inspiring achievement, belonging and connection · inspiring achievement, belonging and connection...
TRANSCRIPT
2017-2018 School Year YMCA OF SOUTH HAMPTON ROADS
INSPIRING ACHIEVEMENT, BELONGING AND CONNECTIONYMCA After-School Program in ChesapeakeThe information contained herein is distributed by the Chesapeake Public Schools as a public service. The Chesapeake Public Schools does not endorse any agency related to the information contained herein, nor is any agency/program related to the information contained herein, sponsored by or in connection with the Chesapeake Public Schools.
Children are like sponges—they watch and absorb knowledge, skills and values from everything and everyone around them. At the Y, we believe the values and skills learned early on are vital building blocks for quality of life and future success.
That’s why our childcare programs are staffed with people who understand the cognitive, physical and social development of kids, the need children have to feel connected and supported in trying new things, and the caring and reinforcement parents and families need to help each other. At our after-school programs at the Y, school-age kids make friends, learn new skills and do homework. With a focus on safety, health, social growth and academic enhancement, Y child care programs serve kindergartners through middle schoolers with a variety of activity options to explore and develop their interests and talents. Most importantly, they learn how to be their best selves. That makes for confident kids today, and contributing and engaged adults tomorrow.
WHY CHOOSE YMCA CHILD CARE? The Y’s child care programs are licensed by social sevices to ensure safety and quality.
Respectful Relationships are formed between the staff and children and the staff and parents. Children have time to play with one another and form lasting friendships.
Caring Environment means our space is warm and inviting with activities indoors and outdoors. Activities are geared to the child’s interests. Children can play alone, in small or large groups, and sched-ules are flexible and the atmosphere is relaxed.
Safety and Health is top priority! We check daily to ensure that all areas your child will be in are clean and free of safety hazards.
Improving Academic Performance In 2014, the YMCA of South Hampton Roads identified improving the academic performance and leadership skills of children enrolled in youth development programs as a priority. As a result, Y-Child Care implemented a new curriculum that emphasizes STEM and literacy education through fun, interactive activities designed to improve the academic achievement of children in our after-school programs.
Additionally, our Academic Achievers program is designed to identify children who need additional educational support to succeed in school and is offered at no additional cost.
Serving over 2,500 children every day, our Before- & After-School programs offer far more than just homework assistance—although we build in time for that as well. Children choose their own activities from a list of many options. These options allow for individual time with friends, small group time and large group activities. We strive to make going outside a part of every day!
Fun Activities: During free choice time, the following are available:
• Arts & Crafts
• Music Activities
• Blocks and Construction
• Drama and Pretend Play
• Language and Reading Activities
• Science, Technology, Engineering and Math Activities (STEM)
• Y Clubs—progressive projects based on your child’s interest
• Sports & Games
• SPARK (Sports, Play and Active Recreation for Kids) activities
Dedicated and Highly Trained Staff Staff meet strict YMCA qualifications, and have passed criminal background and Child Protective Services checks after careful refer-ence checks are completed. Our staff participate in several training and certification programs, including infant/child CPR, First Aid, prevention/recognition of child abuse, OSHA blood borne pathogens, child development, curriculum planning and licensing regulations. Staff are trained in a variety of topics, which include activity planning, safety procedures, licensing, child development and guiding children’s behaviors. Staff-student ratio of 1:15 exceeds state guideline of 1:18.
OUR PROGRAM The YMCA incorporates our five core values of caring, honesty, respect, responsibility and faith into every YMCA program. After-School Child Care, in particular, emphasizes these unique components to help children develop positive identities, values and social skills. These are essential character-building blocks that nurture and empower young people to grow up to be healthy, competent, caring and responsible adults.
After-School Program At the Y, we have over 40 program locations throughout South Hampton Roads and northeastern North Carolina so that parents can have peace of mind. In our programs, we strive to expose children to a variety of new and exciting experiences. The program provides 5–12 year-olds with chances to unwind, explore and experiment, discover new ideas, work cooperatively in small groups and enjoy large group activities.
Inclement Weather Care When weather or other unplanned events cause school to close and the Y is able to open, full-day care is provided at no additional cost to participants in the before- and after-school program.
School’s Out Camp School’s out for the day, but we can help. When schools take a break from their instructional schedule, children need a safe, exciting place to get away from it all. The YMCA offers full-day School’s Out Camp at the Y for an additional fee on many of the days when the public schools are closed. School’s Out Camps allow parents the peace of mind knowing that their child is in a safe, caring environment.
