NEW SCHOOL YEAR. NEW ADVENTURE - YMCA of Lincoln, NE
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
NEW SCHOOL YEAR. NEW ADVENTURE
Hello Parents & Guardians of our Before & After School Program Participants:
The start of a new school year is always exciting, but this year the circumstances are different. We know the
COVID-19 crisis has brought about many challenges and emotions for the kids and families in our community.
We’re are looking forward to providing a healthy environment where we strive to meet the social and emotional
needs of our students. As we prepare for this upcoming school year please be assured that your child’s safety
is our number one priority. We’re following guidelines from health experts, local officials and Lincoln Public
Schools to ensure that our facilities meet the highest standards for hygiene and safety. We love being a part
of our school communities and neighborhoods and we are looking forward to continue offering families a safe
and fun place for their children to go before and after school!
We want to ask for your patience and cooperation as we work together through the changes to our program
that this pandemic has brought about. Please take the time to review the contents of this packet as it outlines
many important details and helpful information that you and your family will need to know while attending our
program.
We know our Y program participants are eager to get back into a new school year routine, to get outside and
enjoy reconnect with their peers after being apart.
We have modified our policies and programs to facilitate safe physical/social distancing practices. Here are
some things you can expect:
We have updated our illness exclusion policy and we will be doing temperature checks upon arrival to
the program before and after school. During the before school program we will be checking children
into the program at door each day. We will also be evaluating the health of students and staff at check
-in and throughout their time in our care. If we identify a symptomatic student or staff we will isolate
them, send them home, communicate with the appropriate parties, and evaluate how we are going
forward from there.
Children will be asked to bring everything they need for the Y program in their backpack each day. A
complete list of what children should and should not bring to our program is outlined in this packet.
When possible, students will be split up into smaller, grade level groups in an effort to control the
intermixing of students as applicable. Transitions will be orchestrated by staff to avoid the co-mingling
of groups as much as possible.
In addition to having Site Supervisors and Program staff caring for the students, we have added a
Greeter position who will be stationed at the door for drop off a pick-up and we have also added a
cleaner/floater position who will be assisting with additional cleaning and sanitation procedures and
filling in for other program staff when and where necessary.
Our staff and students will be required to wear face coverings.
Our staff will be doing additional sanitizing and cleaning of areas before/after transitions.
Handwashing/Hand-sanitizing will be done during transitions as well.
We will be providing only pre-packaged snacks during the after school program.
If you have any questions or concerns or need any help at all, please don’t hesitate to contact us. The safety
of our students is our number one priority and we are excited to spend time reconnecting with our Y family/
our community. See you soon!
Your Lincoln YMCA Youth, Teen & Family and Community Learning Center Directors
IMPORTANT PROCEDURE UPDATES FOR THE 2020-2021 SCHOOL YEAR
LPS will conduct classes and operate within the framework of the four risk color statuses of the COVID-19 Risk Dial as designated by
LLCHD and the City of Lincoln. While in the green, yellow and/or orange status, the YMCA Before & After School programs will remain
in session. If we move into the red status and LPS cancels in-person classes, the Before & After School Programs will not be offered in
this current format. While operating the program the following procedures listed in this packet will be in place. Please keep in mind
that just like our Standard Response Protocols, every building or program may not always be in the same color category.
IF YOUR CHILD IS SICK, PLEASE KEEP THEM HOME
Participants, and/or siblings of participants, who are sick or experiencing any symptoms of COVID-19 or any
other illness symptoms, should NOT be in our programs. If your child has any of the following COVID-19
primary symptoms, please do not bring them, or any enrolled siblings, to the Y Before/After School Program.
These symptoms include:
Fever of over 100.4
Cough
Onset of shortness of breath or difficulty breathing
Chills longer than two hours &/or repeated shaking with chills
Muscle pain & another illness symptom
Headache & another illness symptom
Sore throat & another illness symptom
Congestion and/or runny nose & another illness symptom
New onset of loss of taste or smell
Nausea, Vomiting or Diarrhea
If the participant is already onsite and they begin to show the symptoms noted above, the supervisor will place
the participant in the isolation area and contact parent/guardian for immediate pick up. The participant, and
any siblings of the participant, must be symptom free for at least 72 hours prior to returning to care.
