
1
Which of the following programs are you currently involved
with? (Check all that apply.)
CareerAdvance®
Children First
Sooner Start
LINK Project
CAP Adult Learning Initiative
Women in Recovery
Other

None of the above
3
Are you or is anyone in your immediate family or any person who
may potentially be dropping off or picking up your child at a CAP
Tulsa location a registered sex offender?
Yes

Please explain:

No
Page 1 of 2
8/9/2013 8:02 AM
Emergency Contacts
Do not include Adult 1 or Adult 2 from the previous page.
Contact #1
1
Contact #2
2
Last Name
Last Name
First Name
MI
Contact #3
3
Last Name
First Name
MI
First Name
MI
Relationship to child(ren) applying
CAP Tulsa may contact this person in case of
emergency
Yes
No
emergency
Yes
No
emergency
Yes
No
Your child(ren) can be released to this person
Yes
No
Yes
No
Yes
No
Exceptions/Notes:
Exceptions/Notes:
Exceptions/Notes:
Address
Address
Address
If the exact address is not known, give a description of the
location such as the building name or the nearest street or
intersection.
intersection.
intersection.
Phone 1
Phone 1
Phone 1
Area Code
+ Number
Area Code
+ Number
Home
Work
Cell
Notes:
Home
Work
Area Code
Work
Cell
Phone 3
Area Code
Home
Area Code
Work
Cell
Home
Work
Phone 3
+ Number
Area Code
+ Number
Cell
Cell
Notes:
Work
+ Number
-
Phone 3
+ Number
Cell
Phone 2
+ Number
Notes:
Home
Work
-
Notes:
Notes:
Home
Notes:
-
Area Code
Cell
Phone 2
+ Number
Home
+ Number
-
Notes:
Phone 2
Area Code
Area Code
-
Home
Work
Notes:
Cell
Home
Work
Cell
Notes:
Page 2 of 2
8/9/2013 8:02 AM
Income Worksheet
Did you or anyone in your family receive any of the following during the past twelve months (please mark all
that apply):
Wages, salary, commissions, bonuses, or tips from any job
Self-employment income from own nonfarm businesses or farm businesses, including proprietorships
and partnerships
Interest, dividends, net rental income, royalty income, or income from estates and trusts
Social Security (SSA) or Railroad Retirement
Supplemental Security Income (SSI)
Any public assistance or welfare payments from the state or local welfare office
Retirement, survivor, or disability pensions. Do NOT include Social Security.
Child support or alimony
Private assistance from family, friends or an organization
Any other sources of income received regularly such as Veterans’ (VA) payments or unemployment
compensation. Do NOT include lump sum payments such as money from an inheritance or the sale of a
home.
Have you or anyone in your family worked for more than one employer in the past twelve months?
Yes
No
Please indicate which type of documentation you will provide to verify family income for the past twelve months
or past calendar year (please mark all that apply):
Federal income tax return(s) showing all family income
Receipt(s) of payments for all family income (examples: W-2’s, paystubs, benefit award notification
letters)
Receipt of OKDHS Childcare Subsidy, SSI or TANF (example: award letters)
Agency Use Only
Document Received
Income Worksheet, 2013-2014
For Whom
Adult 1
Adult 2
Other:
Adult 1
Other:
Adult 2
Adult 1
Other:
Adult 2
Adult 1
Other:
Adult 2
Adult 1
Other:
Adult 2
Period
Annual: ________
Bi-weekly
Other:
Annual: ________
Bi-weekly
Other:
Annual: ________
Bi-weekly
Other:
Annual: ________
Bi-weekly
Other:
Annual: ________
Bi-weekly
Other:
Monthly
Weekly
Monthly
Weekly
Monthly
Weekly
Monthly
Weekly
Monthly
Weekly
v 0.5
Private Assistance
Child Support
Please complete this section only if requested.
Please provide a copy of your current photo ID.

