EARLY LEARNING HEAD START/ECEAP SCREENING SUMMARY

Dear Parent/Guardian:

Results of our developmental screening and/or classroom observations indicate the need for further evaluation in these areas:

Communication: Click or tap here to enter text.

Gross Motor: Click or tap here to enter text.

Fine Motor: Click or tap here to enter text.

Problem Solving: Click or tap here to enter text.

Personal-Social: Click or tap here to enter text.

We would recommend you contact the local school district office of special education to schedule further screening for your child as soon as possible. To do this, call Click or tap here to enter text. School District at Click or tap here to enter text. to schedule an appointment.

The school district screening is called Childfind. At Childfind, your child will be screened to see if s/he has delays in problem solving, social and self help development, motor development, and/or communication development. In the event your child shows delays at the screening, s/he will be scheduled for further evaluation. If as a result of this evaluation your child is eligible for special services, the Head Start/ECEAP and school district staff will work with you to develop an Individual Education Program for your child. This may include services that are given right at the Head Start/ECEAP site.

If you have any questions, please call the Child Development Program Manager at 360-478-6878.

So that Head Start/ECEAP may work with the school district to support your child, we would appreciate receiving your permission to communicate with the district.

AUTHORIZATION FOR EXCHANGE OF CONFIDENTIAL INFORMATION

I hereby authorize the exchange of confidential information between:

Agency: Click or tap here to enter text.	and	Olympic ESD #114 Early Learning

105 National Avenue North

Address: Click or tap here to enter text.	Bremerton, WA 98312

Click or tap here to enter text.

Phone Number:	Click or tap here to enter text.

Regarding:	Click or tap here to enter text.	Click or tap here to enter text.

(Child's Name)	(Head Start/ECEAP Site)

Click or tap here to enter text.

(Birthdate)

I understand the information obtained will be treated in a confidential manner and will not be transmitted to a third party without my permission. I also understand that it is my right to request a copy of all information and contest any information I feel is incorrect.

Click or tap here to enter text.	____________________________

Parent/Guardian (Signature)	Date

Parent/Guardian (Please Print) Click or tap here to enter text.

Address: Click or tap here to enter text.

Phone Number: Click or tap here to enter text.