After-School Care: $67/week elementary; $57/week middle
YMCA Child Care programs are provided on-site at:
• B.M. Williams Primary (BMW)
• Butts Road Intermediate (BRI)
• Carver Intermediate (CV)
• Cedar Road Elementary (CR)
• Crestwood Intermediate (CI)
• Deep Creek Elementary (DCE)
• Georgetown Primary (GTP)
• Grassfield Elementary (GRE)
• Great Bridge Intermediate (GBI)
• Greenbrier Intermediate (GI)
• Greenbrier Primary (GP)
• Southeastern Elementary (SE)
• Southwestern Elementary (SW)
• Western Branch Intermediate (WBI)
Transportation to YMCA Child Care programs at the locations listed above is provided from the following schools:
• Butts Road Primary (to BRI)
• Camelot Elementary (to DCE)
• Crestwood Middle (to CI)
• Deep Creek Central (to GRE)
• Great Bridge Middle (to GBI)
• Great Bridge Primary (to GBI)
• Greenbrier Middle (to GI)
• Hickory Elementary (to SE)
• Hickory Middle (to SE)
• Hugo Owens Middle (to GRE)
• Indian River Middle (to GTP)
• Norfolk Highlands (to CV)
• Oscar Smith Middle (to CV)
• Portlock Primary (to CV)
• Sparrow Road Intermediate (to GTP)
• Thurgood Marshall Elementary (to CV)
• Treakle Elementary (to DCE)
• Western Branch Primary (to WBI)
Welcome, Snack &
Attendance
STEM Global Learning
Leadership EnrichmentAcademic SupportHealth & Wellness
THE Y’S AFTERSCHOOL PROGRAM gives kids and teens a safe place to go in the afternoon. But it also helps them realize who they are and what they can achieve, with a balanced program built on academic intervention, health, and enrichment programming.
AFTER-SCHOOL CARE
Visit www.ymcashr.org/schoolage to learn more and to register online, call us at (757) 366-9622 or stop by the Greenbrier North YMCA.
BEFORE-SCHOOL CARE Before-School Care: $40/member rate; $50/regular rate
Before-School Care is available at the Taylor Bend Family YMCA for Western Branch Primary and Western Branch Intermediate. Drop-off begins at 6am and the bus arrives at 7:20am.
Financial AssistanceOur Open Doors program makes financial assistance available, as funds permit, to families who are unable to pay the full program fee. Funds for financial assistance have been made available through gen-erous contributions to our annual giving campaign. Contact your local YMCA for more information on how you can participate in the Open Doors program or visit ymcashr.org/opendoors.
CHESAPEAKE
Chesapeake School-Age Child Care YMCA 2100 Old Greenbrier Road Chesapeake, VA 23320 P 757 366 9622
CURRITUCK
Currituck Family YMCA 130 Community Way Barco, NC 27917 P 252 453 9632
ELIZABETH CITY
Albemarle Family YMCA 1240 North Road Street Elizabeth City, NC 27909 P 252 334 9622
FRANKLIN
James L. Camp, Jr. Family YMCA 300 Crescent Drive Franklin, VA 23851 P 757 562 3491
NORFOLK
Blocker Norfolk Family YMCA 312 West Bute Street Norfolk, VA 23510 P 757 622 9622
PORTSMOUTH
Effingham Street Family YMCA 1013 Effingham Street Portsmouth, VA 23704 P 757 399 5511
SUFFOLK
Suffolk Family YMCA 2769 Godwin Boulevard Suffolk, VA 23434 P 757 934 9622
VIRGINIA BEACH
Hilltop Family YMCA 1536 Laskin Road Virginia Beach, VA 23451 P 757 422 3805
Indian River Family YMCA 5660 Indian River Road Virginia Beach, VA 23464 P 757 366 0488
Mt. Trashmore Family YMCA 4441 South Boulevard Virginia Beach, VA 23452 P 757 456 9622
Princess Anne Family YMCA 2121 Landstown Road Virginia Beach, VA 23456 P 757 410-9557
Salem YMCA Family Center 2029 Salem Road Virginia Beach, VA 23456 P 757 471 9622
CHILD CARE LOCATIONS
SPACE IS LIMITED; REGISTER YOUR CHILD FOR YMCA CHILD CARE TODAY!
The YMCA provides Before- & After-School programs in YMCA family centers and in select public schools throughout the community. For a complete list of schools we serve, visit www.ymcashr.org/programs/schoolage.
YMCA OF SOUTH HAMPTON ROADS 920 Corporate Lane, Chesapeake, VA 23320 P 757 965 5555 W www.ymcashr.org
Please complete all blanks on this form. Incomplete enrollment forms cannot be accepted.According to the minimum standards put forth by the Commonwealth of Virginia, we are unable to care for your child until all required paperwork is submitted, including: Child’s proof of identity Up-to-date shot records Up-to-date physical Medication form, if applicable
PROGRAM: Before- & After-School Before-School After-School Camp Preschool School’s Out Camp
CHILD’S INFORMATION: Child’s full name Nickname Sex Birth date
Street address First day of attendance Last day of attendance
City State Zip Home phone
Grade/ class level
School Programs previously attended
Schools/programs concurrently attending
EMERGENCY INFORMATION: If your child takes any medication, please also fill out the Medication Authorization Form.
