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Section 2 SFo8

Kindergarten Inclusion Support Packages – Disability

Application Form (SFo8)

Complete the Kindergarten Inclusion Support plan before this application form to determine whether or not support additional to existing resources is required.

Kindergarten Inclusion Support Packages – Disability – Application Form (SFo8) page 1

OFFICE USE ONLY

DET file no.

Agency file no.

Approved: Yes No

Awaiting information:

Review date(s):

……../……../……..

……../……../……..


You are required to submit 7 copies, comprising the original plus 6 photocopies to:

Regional Advisory Group Convenor

For addresses, see the Guidelines, Information and Application Kit – Disability

Applications close last day of Term 3

FAXES WILL NOT BE ACCEPTED.

Part 1: Applicant and Child DetailsName of the Children’s Service lodging this application

Phone Email

Postal address Postcode

Location address Postcode

Name of kindergarten teacher completing this form(in consultation with the Program Support Group)

Name of early childhood teacher for the year the child is attending the funded kindergarten program (if known)

Is the kindergarten administered by Kindergarten Cluster Management? Yes No

If yes, provide details of the Kindergarten Cluster Management organisation and authorisation to submit this application

Name Authorising Officer

Role Phone

Email

Address Postcode

Signature

Date

Has the early childhood teacher previously successfully applied for a Kindergarten Inclusion Support package? Yes No

If yes, in what year?

What support was provided?

Specialist training and consultancy

Yes No Details

Minor building modifications Yes No Details

Additional staffing Yes No Details

Have additional attachments been included? Yes No

If yes, please list

Late application

If late application, date of commencement

If late application, days and times of sessions

Reason for late application


Child’s Details

Family name Given name

Date of birth Gender Male Female

Street address

Suburb Postcode

Email Local Government Area

In which country was the child born? Australia Other Other country

Does the child speak a language other than English at home? (in consultation with the Program Support Group) Yes No

If yes, please specify the language

Is the child of Australian Aboriginal or Torres Strait Islander origin? (choose only one box)

Yes, Torres Strait Islander Yes, Aboriginal Yes, both Aboriginal and Torres Strait Islander No, neither Aboriginal nor Torres Strait Islander

Has the child previously been supported by a Kindergarten Inclusion Support package? Yes No

If yes, was the support provided to the kindergarten submitting this application? Yes No

In the year the child will be attending the funded kindergarten program

Will the child be receiving Early Start funding at this kindergarten? Yes No

Is this application to support this child in a funded program for 4-year-old children in the year prior to school?If yes, was the support provided to the kindergarten submitting this application?

Yes No

If yes, will this be the child’s second year of a funded program for 4-year-old children prior to school? Yes No


Privacy Notice for Parents / Guardians / Carers*Please read this notice before you complete the application form. You are encouraged to keep this information.

The Department of Education and Training (the Department) will protect your privacy along with the confidentiality and security of personal information you have provided. We comply with the Information Privacy Act 2000, the Health Records Act 2001 and other relevant Acts.

Why do we ask you for information?

We collect personal information when a kindergarten applies for KIS package to support a child with a disability, developmental delay or complex medical needs to attend kindergarten. This information is collected to clarify:

eligibility of the application the high support needs of the child identified in the application for KIS package applications needs the TYPE of additional supports identified as required by the kindergarten the LEVEL of additional supports identified as required by the kindergarten.Information about your child is collected from you and the people you have approved to be members of your child’s Kindergarten Program Support Group. This information assists the Regional Advisory Group to make an informed decision about the kindergarten’s eligibility and support needs.

The Regional Advisory Group has representatives from:

the Department the non-government organisation which delivers the Kindergarten Inclusion Support packages program other relevant professionals (Early Childhood Intervention, health and/or education). Refer to Section 9 in the Guidelines, Information

and Application Kit – Disability for information regarding the composition of Regional Advisory Group.The Regional Advisory Group returns the information about each child to the regional office and the community service organisation funded to provide kindergarten inclusion support.

Disclosure of information

Some information which does not identify individual children is used to:

analyse and report the performance of the program within, and to, the Victorian State Government. analyse and improve Department-funded programs for children with disabilities/additional needs.

Security and retention of information

All information about your child is kept secure and confidential. We respect your right to privacy and will only release information about your child with your written consent via the Program Support Group. However, there are times when we are required by law to disclose information about your child. In most circumstances we will let you know if we are required to do this. All Department staff handling information are required by law to respect your privacy. Any information that is not required will be destroyed.

Accessing information

A copy of your application is kept at the Department’s regional office and the organisation funded to provide the Kindergarten Inclusion Support in your region. This can be made available to you on request. Please refer to Appendices A and B: Guidelines, Information and Application Kit – Disability for contact information.

If you choose not to tell us something

If you choose not to tell us something that we need to know to make decisions about supports for your child, we may be unable to provide your child’s kindergarten with the support they seek.

