# Enrollment Application

> Briefs, arguments, decisions, and more.

URL: https://www.frixlaw.com/law-library/documents/tribal%3Akickapoo_oklahoma%3Ad2b69c6ab9c580e9

## Record

- **Collection:** Tribal code
- **Document type:** Tribal code

## Text

KICKAPOO HEAD START

Enrollment Application

This is a recruitment application only. It does not guarantee your child’s acceptance. Children are
accepted in accordance with guidelines established by the Policy Council and Head Start federal
regulations. *Priority given to children with special needs, foster children, children experiencing
homelessness, and families receiving SNAP or TANF.

Child’s Full Name: Date of Birth:
Child’s School District: School Year:
Parent/Guardian Name: Phone & email:

Documents Received Date
Required Documents Needed with Application Office use only: Completed by Staff

Child’s Birth Certificate

Child’s tribal membership card or document

Parent/Guardian tribal card or document

SSI, TANF, or SNAP benefits letter (if applicable)

Proof of Residency (documents accepted: current utility bill,
lease agreement, affidavit of shared residency)

Current Immunization Record

Oo o;ojo o0o'o0

Health Insurance Card or letter

(_] IEP/IFSP or other documents (if applicable)

(_] Foster Care or adoption documents (if applicable)

Documents Required Once student is accepted: )) Physical Exam Form ) Dental/Oral Health Form

/

Office use only: |
Date Application Received Signature of Staff Member
Date Application Completed Signature of ERSEA Manager
Date Application Accepted Signature of ERSEA Manager

/

Revised 6/2026

Contact information: 405-964-4227 ext.1500 or Email: Ispain@ktoheadstart.com

Date Application Received:
Kickapoo Head Start

Applicant & Family Member Information

(Child) Applicant Information Please Print

Middle Name Last Name Nickname Birthday Gender

Child’s First Name

OO Male
O1 Female
Address of Family City State Zip Code County
Race: Child's Primary Language Public School District in which child resides:
OO Asian O American Indian/Alaska Native
O Black O Hawaiian/Pacific Islander Other Languages
O White O Multi-Racial:
o othe, Was this child previously in a Head Start Program
, English Other Language | No O Yes
C1 Hispanic or Latino origin CO None 0 Little If yes, which program?
O Non-Hispanic or Non-Latino origin D Little 0 Moderate
O Moderate O Proficient
O Proficient
Primary Health Coverage Medicaid ONoUO Yes
ID Number:
Other Health Coverage
Name of Primary Physician Address Phone
Name of Oral Health Care Provider Address Phone

Mother’s or Guardian’s Information- Please Fill Out Completely

Middle Gender
O Male
O Female
Race: English Language Other Language Custody Check All That Applies:
O Asian © American Indian/Alaska Native | 0) None OO Poor O No 0 Lives with Family
Ol Black O Hawaiian/Pacific Islander 0 Little XO Moderate O Yes O Provides Financial Support
OWhite 1 Multi-Racial OHispanic O Moderate 0 Proficient C0 Teen Parent
CO Other: O Proficient
Highest Grade Completed Employment Status Child's Relationship
OO Master’s Ol McLoud, Oklahoma 74851 @ Phone: (405) 964-4227 ext. 1500 PH email: headstart@okkt.net

C2 OKLAHOMA . . Compliance File Notification:
| ¢ Human Services Child Care Programs and

{vNY Family Child Care Homes

Program Information

Kickapoo Head Start K830005203
Program name License number
105255 S. HWY 102 McLoud 74851
Street address City State ZIP code

P.O. Box 399, McLoud, OK 74851
Mailing address

405-964-4227 ext 1500 Jake Meshquekennock
Phone Owner

Child Information

Please list the name(s) and birth date(s) for any child(ren) you are enrolling in this program:

Name Date of birth

Agreement and Signature

o | understand and am aware:

[] this program is required to maintain a copy of the compliance file on-site and the
information contained in the file is available for inspection.
[_] of the Compliance File location and its contents.
[_] this form is to be completed:
[-] upon child enrollment; and
[_] every 12 months thereafter.
_] a copy of the program specific Notice to Parents is to be provided to parent(s) or
legal guardian(s) upon enrollment.

07LCO46E 3/18/2026 Page 1 of 3
For program specific information contained in the Notice to Parents, select one:
DHS Publication No. 14-01, Notice to Parents for Child Care Program
[_] Form 07LC084E, Notice to Parents for Family Child Care Home

Parent or legal guardian name Parent or legal guardian signature Date

07LCO46E 3/18/2026 Page 2 of 3
This document does not meet posting requirements per OAC 340:110-3-275 through
340:110-3-311, and DHS Pub 14-15 Licensing Requirements for Child Care Programs, and is a
parent provided document only. Information contained in DHS Pub 14-01 Notice to Parents is stated
below. You may obtain a copy of DHS Pub 14-01 by calling 1-877-283-4113, or by faxing (405)
962-1741.

NOTICE TO PARENTS

Please review the following records on a regular basis at child care centers, day-camps, drop-in
programs, out-of-school time programs, part-day programs, and programs for sick children.

Posted: The program is required to post:
e This Notice to Parents; and
° Child Welfare Investigative Summary, with confirmed and substantiated findings
for 120 calendar days from the date the investigation is completed as indicated
on the form.

Compliance file: The program is required to make accessible in a prominent location the following
documents, maintained together, with the most recent on top and all child-identifying information
removed. The compliance file includes items within the last 120 calendar days, at a minimum, from
the date on the document or the investigation completion date on the form, unless requirements
state otherwise.