Allergies and intolerance to food, medications or other substances and actions to take in emergency situation
Chronic physical problems/diseases; pertinent development information; special accommodations needed; special instructions to provider
Child’s physician Physician’s phone
In the event of an emergency, please number, in order of priority (1–6), which phone to contact. Parent/guardian name 1 Cell phone Priority
Address (enter “same” if address is the same as the child’s) Email address
City State Zip Home phone Priority
Place of employment Work phone Priority
Parent/guardian name 2 Cell phone Priority
Address (enter “same” if address is the same as the child’s) Email address
City State Zip Home phone Priority
Place of employment Work phone Priority
Name, street address and phone of emergency contact if parent(s) cannot be reached
Name, street address and phone of emergency contact if parent(s) cannot be reached
Persons authorized to pick up child (appropriate custody or other court order shall be attached if a parent is not allowed to pick up the child)
SWIM PERMISSION: My child has permission to participate in swimming activities. Please check your child’s ability to swim and provide a detailed statement regarding your child’s
swimming skills on the line below. My child cannot swim. My child can swim with assistance. My child can swim without assistance.
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The parent authorizes the application of hypo allergenic sunscreen/insect repellent for his or her child by YMCA staff. (Please note any adverse reaction to sunscreen/insect repellent of which you may be aware.) Yes No
Parent/guardian signature (valid for one year) _______________________________________________________________________________________________________________________________________________________________ Date _______________________________
YMCA CHILD CARE APPLICATION
Parent/Guardian Signature Date
1st Year Review: ________________________________________________________________ __________________________________
2nd Year Review: ________________________________________________________________ __________________________________
3rd Year Review: ________________________________________________________________ __________________________________
Completed form must be kept in the child’s record and first page updated ANNUALLY.
Rev 05/17
RELEASE OF CONFIDENTIAL INFORMATION AUTHORIZATIONPermission is granted to the YMCA of South Boston/Halifax County to access my child’s school records and contact school administrators and staff for purposes pertaining to growth, development and achievement of my child including, but not limited to: SOL Scores, Report Cards, Progress Reports, behavioral issues, homework assignments etc. I understand that access to this information will be used in possible grant writing and assisting the child in achieving his/her academic and social and emotional growth milestones.
I will allow this. I choose not to allow this.
Signature _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date ________________________________________________________
FINANCIAL RESPONSIBILITY: Please read and check each statement below and initial at the bottom.
I am the parent/guardian of the above named child, and my financial responsibility is as follows:
I understand that my weekly tuition is due by 6pm on the Wednesday before each week of care. Payments made after this deadline will be assessed an additional $15.
I understand that my receipts should be kept as a record for filing taxes. The YMCA will not provide a year-end tax statement.
I understand that my child must be picked up by 6pm. I will be charged $15 for each 15-minute interval past 6pm.
YMCA program sessions are not prorated and I must register my child and pay for full sessions.
Child Care registration fees and camp deposits are nonrefundable.
If my payment is returned by my bank, I am responsible for a $25 returned payment fee in addition to the amount of the original payment, which I must pay BEFORE my child is allowed back into the program.
After a second returned payment, I will have to pay cash or money order only for any future sessions/programs.
AUTOMATIC PAYMENTS FOR CHILD CARE AND CAMP The YMCA of South Boston/Halifax County offers automatic draft for your child care and camp payments. You can stop automatic payments with a 30-day written notice. If you would like to utilize this payment option, please check your payment frequency and sign the statement below.
Weekly (on Wednesdays) Bi-Monthly (1st and 15th of each month) Monthly (1st of each month) Other ( )
ELECTRONIC FUNDS (EFT) OR CREDIT CARD AUTHORIZATIONI authorize my bank to honor preauthorized Electronic Funds Transfer (or credit card institution) drawn by the YMCA of South Boston/Halifax County on my account for (membership/program/ contribution) payments as indicated below. When the bank honors the EFT (or credit card) by charging my account, such transfer shall constitute notice of payment due and my receipt for the payment. Should any preauthorized EFT (or credit card) not be honored by said bank when received by them, then it is understood that the payment is to be made by me in the amount of said payment plus posted returned draft/check fee. It is further understood that if such payment is not honored by the bank (or credit card institution), then the YMCA of South Boston/Halifax County, at its discretion, may resubmit the amount due for payment on a future date.
I choose to utilize the EFT option for payment (direct debit from my Checking Savings account)
I choose to utilize the credit card payment option for payment (automatic direct charge to credit card)
By signing below, you are authorizing all of the above.