ILLNESS EXCLUSION FOR COVID-19
If a participant tests positive for COVID-19, or if a participant has been in close contact with a person who
tested positive, we will require the participant, and any enrolled siblings of the participant, to:
Be excluded from care for 14 days
Self-monitor for symptoms
Follow CDC guidance if symptoms develop
At the end of 14 days, the participant must be symptom free for at least 72 hours prior to returning. Refunds
will not be made if the participant attends any part of the month. Any full month that a participant does not
attend will not be charged. However, deposits are non-refundable.
SIGN-IN & HEALTH CHECK PROCEDURES
In an effort to keep everyone as healthy and safe as possible, and to comply with LPS pandemic procedures, we
will be checking children in and out of the Before & After School program at the school entrance for drop-off
and pick-up. This will help limit the number of people coming into and out of school and program area.
Staff cannot accept or release any child before he/she has been checked in or out by an authorized adult. ALL
STUDENTS MUST BE WALKED TO THE ENTRANCE OF THE PROGRAM BY AN AUTHORIZED ADULT. Upon your
arrival, our staff will greet your family and do quick initial assessment of your child, which includes taking their
temperature and verifying a few health questions per DHHS Child Care Licensing Guidelines. If your child’s
temperature is 100.4 or above they will be must be excluded from the program. Authorized Adults must wear
face coverings and maintain physical distancing during drop-off/pick-up.
Staff will then assist in having participants enter the program after the initial check-in. Upon arrival to the
program area, staff will have each student sanitize their hands. We will also be evaluating the health of our
participants throughout their time in the program.
We will be checking children out of our program outside of the entrance each after noon. When you arrive to
pick-up your child from the program you will meet staff in the same location as you did when you arrived for
check-in.
ACCESSIBILITY IS A MUST
Due to the seriousness of COVID-19 a parent/guardian/emergency contact must be accessible by phone, at all
times during the hours of the program. It may also be necessary for you to come to the site to pick up your
child from the site within 30 minutes of the Y contacting you. If we are unable to reach an authorized adult, or
if you fail to pick-up your child within the 30 minute time frame, staff will follow the YMCA safety policy and
procedure and contact the local police. Failure to comply with this policy may also result in dismissal from the
program.
FAILURE TO COMPLY IS NOT AN OPTION
The YMCA is committed to providing a healthy, fun, nurturing environment for children in our care. We believe
that program rules and a specific discipline policy for inappropriate behavior are necessary in order to maintain
a positive and safe environment for all program participants. The Y encourages and supports a team approach
to addressing any behavior concerns. Please read over and talk about the program rules and the behavior
management and disciplinary procedures (located in the Youth, Teen & Family Programs Handbook at
ymcalincoln.org) with your child so they understand them prior to the start of the program. At all times
children in our Before & After School programs should be safe, respectful, responsible, caring and honest. Each
behavior intervention puts students, families and staff at additional risk of exposure to COVID-19. To minimize
risk for all parties involved, multiple interventions will result in suspensions and/or lead to expulsion from
programming. We want to keep our doors open for as many families as possible. Doing so means taking the
safety of everyone seriously. YMCA reserves the right to discontinue Before & After School child care services
for any child/family who fails to comply with our program rules, policies and procedures.
ADDITIONAL PROCEDURE UPDATES TO NOTE
Some additional procedures have been changed for the 2020-2021 Before & After School Program due to
COVID-19. These changes include, but are not limited to:
The drinking fountains will not be open. Students will only have access to water refill stations. We ask
that program participants bring a water bottle to use for drinking. We will keep cups on hand for
students who may not have a water bottle. At our non CLC-Sites a per-packaged snack will be provided
by the YMCA once per day during the after school program.
Handwashing and hand-sanitizing will be done frequently throughout the program. Program participants
and staff must wash their hands or use hand sanitizer before and after snack times.
While in the yellow/orange status on the COVID-19 Risk Dial as designated by LLCHD and the City of
Lincoln there will be limited access to our program areas. Parents/ Guardians will have very limited
access to the school/program areas. If a parent/guardian needs to physically enter the program area
their access must be approved by a supervisor and they must wear a face covering and practice
appropriate physical distancing. Other visitors and guest speakers will not be allowed in the school/
program areas.
WHAT SHOULD MY CHILD BRING TO THE PROGRAM?
