Form 4758t-E - Family Partnership Agreement - Riverside County Division Of Children And Family Services

Download a blank fillable Form 4758t-E - Family Partnership Agreement - Riverside County Division Of Children And Family Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 4758t-E - Family Partnership Agreement - Riverside County Division Of Children And Family Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Division of Children and Family Services

Site: ________________________________

Early Childhood Education Programs

Teacher:

_____________________________

Introduction Date:

____________________

Family Partnership Agreement

Child’s Name: ___________________________________________________________ Parent/Guardian Name: __________________________________________________

Do you have other children enrolled in Head Start or Early Head Start?  Yes  No If yes, complete the following information for each child.

Child’s Name:______________________________ Site:______________________________ Teacher: _____________________________

 EHS  HS  HB  CB

Child’s Name:______________________________ Site:______________________________ Teacher: _____________________________

 EHS  HS  HB  CB

Goal Status:  Family Not Ready, Reason and Date: _________________________________________________________________________________________________

 Pre-Existing Goal, List agency name: _________________________________________________________________________________________________

 New Goal

(Pre-existing goal/plan sample agencies: Education, Health, Disabilities, Mental Health, CalWorks, CPS, Foster Care, Probation)

Goal Description: _________________________________________________________________________________________________________________________________

Family Engagement Outcome Category (Select only one):

 Family Well-being

 Parent-Child Relationships

 Family as Lifelong Educators

 Family as Learners

 Family Engagement in Transitions

 Family Connection to Peers and Community

 Families as Advocates and Leaders

Action Steps to be taken by Family Member or Staff

Target Date

(For pre-existing goals - Only document information, resources, or referrals that will be provided by staff to support the pre-existing goal)



_________________________________________________________________________________________________________________________

_________________



_________________________________________________________________________________________________________________________

_________________



_________________________________________________________________________________________________________________________

_________________



_________________________________________________________________________________________________________________________

_________________

Expected Date of Completion: _________________

Parent/Guardian Signature: ___________________________________ Date: ________________ Staff Signature: __________________________ Date: _________________

Goal Follow Up: #1 Date:______________ Staff Initials:______________ As needed #3 Date:______________ Staff Initials:______________

#2 Date:______________ Staff Initials:______________ As needed #4 Date:______________ Staff Initials:______________

ChildPlus Report #4110 must be attached with each follow up action.

Form No. 4758T-E (Revised 05/15)