* Any of the following people can sign the Privacy Declaration:

a person with parental responsibility for ‘major long term issues’ as defined by the Family law Act 1975 (Cth)

an officer delegated to exercise the powers and functions of the Secretary of the Department of Health and Human Services under sections175(1)(b).(2) & (3) of the Children, Youth and Families Act 2005 (Vic).

a carer authorised under a Department of Health and Human Services Instrument of Authorisation to make decisions about ‘major long term issues’ as defined by the Family Law Act 1975 (Cth)

If none of the above people are available, an informal carer may sign this form. An informal carer is a relative or other responsible adult with whom the child lives and who has day to day care of the child. Informal carers should sign an ‘Informal Carer Statutory Declaration’ to confirm their status. This is available at www.ccyp.vic.gov.au.


http://www.ccyp.vic.gov.au/

Privacy Declaration by Parents/ Guardians / CarersPlease tick () correct box.

Name of child

I We do do not approve this application being made by the kindergarten to assist the access and participation of my child at kindergarten.

I We have have not given consent to the people listed in Section 2 as members of the Program Support Group.

I We have have not been given a copy of the Information Privacy Statement that forms part of this application.

Parent/guardian/carer 1

Title Mr Mrs Ms Name

Signature Date

____ / _____. / _______

Parent/guardian/carer 2

Title Mr Mrs Ms Name

Signature Date

____ / _____. / _______


Details of Early Childhood Programs Child Attends For the year prior to the child attending the funded kindergarten program, list the early childhood programs that the child attends. Include a contact person, phone number and attendance details.er early c

Details of early childhood programs

Name of early childhood intervention program/service

Contact person Phone number

Total hours attended by child per week

Other (e.g. Early Start, three year old activity group/child care/occasional care)



Other (e.g. Early Start, 3-year-old activity group/child care/occasional care)







Details of Early Childhood Programs Child Will AttendFor the year the child will attending the funded kindergarten program, list the proposed early childhood programs that the child is expected to attend.

Kindergarten Program

Anticipated total available hours per week of a funded kindergarten program for 4-year old children in the year prior to school

If applicable, what are the total hours per week of Early Start Kindergarten funding?

Proposed session times the child will attend

Monday Tuesday Wednesday Thursday Friday

Other early childhood programs (if applicable)

Name of early childhood intervention program/service



Other (e.g. Early Start, three year old activity group/child care/occasional care)










Part 2: Details of All Persons Completing This Application

By signing this form I agree to be a member of the Program Support Group and I declare that to the best of my knowledge this application:

is complete addresses all relevant guidelines in the Kindergarten Inclusion Support Packages – Disability: Guidelines, Information and Application

Kit accurately represents the kindergarten program and the developmental abilities and needs of the child.

Name of parent/guardian/carer 1

Mr Mrs Ms

Street address

Suburb Postcode

Home phone number Mobile Business phone

Signature Date _____./ _____./ ______

Name of parent/guardian/Carer 2

Mr Mrs Ms

Street address

Suburb Postcode


Signature Date _____./ _____./ ______

Name of professional 1

Service/Agency name

Role Phone

Signature Date _____./ _____./ ______


Service/Agency name

Role Phone

Signature Date _____./ _____./ ______


Service/Agency name

Role Phone:

Signature Date _____./ _____./ ______


Service/Agency Name

Role Phone

Signature Date _____./ _____./ ______

Please copy this page and attach to the application if further details and signatures are required.


Part 3: Eligibility CriteriaPlease refer to the checklist indicators in the Kindergarten Inclusion Support Packages – Disability: Guidelines, Information and Application Kit, which describes the child’s need for support in the following areas.

3.1 (a) Child’s diagnosis/areas of developmental delay

3.1 (b) Child is undergoing continuing assessment by a person with a relevant qualification

3.2 Reasons for support

If the child is eligible under more than one criterion, tick the corresponding boxes. Complete only questions that are relevant.

Child is at significant risk of injury to self or others (complete 3.3 below)

Child is extremely restricted in their capacity for movement (complete 3.4 below)

Child has exceptional support needs requiring immediate medical intervention for life threatening situations (complete 3.5 below).

3.3 Child is at significant risk of injury to self or others

Describe the child’s behaviour that will need to be taken into account by the kindergarten program to ensure that the child is included in the program; that he/she and others are safe and the risk of injury is minimised?

When might the child require extra supervision in the kindergarten program? What behaviours are predictable? Are there any known ‘triggers’ for those behaviours? What works well in managing those behaviours?

3.4 Child is extremely restricted in their capacity for movement

Describe the child’s physical abilities

What equipment will be used by the child to help them move around the kindergarten and participate in the program?

When will the child require assistance to move at the kindergarten?

Give examples of any other support required to help the child to participate in the kindergarten program

3.5 Child has exceptional support needs – medical

Describe the child’s medical condition

What kind of support will the child need at kindergarten?

How often and when will the child require medical intervention at kindergarten?

Give examples of any other support required to help the child’s to participate in the kindergarten program


Section A: Only to be completed if section 3.5 above has been completed

GENERAL MEDICAL ADVICE FORM for a child with exceptional support needs that require immediate medical intervention for life-threatening situations

This form is to be completed by the child’s medical practitioner and provides a description of the health condition and first aid requirements for a child with exceptional support needs. This information will assist the kindergarten in developing a Child Health Support Plan, which outlines how the kindergarten will support the child’s medical needs.