In an effort to cut down on the number of items shared between students, we are asking that students bring
some personal items to be used throughout their time in the program. We are asking that children bring the
following items for the program in their backpack. Please make sure your child has the following items, labeled
with their first and last name, in their bag each day:
A water bottle
Pencils to use for doing homework– PLEASE WRITE THEIR NAME ON THEIR PENCILS
Art Supplies for activities– crayons, markers, scissors, glue stick
A personal reading book
Change of clothes
Be sure to wear comfy clothes & closed toed shoes. Children should be dressed appropriately for active
play. We plan to have lots of fun, go outside, do hands on projects and much more. Your child’s clothes
may get a little messy and shoes should allow them to run around safely.
PLEASE DO NOT BRING: electronics, money or valuable items! We also do not allow personal toys/card games.
The YMCA is not responsible for any personal belongings that may become lost or stolen while participating in
our Youth, Teen & Family Programs.
WEATHER & OUTDOOR PLAY
Students should come to the program dressed ready for the day and appropriately for the weather, as we do
try to go outside everyday weather permitting. When deciding if we will go outside each day we will follow the
Child Care Weather Watch guidelines as recommended by the Lancaster County Health Department, in addition
to following the direction of the school administration. We highly encourage children to wear tennis shoes or
closed toe shoes as it is difficult to play and run wearing sandals/flip flops.
TRAVEL PROCEDURES
If you have vacation traveling plans, the travel guidelines and procedures should be followed as parents and
will be implemented by staff. When traveling, and upon return to your home, please self monitor all family
members. When returning for care, your child's health will continue to be monitored according to the policies
outlined in this packet.
COMMUNICATION FROM BEFORE & AFTER SCHOOL
We will communicate with Parents/Guardians in a variety of different ways. Here are some things to note about
changes to our communication procedures:
A majority of our communications with you will be done via email or over the phone.
We ask that parents check their child’s backpack at the end of each and every day. We will place Health
Reports*, Behavior Reports, personal notes, etc. in there that are specifically for your child(ren).
*Please note that our staff do their best to fill out Health Reports for all injuries that are reported to them or
that they witness. If you find that your child was hurt and you did not receive a Health Report, please contact
one of our Director as soon as possible so they can assist with the matter.
All of our Youth, Teen & Family Programs have a phone on site. For the safety and privacy of the students in
our programs, the YMCA strongly discourages the use of personal cell phones during program hours and
encourages parents/guardians and students to utilize the program phone when they need to communicate with
one another.
GROUPS, ACTIVITIES & HOMEWORK
When possible, students will be split up into smaller, grade level groups in an effort to control the intermixing
of students as applicable. Transitions will be orchestrated by staff to avoid the co-mingling of groups as much
as possible. With that being said, due the limited number of children allowed in each room, some grade levels
will be combined with other grade levels. Mixed-student groups in the Before & After School Programs, unlike
the organization in the mandatory school day, are optional activities, so families would be choosing to move
beyond the student grouping system offered during the school day in the elementary and middle schools.
We strive to provide a safe, fun and happy environment for our students by providing a wide variety of age-
appropriate activities to promote self-confidence, cooperation and teambuilding. Activities include: sports and
fitness activities, science, technology, arts, crafts, indoor outdoor active play, games, music, exploring nature
and more.
During the after school program, students will have the opportunity to work on their homework. We will
encourage all students to begin working on their homework upon arrival in our program after school. Due to the
large number of children in our program and the additional responsibilities of our program staff, our staff are
unable to provided one-on-one homework support and are unable to check each and every child’s homework
folder or backpack to ensure they are doing their homework. Our staff will do their best to answer student
questions that may come up while your child is working on their homework, but they cannot be responsible for
checking your child’s homework. If you find that your child is not working on their homework afterschool and
you would like them to be, please speak to the Site Supervisor so that we can offer your child specific
reminders and encourage them to work on it.
OTHER REMINDERS
The Youth Teen & Family Programs Handbook outlines the basic policies and procedures for those families
participating in any YMCA Youth, Teen & Family Programs. Please note that due to COVID-19 some of our
policies have been modified or changed for the 2020 Before & After School Program and those changes are
what have been outlined in this packet. The YMCA of Lincoln Youth, Teen & Family Programs Handbook can be
found on our website at: https://www.ymcalincoln.org/sites/default/files/2020-01/clc_ytf_handbook.pdf
Please remember:
Lincoln Public Elementary schools and Middle schools will dismiss 80 minutes early for PLC days as noted
on the LPS Student Calendar. On these days the after school Program will begin immediately when school
releases for those enrolled in the after school program.