 How do friends, family, or others help to support you and your

 I receive child support
family? (Check all that apply.)
Paying bills
Other
Buying food
Getting personal care items

The child support is provided:
Weekly
Please indicate type:
Court Ordered
Weekly
The assistance is provided:
Biweekly
Biweekly
Monthly
Voluntary
Name of person providing child support
.00
$
The assistance has a cash value of:
.00
$
in the amount of:
First Name
MI
Monthly
Phone number of person providing child support
Name of person providing assistance
First Name
Area Code
MI
+ Number
-
Phone number of person providing assistance
Area Code
+ Number
Certification
-
I certify that the income information provided in this application is true and correct
to the best of my knowledge. I understand that the information about my income
may be reviewed by representatives of the State of Oklahoma, the Federal
Government, independent auditors, or others as necessary for the administration of
CAP Tulsa programs and services. I understand that deliberately providing false,
inaccurate or incomplete information can result in being removed from
consideration for service or termination of any or all services being provided
through CAP Tulsa.
Certification of No Income
I certify that my family has received no income from any source during the past 12
months. My family expenses are covered by savings, receipt of public benefits,
assistance from family members, friends or other sources, or a combination thereof.

 Applicant Signature

 Applicant Signature
Month
Month
Day
Day
Year

 Applicant Legal Name
Year
First Name
MI

 Applicant Legal Name
For Agency Use Only
First Name
MI

 Reviewer Signature

 Notes
Month
Day
Year

 Reviewer Name


First Name
Verified Income Documentation
Page 2 of 2
8/9/2013 8:03 AM
Child Information Form
for CAP Tulsa Early Childhood Programs
A separate copy of this form must be completed for each child applying to CAP Tulsa Early Childhood Programs.
1
Adult 1 Name
Program & Site Preference
Please check all that apply.
First Name
I am interested in my child being enrolled in an early childhood
education program at a CAP Tulsa center.
MI
Preferred center: (See staff for site map if needed.)
2
Adult 1 Date of Birth
Month
Day
Year
I am interested in my child receiving early childhood education services
at my home. (Child must be younger than 30 months.)
I am interested in an early childhood education program that combines
services at my home and at a CAP Tulsa center. (Child must be younger than
Child Information
1
24 months.)
Legal Name
Last Name
First Name
MI
Child Care Information
1
2
Is this child currently in a full-time childcare or education program?
Yes
Preferred Name

What type?
No
3
Date of birth
Month
4

Childcare Center
Friend’s/Relative’s Home
Family Childcare Home
Own Home
Pre-School
Day
Year
2
Are you looking for a childcare or education program so that you
can attend school or work?
Yes
No
3
Are you looking for childcare before 8:30am and/or after 2:30pm?
Place of birth
City
State
Please note: All CAP Tulsa early childhood centers provide services from 8:30am to 2:30pm.
Some centers offer extended care from 7:00am to 6:00pm. Extended care is available as a
private pay arrangement. Eligible families can use OKDHS childcare assistance to help pay the
cost of extended care.
Country
Yes
5
How is this child related to Adult 2? (Check one.)
Other relative
Roomer or boarder
Brother or sister
Foster child
Grandchild
6
Child’s Development
1
Do you have concerns about your child’s overall health and
development?
Yes

Who has custody of this child? (Check one.)
Shared Custody Agreement
Please describe your concerns:
Who has expressed concerns?
Both Adult 1 and Adult 2

With whom?

Other Person
Primary Care Physician
Sooner Start
Medical Provider
Family Member
CAP Tulsa Early Childhood Staff
Other
7

No
Other nonrelative
Adult 1
No

What is this child’s primary language?
2
Does your child have a certified IEP/IFSP? (If yes, provide a copy.)
An IEP/IFSP is an individualized plan written by the public school or SoonerStart that assists your child
to achieve goals and objectives listed on the IEP/IFSP.
8
How well does this child speak English?
Very well
Not Well
Well
Not at all
Yes
No
Page 1 of 3

Date of IEP/IFSP:
Month
Day
Year
8/9/2013 8:04 AM
3
Does your child have a documented disability or need assistive
services? (If yes, you must provide a copy of the medical record with the diagnosis
Medical Information
along with the formal evaluation(s) completed by your child’s primary care
physician or medical provider.)
Yes
1
No
Physician
Last Name
4
First Name
MI
First Name
MI
First Name
MI
Do you have concerns about your child’s mood or behavior? (For
example: excessive crying, aggressive behavior, tantrums, or inappropriate sexual
behavior.)
Yes

