Elkhart and St. Joseph Counties Head Start Consortium
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Health All Forms

HEALTH
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All Forms

Health Care Plans

Medication Administration MAR Record 23-24Download
Parent Permission for Medication English/Spanish 23-24Download
Individualized Health Care Plan 23-24Download
Rejected Medications 23-24Download

Incident Reports

Accident Incident Reporting 23-24Download

Medical Forms

Dental Form 23-24Download
Hemoglobin Screening Letter Parent 23-24 docxDownload
Hemoglobin Screening Letter Parent 23-24Download
Immunization Letter Physician Letter 23-24 docxDownload
Parental Declination of Child Vaccination 23-24Download
Right to Refuse Services 23-24Download
WELL CHILD EXAM 23-24 No HighlightDownload
Family Services Referral Form 23-24Download
Medical Statement Food Allergy Restriction Plan 23-24Download
TB TDAP Form 23-24Download

Prenatal and Post Partum Packet

EHS Prenatal Information form 23-24Download
Newborn Health Visit Appendix A 23-24Download
Prenatal Post Partum Physician Letter 23-24Download
Child Birth Record 23-24Download
Prenatal Post Partum COVER English Spanish 23-24Download
Prenatal Exam EHS 23-24Download

Screenings and Assessments

EHS Child Daily Record 23-24 No TimesDownload
Hearing Screen Form 23-24Download
Screening Authorization Release Form English Spanish 23-24Download
Vision Screening Form 23-24Download
Vision Snellen Eye Chart InstructionsDownload

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© Elkhart and St. Joseph Counties Head Start Consortium 2023 | Designed by Compulse Integrated Marketing
The Head Start Program is a federally funded school readiness program that offers cognitive, social, and emotional development skills to children up to five years old. Head Start provides services to low-income families located in Elkhart and St. Joseph County schools including; Baugo, Concord, Elkhart, Goshen, John Glenn, Middlebury, Mishawaka, Penn-Harris-Madison, South Bend, Union North, and Wa-Nee, Indiana.