Name of kindergarten

Child’s name Date of birth

MedicAlert number (if relevant)

Review date

Description of the child’s medical condition and recommended support and care

Level of support required

Include how closely this child needs to be supervised and how frequently health support procedures are required

Type of support

Describe health support requirements, including procedures, preparation of equipment, environmental changes, positioning, and care and transfers

General supervision for safety

For example, observable symptoms that signal staff should stop the procedure

Description of child’s medical sign/symptoms and first aid response

Observable signs/symptoms First aid response

1.

2.

3.

4.

5.


Privacy Statement

The kindergarten collects personal information so as the kindergarten can plan and support the health care needs of the child. Without the provision of this information the quality of the health support provided may be affected. The information may be disclosed to relevant early childhood educators and appropriate medical personnel, including those engaged in providing health support as well as emergency personnel, where appropriate, or where authorised or required by another law. You are able to request access to the personal information that we hold about you/your child and to request that it be corrected. Please contact the kindergarten directly or FOI Unit on 96372670.

Authorisation

Name of medical practitioner

Professional role

Contact details

Signature Date

_____./ _____./ _______

Name of parent/ guardian/ carer 1

Contact details

Relationship to child

Signature Date

_____./ _____./ _______


Contact details


Signature Date

_____./ _____./ _______

First AidIf the child becomes ill or injured at kindergarten, the kindergarten will administer first aid and call an ambulance if necessary. If you anticipate the child will require anything other than a standard first aid response, please provide details on the next page, so special arrangement can be negotiated.


Section B: Only to be completed if section 3.5 above has been completed

CHILD HEALTH SUPPORT PLAN This plan outlines how the kindergarten will support the child’s health care needs, based on health advice received from the child’s medical practitioner. This form must be completed for each child with an identified health care need (not including those with anaphylaxis as this is done via an Anaphylaxis Management Plan, see: http://www.education.vic.gov.au/ecsmanagement/educareservices/anaphylaxis.htm).

This plan is to be completed by the early childhood teacher, in collaboration with the parent/guardian and members of the Program Support Group, as appropriate.

This plan should be developed based on medical advice documented on the General Medical Advice Form.

Kindergarten Phone

Proposed date for review

Describe the complex medical needs identified by the child's medical/health practitioner?

Other known medical conditions

When will the child commence attending kindergarten?

Detail any actions and timelines to enable attendance and any interim provisions

Contact information

Name of parent/ guardian /carer 1

Mr Mrs Ms


Address



Mr Mrs Ms


Address


Name of other emergency contact (if parent/guardian not available)



Medical /Health practitioner contact

Name Business phone


http://www.education.vic.gov.au/ecsmanagement/educareservices/anaphylaxis.htm

List ALL those who will receive copies of this Child Health Support Plan

1. Child’s family

2. Other

3. Other

4. Other

The following Child Health Support Plan has been developed with my knowledge and input

Name of parent/guardian/carer Mr Mrs Ms

Signature Date_____./ _____./ ______

Name of early childhood teacher(or nominee)

Signature Date_____./ _____./ ______

Name/s and signature/s of other persons completing this form

Name Signature Date_____./ _____./ ______





How the kindergarten will support the child’s health care needsStrategy – how will the kindergarten support the child’s health care needs? Person responsible

Overall support

Is it necessary to provide the support during the kindergarten session? Provide details of this support, and how and when required.

How can the recommended support be provided in the simplest manner, with minimal interruption to the education and care program?

Who will provide the support?

How can the support be provided in a way that respects dignity, privacy, comfort and safety and enhances learning?

First aid

Does the medical information highlight any individual first aid requirements for the child, other than basic first aid? What are they and where is this information kept?

Do early childhood educators require training in addition to basic first aid training, e.g. staff involved with excursions and specific educational programs or activities?

What training is required for early childhood educators?

Routine supervision for health-related safety

Does the child require medication to be administered and/or stored at the kindergarten?

Are there any facilities issues that need to be addressed? If so how will this be achieved?

Does the child require assistance by a visiting nurse, physiotherapist, or other health worker? If so, list the contact details.


Strategy – how will the kindergarten support the child’s health care needs? Person responsible

Who is responsible for management of health records at the kindergarten?

Where relevant, what steps have been put in place to support continuity and relevance of program for the child?

Personal care

Does the medical information highlight a predictable need for additional support with daily living tasks?

Other considerations

Are there other considerations relevant for this health support plan?


Office use onlyDate application received

Is this a late application? Yes No

Date application directed to Regional Advisory Group

Date application assessed by Regional Advisory Group

Outcome of assessment

Eligible Not eligible Date

Appeal lodged

Yes No Date

If yes, date appeal finalized

Was the appeal upheld?(tick one box only)

Yes No Date

Letters advising outcome of application sent

Kindergarten management Date

Kindergarten Teacher Date

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kindergarten inclusion support packages - … · web viewyes, torres strait islander yes,...

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