Name of clinic, if applicable

No
Area Code
+ Number
-
Nutritional Information
1
2
Dentist
Last Name
Does your child have a food allergy? (If yes, you will need to provide
documentation from primary care physician if we are able to enroll your child.)
Yes

What is the allergy to?
Area Code

+ Number
-
No
Please describe any reaction:

3
Specialist (if applicable)
Last Name
2
Is your child on a special diet prescribed by a doctor? (If yes, you will
Area Code
+ Number
need to provide documentation from primary care physician if we are able to enroll
your child.)
Yes

Please explain:
-

No
4
Health Insurance
a. Type:
3
Please list foods your child cannot or should not eat:
SoonerCare/Medicaid
Private
Other
None
Yes
No
b. Insurance Provider’s Name:

c. Policy Number or ID:
Please indicate reason for not eating these foods:
Medical
4
Religious
d. Recertification/
Expiration Date:
Personal
Month
Day
Year
Do you have concerns about your child’s eating behaviors?
Yes

e. Dental Coverage Included:

No
5
Please complete these questions only if your
child is 0-12 months old.
5
6
Does your child receive care through Indian Health Services?
No
Yes
No
Yes
No
Does your child receive regular medical care?
What does your child eat?
Breast Milk
Yes
7
When was your child’s last well-child exam?
8
Does your child receive regular dental care?
Milk
Formula
Other

Specify brand:


9
6
Feeding method
Breast Fed
When was your child’s last dental screening?
Bottle Fed
Page 2 of 3
8/9/2013 8:04 AM
Medical History
1
Birth History
Has your child ever been hospitalized or had surgery?
Yes

Please explain:
1
Birth weight
Pounds

2
Ounces
Length
Inches
No
3
2
Term
Has your child ever had a serious accident?
Yes

Please explain:

Premature by
No
3
Gestational age
weeks
Overdue by more than 2 weeks
4
Type of delivery
5
Length of infant’s hospital stay
Vaginal
Cesarean
Unknown
Identify any past or present health conditions your child has had:
a. Anemia
k. Wears hearing aid
b. Cancer
l. Frequent diarrhea
c. Eczema
m. Traumatic brain injury
d. Diabetes
n. Hearing difficulties
e. Seizures
o. Trouble chewing/swallowing
f. Allergies
p. Asthma
g. Overweight
q. Glasses are prescribed
h. High lead level
i. Sickle cell disease
j. Vision problems
t. Other
Routine
Non-routine
6

Length of stay:
Delivery location
Hospital/Clinic
Home
r. Heart murmur/condition
Birthing Center
Unknown
s. Frequent constipation
Other

7
Were there any complications associated with this delivery?
(Compression of the placenta/cord, breech or abnormal position of fetus, premature
rupture of membranes, uterine bleeding, etc.)
Yes
4
Does your child take medications at home?

Please describe:

No
Yes
Unknown
No
5
Will your child need to take medications at school? (If yes, provide a
8
(Pre-term, respiratory distress, low birth weight, birth defect, etc.)
copy of the medication prescriptions.)
Yes

What are the names of the medications?
Did the baby have any problems at birth?
Yes


Please describe:

No
No
Please describe any observable birth defects:
Why does your child take these medications?


9
Did the mother have any health problems during pregnancy or
delivery? (High blood pressure, diabetes of any kind, eclampsia, abruptio
placenta or placenta previa, etc.)
Yes

Please describe:

