Health Inadequacy Exclusion Notice Form
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1SETA HEAD START
925 Del Paso Blvd., Suite 200 ּ Sacramento, CA 95815 ּ (916) 263-3804
HEALTH INADEQUACY/EXCLUSION NOTICE
SALUD IMPERFECTA Y AVISO DE EMISION
Parent/Guardian Name: __________________________________________________________ Date Given to Parent: ___________
Child’s Name: ____________________________________DOB:___________________ Phone: _____________________________
Head Start Center: _______________________________________________ Enrollment Date: ______________________________
Dear Parent/Guardian:
Upon registration, you agreed to provide us your child’s current physical and immunization status. As of today, this documentation
has not been received by your Head Start representative. Under California State Law, we are required to have documented proof of a
current physical examination and current/up-to-date immunizations. You have left us with no option but to exclude your child from
our program. This action will put your child’s current placement in Head Start at risk. If dropped, your child will be placed on the
existing waiting list. If you have any questions, or need assistance obtaining any of the below mentioned items, please call
______________________________ at ___________________.
Estimado padre o tutor:
Al inscribir a su hijo(a) en Head Start, estuvo de acuerdo en proporcionarnos el comprobante de examen físico y registro de vacunas.
Hasta hoy el representante de Head Start no ha recibido esa información. Bajo la ley del estado de California es requisito tener
documentación del examen físico actual y copia del registro de vacunas actualizadas. No nos deja otra opción que expulsar a su
niño(a) del programa. Esta acción pondrá en riesgo a su niño(a) en Head Start. Si el niño(a) es despedido, será colocado en la lista
de espera. Si tiene preguntas o necesita ayuda para obtener los documentos mencionados enseguida, favor de llamar a
_________________________________________ al _________________________.
INFORMATION NEEDED (only the checked items apply)
INFORMACION NECESARIA (solamente la casilla marcada)
A complete annual physical or physical appointment date*
Un examen físico completo o fecha de la cita*
Current immunizations – needs: _______________________
Vacunas actualizadas – necesita: _______________________
* Failure to keep this appointment will result in your child being excluded beginning the day following the missed appointment.
* El faltar a esta cita tendrá como resultado la expulsión del niño al día siguiente.
Exclusion will take place on __________________________. Your child will not be permitted to return to our program until our staff
receives the item(s).
La expulsión se llevará a cabo el __________________________. Su niño no podrá regresar al programa hasta que nuestro personal
reciba la documentación necesaria.
Your child will be dropped as of ________________________ if you do not comply with this regulation.
Su niño(a) será expulsado(a) a partir de ________________________ si no cumple con esta regla.
Parent/Guardian Signature: ____________________________________________ Date: _______________________
Firma de Padre
Staff Signature: _____________________________________________________ Date: ________________________
White – Parent
Canary – Family Service Worker/Site Supervisor
Pink – SOP Health Services
Distribution:
Revised 8/15
H/N Services G:\Master Forms\01 Numbered Forms Word Only\079 Health Inadequacy-Exclusion NCR (ES).rtf
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