We have several different positions within our Youth Program staff structure, including; Program Staff,
Site Supervisors and a Program Director. In addition to having Site Supervisors and Program staff caring
for the students, we have added a Greeter position who will be stationed at the door for drop off a
pick-up and we have also added a cleaner/floater position who will be assisting with additional cleaning
and sanitation procedures and filling in for other program staff when and where necessary. All program
staff are well trained and receive continuous training throughout the year. We encourage parents/
guardians to get to communicate with our staff at drop-off or pick-up, or over the phone during the
program hours, to discuss any questions or concerns.
Your membership status at the time of registration determines the fee for the program. If your
membership status changes or if you wish to withdraw your child from the before and after school
program/after school enrichment program you must visit the YMCA facility front desk to complete a
Program Change/Withdraw Form at least two weeks prior to the end of the month to amend your fees or
to cancel/change your child’s enrollment. Please note: the registration fee is non-refundable and
non-transferable.
The monthly program fees for Before & After School care do not include or guarantee childcare on
non-school days. Supplemental child care may be available on many of the non-school days through our
Non-School Days Fundays program. Once a schedule is set we will communicate with families via email
and information will be posted on our website.
2020 YMCA BEFORE & AFTER SCHOOL WAIVER & RELEASE
Upon signing up for YMCA programs for you or all individuals on your account, and/or enrolling and participating in YMCA programs
activities, you, individually, and on behalf of all individuals on your account:
1) agree that you are voluntarily participating and assume all risks, known and unknown, associated with your presence in and/or use of YMCA facil-
ities, equipment and premises, and your participation in its programs/activities, including, without limitation, any loss, damage to, or theft of per-
sonal property, and any personal injury, illness (including but not limited to COVID-19) or death; and
Parent/Guardian Initials: ______
2) agree to release and discharge the YMCA and its representatives, employees, volunteers, and agents, from any and all liability, for any and all
losses, damages or expenses, and any claim, demand or suits therefore, on account of injury, illness (including but not limited to COVID-19) or death
to person or property, arising from your presence on YMCA property, your use of its equipment and facilities, and/or your participation in YMCA
membership or its programs/activities; and
Parent/Guardian Initials: ______
3) agree not to initiate or commence any claim, suit or cause of action against the YMCA and/or any of its representatives, employees, volunteers or
agents, with respect to any losses, damages or expenses which are listed above and are the subject of this waiver and
release, and further agree to indemnify and hold harmless said parties from any and all losses, damages or expenses arising out of or in any way
connected with you or all individuals’ presence on YMCA property, use of its equipment or facilities, and/or participation in
membership or its programs/activities.
Parent/Guardian Initials: ______
In addition, the undersigned acknowledges that novel coronavirus (“COVID-19”) infections have been confirmed throughout the United States, in-
cluding several cases in Lincoln, NE. In accordance with the most recent guidance and protocols issued by the World Health
Organization (WHO), the Centers for Disease Control and Prevention (CDC), the State of Nebraska, and the Lincoln Lancaster County Health Depart-
ment (LLCHD) (together, the “Public Health Agencies”) for slowing the transmission of COVID-19, the undersigned hereby agrees, represents, and
warrants that neither the undersigned nor such participating children shall visit or utilize the facilities, services, and programs of the YMCA (other
than any exclusively online services and programs) within 14 days after (i) returning from highly
impacted areas subject to a CDC Level 3 Travel Health Notice, (ii) exposure to any person returning from areas subject to a CDC Level 3 Travel
Health Notice, or (iii) exposure to any person who has a suspected or confirmed case of COVID-19.
Parent/Guardian Initials: ______
The CDC Travel Health Notices list is updated regularly. The undersigned agrees to check the CDC Travel Health Notices list (https://www.cdc.gov/
coronavirus/2019-ncov/travelers/index.html) prior to utilizing the facilities, services, and programs of the YMCA, on a daily basis if necessary. The
undersigned hereby agrees, represents, and warrants that neither the undersigned nor such participating children shall visit or utilize the facilities,
services, and programs of the YMCA if he or she (i) experiences symptoms of COVID-19, including,
without limitation, fever, cough or shortness of breath, or (ii) has a suspected or diagnosed/confirmed case of COVID-19. The
undersigned agrees to notify the YMCA immediately if he or she believes that any of the foregoing access/use restrictions may apply.