No
Page 3 of 3
8/9/2013 8:04 AM
CAP Tulsa Early Childhood Programs
Authorizations and Releases Form
This entire form must be completed and signed for each child applying to CAP Tulsa Early Childhood Programs.
Shall Be Referred to as Child and Parent Below:
(Child) Child’s Name:
Date of Birth:
(Parent) Parent/Guardian Name:
Date of Birth:
Consent for Health Services and Educational Assessments
As partial fulfillment of my partnership with CAP Tulsa Early Childhood Education Programs, I hereby agree that Child:
1.)
2.)
Shall receive all of the health services including but not limited to those required by the Head Start Performance Standards, within the mandated timeframe
from the first day of attendance. These services may be provided by Early Childhood Education Programs staff or by collaborative and/or contracted providers.
Providers might include area public school systems, university medical centers, and/or affiliated agencies. I understand that these services may include, but are
not limited to:
• Developmental and Educational Screenings/Observations
• Social/Emotional/Behavioral/Mental Health Observations
• Vision/Hearing Screening
• Height & Weight Assessment
• Dental Screening/Exam
• Well-Child Exam
• Blood Lead Level Screeings
Shall brush his/her teeth daily in the center he/she attends, with an ADA approved fluoride toothpaste and toothbrush provided by CAP Tulsa Early Childhood
Education Programs.
As partial fulfillment of my partnership with CAP Tulsa Early Childhood Education Programs, I (PARENT) hereby agree and/or understand that:
1.)
2.)
3.)
4.)
5.)
6.)
7.)
8.)
I will receive information regarding Child’s health and educational status, screenings, observations, and evaluations; information will be shared with
collaborative and/or contracted providers which may include area public school systems, university medical centers, and/or affiliated agencies.
I will take Child for all recommended medical and dental examinations and follow-up services if a concern is found; and I will provide program staff with copies
of results from these appointments.
I will keep Child’s immunizations up to date as required by state law unless an official, state exemption has been granted and presented to CAP Tulsa staff; and I
will provide program staff with copies of current immunization records.
I will provide a doctor’s statement that explains all necessary procedures, treatments, or medications to be performed at school
a. All medications must have a physician’s statement before being administered at school. This includes prescribed and over-the-counter medications and
products (e.g., diaper rash ointment, sunscreen, lotions, lip protector).
b. All food allergies must have a current statement from a physician regarding the allergy on file with Nutrition Services before dietary exceptions can be made.
I will request assistance from CAP Tulsa program staff to meet requirements.
I may be asked to sign specific release of information forms to assist the Early Childhood Education Programs staff in obtaining Child’s updated health
information.
In the event I am unable to attend, a CAP Tulsa Early Childhood Program staff member may accompany Child to a well-child exam provided by collaborative
and/or contracted providers. I understand that in order to complete the exam, my child may be required to remove part or all of his/her clothing.
Oklahoma State law requires Early Childhood Programs staff to report any suspected cases of child abuse.
This consent shall remain in effect for the duration of enrollment unless revoked in writing, by Parent, to CAP Tulsa Early Childhood Education
Programs.
Parent Signature:
Date:
Authorization for Emergency Treatment and Transport
I, the undersigned parent or legal guardian of Child do hereby authorize any emergency x-ray, examination, anesthetic, dental, medical or surgical
diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor
under the general, specific or special consent of CAP Tulsa Early Childhood Education Programs, the temporary custodian of the minor. It is
understood that this emergency consent is given in advance of any specific diagnosis or treatment being required. This consent shall remain in
effect for the duration of enrollment unless revoked, by Parent, in writing to CAP Tulsa Early Childhood Education Programs.
I understand that, if Child has a medical emergency while at CAP Tulsa Early Childhood Education Programs, 911 will be called to transport Child
immediately to the nearest hospital. To the extent possible, transport will be provided to the specified preferred hospital. This consent shall
remain in effect for the duration of enrollment unless revoked in writing, by Parent, to CAP Tulsa Early Childhood Education Programs.
Preferred Hospital:
Parent Signature:
Date:
Permission to Record Child via Video, Photograph or other Media
I authorize CAP Tulsa to record Child via video, photograph, or other media for research, training, promotional, or marketing purposes for Early
Childhood Education Programs. This consent shall remain in effect for the duration of enrollment unless revoked in writing, by Parent, to CAP Tulsa
Early Childhood Education Programs.
Parent Signature:
Date:
Notice of Privacy Policy Receipt
This is to acknowledge that I have received a copy of CAP Tulsa’s Privacy Policy. The Privacy Policy provides me with information about how CAP
Tulsa may use and disclose Child’s educational, health, and financial information.
Parent Signature:
Date:
\
Page 1 of 1 (version 1.0.2013)