The compliance file only contains: compliance monitoring from Licensing, Stars and tribal agencies,
such as: monitoring visit forms; including the most recent visit; case status information; such as
forms and correspondence regarding: issuance of permits and licenses; non-compliances and Stars
violations: notices to comply; complaint findings; office conferences with Licensing, Stars and tribal
agencies; Stars alternative settlements and reductions; consent agreements, denials of a request for
license, and revocations of a license; child welfare investigative summary, regardless of findings;
however, confirmed or substantiated findings are maintained in the file for 12 months; granted
criminal history restriction waiver notifications are maintained in the file for as long as the individual
is employed or is living in the facility; and other documents indicating placement in the compliance
file.

Online

Child care locator and case summary: Access at the below Web address.
Licensing requirements for child care programs: Access at the below Web address or contact
the local OKDHS office below for a mailed copy. \

At the OKDHS local office

Public licensing file: Contact the local office below to schedule an appointment.
Case summary: Contact the local office below for a faxed or mailed copy.

If you believe licensing requirements are not being met or you have questions, please contact a
child care licensing specialist from OKDHS Child Care Services at:

OKDHS local office
Child Care Services
Address: Phone:

http://www.okdhs.org/services/cc/Pages/ChildCareMain.aspx

07LCO46E 3/18/2026 Page 3 of 3
90! Heay Kickapoo Head Start

¥ ig % National Center on P.O. Box 399

o + McLoud, OK 74851

4 ¢ Health, Behavioral Health, and Safety 405-964-4227 ext. 1502
Monat oe Ispain@ktoheadstart.com

Head Start Oral Health Form—Children

Child’s name Date of birth Parent’s/guardian’s name Phone number

Address City State Zip code
This practice is the child’s dental home: 1 Yes EI No

Current Oral Health Status

Does the child have any teeth with untreated decay? 1 Yes (decay) No (decay free)

Does the child have any teeth that have previously been treated for decay, including fillings, crowns,
or extractions? OYes OINo

Are there treatment needs? [1 Yes, urgent O Yes, not urgent [No treatment needs

Oral Health Care Services Delivered During Visit

Diagnostic/Preventive Services | Counseling/Anticipatory Guidance _ Restorative/Emergency Care

Examination: OYes OINo OYes ONo Fillings: OYes ONo
X-rays: OYes ONo . Silver diamine
Referral to Specialty Care ida:
Risk assessment: ElYes EINo . y fluoride: OYes HNo
} OYes ONo Crowns: OYes ONo
Cleaning: OYes ONo ;
Fluorid ich: Yes ON Extractions: OYes ONo
doriewarnisi eS ° (Please specify specialist) Emergency care: D1 Yes EINo
Dental sealants: D1 Yes OANo
Other:
(Please specify)
Future Oral Health Care Services
All treatment completed: O1 Yes O1No Next recall date: (month/year)

More appointments needed for treatment? HO Yes OI No
If yes: Approximate number of appointments needed: Next appointment: Date: Time:

Additional Information for Parents, Head Start Staff, and Medical Providers

Oral Health Provider’s Contact Information and Signature

Provider name (please print) Phone number Fax number
Practice name Address
Provider signature Date of service

This resource is supported by the Administration for Children and Families (ACF) of the United States (U.S.) Department of Health and Human Services (HHS) as part of a financial
assistance award totaling $8,200,000 with 100% funded by ACF. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by,
ACF/HHS or the U.S. Government.
Head Start requires a COMPLETE CHILD’S HEALTH EXAM, including BLOOD LEAD TEST. Documentation of ALL
screenings is necessary in order to provide prompt assistance to families to best meet the health and developmental

ATTENTION PROVIDER:

needs of the child. Please complete all boxes, sign and date, and return this form to the parent.

HEAD START PHYSICAL EXAM (TO BE COMPLETED BY PROVIDER)

PHYSICAL EXAM PERFORMED TODAY (PLEASE CHECK ONE)

3 Yr [ |

4Yr [ | 5 Yr []

CHILD'S NAME

DATE OF BIRTH

CENTER

Kickapoo Head Start

PHYSICAL EXAMINATION ADMINISTERED BY (TYPE OR PRINT NAME)

HEALTH CARE PROVIDER INFORMATION
SIGNATURE

CLINIC/TYPE OF PRACTICE

TELEPHONE NUMBER

DATE OF EXAM

LOCATION
EXAMINATION RESULTS
HEIGHT WEIGHT BLOOD PRESSURE
inches Ibs/oz
EXAM Normal {Abnormal EXAM Normal |Abnormal EXAM Normal |Abnormal
Mouth/ Teeth/
Skin Oral Health Assessment Neurologic
Head Throat Extremities
Neck Chest Motor Ability
Lymph Nodes Lungs Psychological
Eyes Heart Speech
Ears Back Developmental
Nose Abdomen Behavioral
Vision Acuity Right Left Both Hearing Screening Frequency (Hz) Right (db) | Left (db)
1000 Hz dB dB
— / / — 2000 Hz dB dB
Test Type Test Type ee = =
4000 Hz dB dB
Hemoglobin Lead
1 No Risk Risk Assessment required at 3, 4, and 5 years, _ LEAD LEVEL (mcg/dl)
record the Hemoglobin/Hematocrit test result below
© AtRisk nae HGP wey ire Lead test between 24 & 72 months
CD Iron Prescribed
Does the child have Food or Milk allergies? Please list: Lead Risk Assessment
(1) AtRisk (1) No Risk
Immunizations
ae 3 GIVEN TODAY
Treatment/Restrictions/Recommendations Yes ‘eo No List:
Does the child have Asthma? Yes No
Medication required at school? Yes No
Diagnosis/Abnormal Findings List medications & purpose (Medication Administration Form needed)

(Head Start Office Use) date received Complete Physical Form:

Staff Signature:

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Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Akickapoo_oklahoma%3Ad2b69c6ab9c580e9. Public record. Not legal advice.