Parent/Guardian Initials: ______
The YMCA has taken certain steps to implement recommended guidance and protocols issued by the Public Health Agencies for slowing the trans-
mission of COVID-19, including, without limitation, the access/use restrictions set forth above. The undersigned acknowledges and agrees that the
YMCA may revise its procedures at any time based on updated recommended guidance and
protocols issued by the Public Health Agencies and further agrees to comply with the YMCA’s revised procedures prior to utilizing the facilities, ser-
vices, and programs of the YMCA. The undersigned further acknowledges and agrees that, due to the nature of the facilities, services, and programs
offered by the YMCA, social distancing of 6 feet per person among children and their caregivers in a childcare setting is not possible. The under-
signed fully understands and appreciates both the known and potential dangers of utilizing the facilities, services, and programs of the YMCA and
acknowledges that use thereof by the undersigned and/or such
participating children may, despite the YMCA’s reasonable efforts to mitigate such dangers, result in exposure to COVID-19, which could result in
quarantine requirements, serious illness, disability, and/or death.
Parent/Guardian Initials: ______
I HAVE READ AND UNDERSTAND THIS DOCUMENT AND RELEASE
If other than yourself, printed name of program participant Registered _________________________________________________
Date______________________________________________ Print name _____________________________________________________
Signature ___________________________________________________________________________
YOU WILL RETURN THIS TO STAFF ON YOUR FIRST DAY OF THE PROGRAM
ADDITIONAL PROGRAM FORMS Communication between program staff and the parents/families of our program participants is key to the success of each child in our program! Our goal is to help every child have a fun and safe time while in our care. Communication about a child’s progress and behavior will be shared by the Y staff, generally over the phone or via email. Other means of communication include phone calls, e-mail, parent newsletters or a note sent home with the child. MEDICATION REQUEST FORM included in this packet Because we are a state licensed program, we cannot administer medications without written instruction and consent from the parent. If your child has medication he/she needs to take, please fill out a Medication Request Form and ensure it is always up-to-date while on file. If during the course of the program, you find you need to fill one out, the program staff will have extra copies. All medications to be given to your child must be in the original container and sealed in a clear plastic bag. Medications need to be labeled with the child’s name, doctor, medication name, dosage, and pharmacy. If your child has an Epipen we will need an Allergy Plan from your child’s doctor. If your child has an inhaler for Asthma we will need an Asthma Plan from your child’s doctor. ADDITIONAL SUPPORT PLAN included in this packet We do understand that some of our participants may need some additional support to help them be successful in our program. The YMCA of Lincoln, NE does not discriminate against children with special needs or those who need additional support in our programs. We do however, request this information in order to provide a safe and enjoyable experience for each child. Please note that the terrain of our facilities, program constraints and our activity levels may make it difficult to accommodate children with certain special needs/additional supports. This form is to be used by the Program Director and the parent/guardian, in order for the YMCA to be made aware of a child’s additional supports and/or specific special health, dietary, mobility or disability needs and to put in place safety and/or medical accommodations as applicable. The Y will make every reasonable effort to accommodate a child’s special needs/additional supports but we cannot guarantee that this is possible in all circumstances. The Additional Support Plan is included in this packet and should be filled out by the parents and returned to the Program Director, prior to the first day of camp.
PARTICIPANT MEDICATION REQUEST FORM
I understand that all medications must be brought in their original container, listing all of the
following and then sealed in a plastic bag:
*Doctor’s Name *Name of Medication *Dosage *Child’s Name *Pharmacy
PLEASE COMPLETE THE FOLLOWING INFORMATION:
I, ___________________________, do herby request and give my permission to the staff at the YMCA of Lincoln
Parent/Guardian
to give the medication listed below to ____________________________________________________________________.
Child’s First & Last Name
Name of Medication: _________________________________________________________________________________________
Dosage: __________________________________________________________________________________________________________
Time and Date medication is to be given: ________________________________________________________________
___________________________________________________ _______________________________
Signature of Parent/Guardian Date
_________________________________________________________________________________
I, ___________________________, do herby request and give my permission for my child ____________________________________
Parent/Guardian Child’s First & Last Name
to administer their own medication under the supervision of the YMCA staff.
Name of Medication: _________________________________________________________________________________________
Dosage: __________________________________________________________________________________________________________
Time and Date medication is to be given: ________________________________________________________________
___________________________________________________ _______________________________
Signature of Parent/Guardian Date
Competency Statement
I, _______________________, have determined the YMCA Staff competent to give or apply medication to my child.