CAP Tulsa Early Childhood Programs
Expectations for Participation in our Programs
Each family is required to turn in one signed copy of this agreement prior to the start of the program year.
This agreement applies to all applicants and their parent(s) regardless of the number of children applying.
Please list all children applying to CAP Tulsa Early Childhood Programs from your family below.
Child’s Name
Child’s Date of Birth
CAP Tulsa is committed to providing high quality programming to our families. In order to deliver this level of quality we utilize a
combination of federal, state and private dollars. The cost to serve one child in our program is as follows: $23,000 dollars a year for
Infant Toddler services and $14,000 dollars a year for our Pre-K children. In order to guarantee that we are good stewards of the
monies entrusted to us, we must ensure that those participating in our programs are receiving all of its benefits. In order to do this,
we have come up with a set of expectations that will help you and your child to achieve this goal, as well as a tool (FIT) to assist you
in tracking your personal investment in your child’s success. Our expectations are that you:
•
See that your child attends regularly. Failure to attend regularly could result in your child losing their slot and being dropped from
the program. Also, a child must be here in order to receive the benefits of the program. We have a waiting list of several hundred children; if
you do not believe you can take full advantage of our program then allow the next child on the list the opportunity by telling us now.
•
Be on time. Being on time and staying for the full day not only impacts the child’s learning but their nutrition as well. We serve a nutritious
breakfast, lunch and snack during the day. Coming in late or picking up early could result in your child missing breakfast, lunch or afternoon
snack. (No outside food is allowed.)
•
Keep your child’s immunizations and Well Child Checkups current and up to date, handle any medical needs that
arise and provide documentation to classroom staff. Doing so not only protects the health of your child, but the other children in
the room. Establish a Medical Home. It is a Head Start requirement that families have an ongoing source of family health care. If you
do not already have a primary care doctor, you agree to work with staff to establish a medical home. Children who are healthy get more out
of their school experience.
•
•
Ensure that we always have current contact information so you can be reached in case of emergency.
Be an active participant in home visits and parent conferences provided by teachers and staff. All parents are
expected to participate in two home visits and two parent conferences during the course of the school year.
•
•
Participate with your child in at-home activities, such as Learning Games, which are designed to promote literacy
and learning and to bridge the gap from home to school.
Attend a minimum of three monthly Parent Connections during the school year. Parent Connections are an opportunity to
learn about what is going on at your child’s school, as well as connect with other parents.
•
•
Review information sent home in Tuesday Folders.
Establish and maintain an on-going communication with school staff. This consists of both face to face and written
communications. This will include the completion of a Family Partnership Agreement.
•
•
•
•
Become familiar with the “Family Investment Tracker” (FIT). This means taking the time to review where you are in meeting the
above expectations. To do this we have created the “Family Investment Tracker”, which you will be asked to review with your child’s teacher
at Home Visits and Parent Teacher Conferences. The FIT was created to assist you in tracking your personal investment in your child’s success.
Complete a benefit eligibility screening that will determine other programs for which you may qualify.
Read and comply with the Parent Handbook. You will receive a parent handbook at program orientation or on your child’s first day
of school. If you have questions regarding anything in the handbook, ask program staff for clarification.
Participate fully in CAP Tulsa Early Childhood Programs. Full participation including regular attendance and completion of
programs that support and strengthen the parent-child relationship ensures continuing enrollment in the programs.
I agree to work with the Site and Classroom staff in meeting these expectations.
____________________________________________________
Parent/Guardian Signature
_______________________________
Date
CHILD AND ADULT CARE FOOD PROGRAM (CACFP)
ENROLLMENT FORM
1. Child’s Name: _______________________________
2. Normal Days In Attendance:
X
SUN
MON
Date of Birth: ___________
X
X
X
TUES
WED
THUR
X
FRI
SAT
3. Head Start Facilities Only: Indicate Session and sign and date form.
 A.M.
 P.M.
 Yes
4. Special dietary needs *
 All Day
 No
5. Normal Hours of Attendance: __8:30___ to ___2:30__
6. Normal Meals Eaten:
 Breakfast
 Lunch
 Supper
 A.M. Snack
 P.M. Snack
 Late P.M. Snack
7. Signature of Parent/Guardian: ___________________________
Date:______________
* Attach signed medical statement.
Name of Parent/Guardian:
Address: ________________________
City:
Zip:
Home Telephone:
Renewal Updates
If there are no changes to the above information, sign and date. If there are changes, a new enrollment
form must be completed, signed and dated.
Parent/ Guardian Signature
Date
CAP Tulsa
Privacy Policy
