• Child's Full Name:
• Date of Birth:
• Upload copy of birth certificate:
• Parent/Guardian Full Names
• Parent/Guardian 1:
• Parent/Guardian 2:
• Home Phone (Parent/Guardian 1):
• Mobile Phone: (Parent/Guardian 1)
• Home Phone (Parent/Guardian 2):
• Mobile Phone (Parent/Guardian 2):
• Full Address:
  (where child resides)
• Full Address:
  (if different from child's)
• Email:

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School Child will Attend in 2017/2018 School Year

• School:
• Teacher's Name:
• Days Attending School:
  MonTuesWedThursFri
•  
  MorningsAfternoonsFull Days
• School Phone:
• School Address:
• Referring Therapist:

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• Has your child had a recent vision test?:
  YesNo
• Has your child had a recent hearing test?:
  YesNo
• I authorize Foothills Creative Beginnings to apply and administer PUF or Mild/Moderate funding for my child.
• I am requesting Foothills Creative Beginnings to apply for PUF or Mild/Moderate Funding
• I, , give permission to Foothills Creative Beginnings Preschool and ECS Association to release records, assessments and therapy reports for my child to their receiving school.

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I have checked my agreement with each of the following policies which are expectations of PUF as administered by:
Foothills Creative Beginnings Preschool and ECS Association

• To obtain PUF or M/M Funding I must sign the PUF / M/M application and provide a copy of my child's birth certificate (and documentation that supports my ability to work in Canada, if my child was not born in Canada).
• Attendance: My child must be registered and regularly attend a preschool or kindergarten program in order to receive this funding. Lack of attendance in an educational setting can jeopardize my child's funding.
• I will provide 24 hours notice to my therapist, if my child will miss their therapy session. I must let my therapists know if my child will be unable to attend a session. I will be allowed one no-show appointment; all others, I may be required to pay a $50 short notice cancellation fee if FCB incurs a charge due to the short notice cancellation/no show.
• I will notify my child's PUF / M/M Coordinator if my child's therapist did not show to the scheduled therapy time.
• I will let my child's teaching assistant and teachers know if my child will be absent at preschool or kindergarten on any given day.
• I will provide one month's notice if i decide to withdraw my child from a therapy program (PUF or M/M Service) which alternatives will be discussed.
• I understand that extended conversations with my child's therapist could result in a reduction of therapy hours. A therapy session consists of 45 minutes of direct therapy with 15 minutes for communicating/debriefing. Additional interaction may be considered consultative in nature and may be billed, thus reducing your child's therapy hours.
• I understand that if I am not on time for my therapy session, my session time will be reduced accordingly. (Therapy time will not be extended).
• For serious illness, I will provide a signed report from my child's doctor. It will be kept in a private file, and will be available to staff only, in case of any related emergency requiring staff assistance.
• PUF ONLY: I want my child's PUF Coordinator to provide a minimum of 4 (90 minute) Family Orientated Programming sessions (FOPS). I agree to have a parent or a dedicated caregiver (who will fully communicate the contents of the sessions to the parents) present for these sessions.
• PUF ONLY: I will attend 3 - 1 hour Individual Program Plan (IPP) meetings during the year. Time for the meeting will be limited to one hour per meeting.

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• By checking this box you are digitally signing this form (you will not be able to submit the form until you digitally sign and accept the above policies)

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