Parent/Guardian
___________________________________________________ _______________________________
Signature of Parent/Guardian DateMedication Administration Log- FOR STAFF USE Date Time Given Dosage Staff Initials Date Time Given Dosage Staff Initials
YMCA of Lincoln Youth, Teen & Family Program Additional Support Plan Must be completed by Parent/Guardian The YMCA of Lincoln, NE does not discriminate against children with special needs or who need additional support in our programs but requests this information in order to provide a safe and enjoyable experience for each child. Please note that the terrain of our facilities, program constraints and our activity levels may make it difficult to accommodate children with certain special needs/ additional supports. This form is to be used by the Program Director and the parent/guardian, in order for the YMCA to be made aware of a child’s additional supports and/or specific special health, dietary, mobility or disability needs and to put in place safety and/or medical accommodations as applicable. The Y will make every reasonable effort to accommodate a child’s special needs/ additional supports but we cannot guarantee that this is possible in all circumstances. Child’s First and Last Name: _________________________________ Date of Birth: _________________ Age: _______ Grade: ______________________________ Male Female Primary Phone: _______________________________________________________________________ Address: ____________________________________________________________ City: _____________________________ Zip: ____________ __________________________________ Parent/Guardian’s Name: Mother: ____________________________________________________ Work: ______________________________________ Cell: ____________ _________________________________ Father: ____________________________________________________ Work: ______________________________________ Cell: ___________ __________________________________ NATURE OF YOUR CHILD’S UNIQUE NEEDS OR DISABILITY: (Please check if applicable) Partial Visual Impairment ADHD/ADD Asthma Hearing Impaired Asperger Syndrome Learning Disability Autism Seizure Disorder Developmentally Delayed Diabetes Physical Limitations- _________________________________________________________________________________________________________ __________________________ Tourette Syndrome- How is it displayed____________________________________________________________________________________________________________ Allergies____________________________________________________________________________________________________________________ ________________________________ Dietary Restrictions_________________________________________________________________________________________________________ ____________________________ Mental Health Disability - How is it displayed_____________________________________________________________________________________________________ Other _______________________________________________________________________________________________________________________ ________________________________ Tell us about your child and their needs/ additional supports: Tell us what a typical day is like: Please describe your child’s allergies (food/medication): Please describe your child’s medical conditions and/or physical limitations:
Please describe your child’s behavioral challenges (impulsive tendencies/not listening/hitting/yelling/biting/running away):
What are some strategies that help your child at home and in school/child care settings?
Child’s preferred calming method:
If your child needs more assistance or support than the staff is able to provide, during the hours of the program, who should we
contact to come and assist at the program site, and if necessary, come and take them home for the day:
1. Name: _______________________________________________ Phone Number: ______________________________________ Relationship: _ _____________________________
2. Name: _______________________________________________ Phone Number: ______________________________________ Relationship: _ _____________________________
3. Name: _______________________________________________ Phone Number: ______________________________________ Relationship: _ _____________________________
COMMUNICATION LEVEL: (Please check if applicable)
No reaction Non-verbal Limited verbal Verbal
Will accept touch (pat on the back/hand shake/tag during a game)? YES NO
Will accept touch hugs? YES NO
Are loud noises distressing? YES NO
If yes, suggestions for coping: ___________________________________________________________________________________________ ____________________________
What are some strategies to communicate with your child effectively?
LOCOMOTION: (Please check if applicable)
Independent Walker Wheelchair
Assistance needed in eating or drinking? YES NO
Assistance needed in toileting? YES NO
SPECIAL APPLIANCES/TECHNOLOGIES: (Please check if applicable)
My child uses a wheelchair:
Pushes independently Sometimes needs assistance to be pushed uphill
Must be pushed at all times Uses an electric chair
My child uses crutches or a walking cane:
Independently Sometimes needs assistance
Must be assisted at all times Other- _______________________________________________________________________________________________
My child uses an insulin pump and blood glucose meter:
Independently Sometimes needs assistance
Must be assisted at all times Other- _______________________________________________________________________________________________
My child uses a hearing aid.
Parent/Guardian’s Signature:______________________________________________________ Date:_________________________________________________
Director’s Signature: ________________________________________________________________ Date Assessment of Receipt: __________________
Determination:_________________________________________________________________________________________________________________________________
Assessment Reviewed By: __________________________________________________________________________________________________________________
Notification to Requesting Party: _____/_____/_____ By: __________________________________________________________________________You can also read