We Are Committed to Safeguarding Customer Information
In order to better serve your needs now and in the future, we may ask you to provide us with certain information. We
understand that you may be concerned about what we will do with such information – particularly any personal
educational, health or financial information that identifies you (“personal information”). We agree that you have a right
to know how we will utilize the personal information you provide to us. Therefore, we have adopted this Privacy Policy
to govern the use and handling of your personal information.
Applicability
This Privacy Policy governs our use of the nonpublic personal information that you provide to us. It does not cover
information we have obtained from any other source, such as information obtained from a public record or from another
person or entity.
Types of Information
Depending upon which of our services you are utilizing, the types of personal information that we may collect include:
•
Information we receive from you on applications, forms and in other communications to us, whether in writing,
in person, by telephone or any other means;
•
Information about your transactions with us, our affiliated companies, or others; and
•
Information we receive from a consumer-reporting agency.
Use of Information
CAP Tulsa follows all federal and state laws applicable to the information you provide. In particular, the Family
Educational Rights and Privacy Act (FERPA) governs our treatment of student education records and the Health
Insurance Portability and Accountability Act (HIPAA) governs our treatment of identifiable health information.
Summary information about each of these laws is provided below.
In general, the information we request from you will be used and disclosed in association with the services provided to
you, the payment for such services and CAP Tulsa business operations (including quality control efforts and customer
analysis). We will not release your information to nonaffiliated parties except: (1) as necessary for us to provide the
product or service you have requested of us; or (2) as permitted by law.
We may also provide your personal information to companies under contract or otherwise affiliated with CAP Tulsa.
Such affiliated companies may include financial service providers, wholesale investors, community-based non-profit
organizations, education organizations, school officials, clinics, state agencies, and companies involved in real estate
services, such as appraisal companies, home warranty companies, and escrow companies. Absent your prior consent,
the amount of identified personal information disclosed to affiliated companies will be limited to that necessary for
purposes of providing services, payment activities and business operations. We may provide aggregated customer
information without prior consent.
Former Customers
Even if you are no longer our customer, our Privacy Policy will continue to apply to you and your personal information,
which we may maintain for an indefinite period after the customer relationship has ceased.
Page 1 of 3
Confidentiality and Security
We will use our best efforts to ensure that unauthorized parties do not have access to any of your information. We
restrict access to your personal information to those individuals and companies described as above. We will use our best
efforts to train and oversee our employees and agents to ensure that your information will be handled responsibly and in
accordance with this Privacy Policy. We currently maintain physical, electronic, and procedural safeguards that comply
with federal and state regulations to guard your personal information.
Amendments
CAP Tulsa reserves the right to change the terms of this Privacy Policy and will provide a revised copy upon request
either by hand delivery, U.S. Mail or by posting the revised Privacy Policy on the CAP Tulsa website at
http://www.captulsa.org.
Notification of Rights under FERPA
The Family Educational Rights and Privacy Act (FERPA) affords parents and students over 18 years of age (“eligible
students”) certain rights with respect to the student’s educational records. These include:
1.
The right to inspect and review the student’s education records. Parents or eligible students should submit to
CAP Tulsa a written request that identifies the records they wish to inspect. CAP Tulsa will notify the parent or
eligible student of the time and place where the records may be inspected.
2.
The right to request the amendment of the student’s education records that the parent or eligible student
believes are inaccurate, misleading, or otherwise in violation of the student’s privacy rights under FERPA. CAP
Tulsa retains the right not to amend the record as requested. If CAP Tulsa decides not to amend the record as
requested, CAP Tulsa will notify the parent or eligible student of the decision and advise them of their right to a
hearing regarding their request for amendment.
3.
The right to consent to disclosures of personally identifiable information contained in the student’s education
records, except to the extent that FERPA authorizes disclosure without consent. One exception that permits
disclosure without consent is disclosure to school officials with legitimate educational interests. A school
official is a person employed by CAP Tulsa as an administrator, supervisor, instructor, or support staff member
including, health and medical staff; a person serving on the CAP Tulsa Board; a person or company with whom
CAP Tulsa has contracted as its agent to provide a service instead of using its own employees or officials; or a
parent or student serving on an official committee, such as a disciplinary or grievance committee, or assisting
another school official in performing his or her tasks. A school official has a legitimate educational interest if
the official needs to review an education record in order to fulfill his or her professional responsibility.
HIPAA Privacy Notice
This notice describes how your health information may be used by CAP Tulsa. This notice also tells you about your
rights to keep your health information private and explains how you may access to your health information.
Health information rights
Right to inspect and copy:
You have the right to see your health information that CAP Tulsa has on record. You also have a right to get a copy of
this information. You do not have the right to see psychotherapy notes. You also do not have the right to see health
information needed for court or administrative actions.
Right to request an amendment:
If you think the health information CAP Tulsa has is wrong, or part is missing, you can ask CAP Tulsa to make
corrections. You must ask in writing. CAP Tulsa can turn down the request if you do not give a reason. Your request can
also be turned down if CAP Tulsa did not create the health information or if CAP Tulsa thinks the information is right.
Right to an accounting of disclosures:
CAP Tulsa does not have to tell you when your health information is disclosed for purposes of your medical treatment,
payment for medical treatment, or operation of a health care program operated by CAP Tulsa. If your health information
Page 2 of 3
is disclosed for any other reason, you will be given a list of the disclosures if you ask. You will only be given disclosures
made after April 14, 2003. A maximum of six years of disclosures will be given to you.
Right to ask for limits:
You can ask CAP Tulsa to only use your health information for medical treatment, payment for medical care, or
operation of a health care program. CAP Tulsa does not have to agree to your request. If CAP Tulsa agrees to your
request, CAP Tulsa can still use your health information to provide emergency care.
Right to request confidential communication:
You can ask CAP Tulsa to talk with you about health care in a certain way. For example, you can ask CAP Tulsa to only
call you at home. CAP Tulsa will try to meet all reasonable requests.
Right to request a paper copy of this notice:
You can have a paper copy of this notice by mailing your request for a paper copy to: Privacy Officer, CAP Tulsa, 4604
South Garnett Road, Tulsa, OK, 74146. A copy of this privacy policy can also be found at www.captulsa.org
If you want to use any of these rights, send a written request to: Privacy Officer, CAP Tulsa, 4604 South Garnett Road,
Tulsa, OK, 74146. For more information, contact your family support worker, site director or CAP Tulsa’s Early
Childhood Programs.
What CAP Tulsa can do with your health information
CAP Tulsa can use your health care information, as described below.
Treatment:
People who give you health care can use your health information to design a plan of care for you. These people include
nurses, doctors, therapists, and social workers. People who work for CAP Tulsa may share your health information so
they can manage your services.
Payment:
CAP Tulsa can give your health information to a health plan to pay for your services. Your health information can also
be given to government programs so your benefits can be managed better. Examples of these programs are Medicaid and
Workers' Compensation.
Operations:
CAP Tulsa can use your health information to make sure that you get good health care. Your health information may be
given to people or companies who CAP Tulsa pays to give you health care. These people and companies have to follow
the same rules that CAP Tulsa does about keeping your health information private.
Government agencies providing benefits or services:
CAP Tulsa can give your health information to government agencies that are giving you benefits. CAP Tulsa will do this
only if it is needed for you to get benefits.
Health oversight activities:
CAP Tulsa can share your health information with other agencies when required by law for oversight activities.
Examples of oversight activities are audits and inspections.
Law enforcement:
CAP Tulsa will give health information to a law enforcement official only when required by state or federal law.
Coroners, medical examiners, and funeral directors:
CAP Tulsa will give health information to a coroner, medical examiner, or funeral director when required by law.
Organ donors:
If you are an organ donor, CAP Tulsa can give your health information to an organization that participates in organ
donation or transplant.
Stop a serious threat to health or safety:
CAP Tulsa can give your health information to stop a serious threat to the health and safety of you or someone else.
Military:
If you are a veteran, or a current member of the armed forces, CAP Tulsa can be made to give your health information to
the military or Veterans Administration.
When required by law:
CAP Tulsa will give your health information when federal, state, or local law requires.
Page 3 of 3

Application Checklist for Parents

Transcription

Similar documents

day 4 racing - SRCA Dragstrip

ENGAGEMENT creativity

here - Laffa

here - Laffa

march - Cobblestone Apartments

Riverside Market

Mad Scientists On Wheels

Cobblestone Apartments

TheDirtboxwailersEPK