Signature __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date _____________________________________________________
STATEMENT OF AUTHORIZATION: Please read and check each statement and sign below.
My child has permission to be transported by a YMCA vehicle and to participate in all YMCA program activities and related field trips.
The YMCA agrees to notify me (parent/guardian) whenever the child becomes ill. I agree to pick up the child within 30 minutes of receiving the call that my child is ill. (A temperature of over 100°F, recurring vomiting/diarrhea or a communicable disease would require exclusion from the YMCA.)
I (parent/guardian) authorize the YMCA to obtain immediate care if any emergency occurs when I (parent/guardian) cannot be located immediately. I understand that in an emergency, my child may be transported in a private vehicle.
I agree to inform the YMCA child care staff/director within 24 hours or the next business day if my child or any other immediate household member has developed any reportable communicable disease, as defined by the State Board of Health, except for life-threatening diseases which must be reported immediately.
I have been informed of my YMCA Child Care program’s Emergency Preparedness Plan.
STATEMENT OF UNDERSTANDING: The following information is important for the safety and protection of your child. Please read this information and c and sign below.
• I understand that I am not to leave my child at the YMCA or program site unless a YMCA Child Care staff member or volunteer is there to receive and supervise my child.
• I understand that it is my responsibility to sign my child in upon arrival in the morning and sign my child out before leaving in the afternoon. Sign-in/sign-out sheets are available as you enter the program. There must be an exchange of responsibility from one adult to another, not from a child to staff. All persons signing children in/out must be at least 16 years of age. (See other pick-up provisions in Parent Handbook.)
• I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child must be listed on this form. Authorization by telephone will not be accepted.
• I understand that YMCA staff and volunteers are not allowed to babysit or transport children at any time outside the YMCA facilities and program. If a violation of this policy is discovered, the YMCA will take immediate disciplinary action toward staff and volunteers.
• I understand that by state law, the YMCA is mandated to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.
• I consent for the use of photographs or digital images of my child in any printed/filmed material for promotions of the YMCA of South Boston/Halifax County.
• I am an adult over 18 years and wish to have my child participate in YMCA of South Boston/Halifax County Child Care programs. I understand that even when every reasonable precaution is taken, accidents can sometimes happen. Therefore, in exchange for allowing my child to participate in YMCA Child Care, I understand and expressly acknowledge that I, for myself and for anyone entitled to act on my behalf, waive and release the YMCA, sponsors, representatives and successors from all claims or liabilities of any kind arising out of my participation in activities at or sponsored by the YMCA. I further agree to indemnify and save harmless the YMCA from any claims or demands arising out of any such injuries or losses. I understand that this release includes any claims based on negligence, action or inaction of the YMCA of South Boston/Halifax County, its staff, directors, members and guests. I have read, understand and am voluntarily signing this authorization and release.
I have read and understand the statements above regarding YMCA policies and procedures.
I have received a copy of the YMCA Parent Handbook.
I have provided a copy of my child’s physical and immunization records along with this form.
I have read and understand the statement above regarding the Model Release.
Signature __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date _____________________________________________________
Mission: To put Judeo-Christian principles into practice through programs that build healthy spirit, mind and body for all.
YMCA OF SOUTH BOSTON/HALIFAX COUNTYP (434) 572-8909 W www.ymcasouthboston.org
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
CHILD’S NAME: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ CHILD’S PROOF OF IDENTITY: The Code of Virginia states that “Proof of identity means a certified copy of a birth certificate or other reliable proof of the child’s identity and age. The following documents are acceptable forms of reliable proof. Please check which document you are submitting.
Certified copy of birth certificate
Birth registration card
Notification of birth (hospital, physician or midwife record)
Passport
Copy of placement agreement or entrustment agreement from a child placing agency (foster care and adoption agencies)
Record from a public school in Virginia
Certification by a principal or his designee in the US that a certified copy of the child’s birth record was previously presented
Copy of the conferring temporary legal custody or entrustment agreement of a child to an independent foster parent
Child identification card issued by the Virginia Department of Motor Vehicles (DMV)
For Office Use OnlyForm of Identity Verification Date of Birth Place of Birth Start Date End Date
Document Number Date Issued Staff Signature
I, order the medication listed to be administered.
Name of medication Strength
Dosage Times to be given Frequency
Reason the child is taking this medication (unless confidential by law)
Describe any additional training, procedures or competencies the child’s program staff will need to know.
This authorization is effective from: until (start date) (end date)
Physician’s signature
Date: Physician’s phone number:
Medication Authorization Form For Prescription and Non-prescription (OTC) Medication
INSTRUCTIONS:• Section A & C must be completed by the parent/guardian for ALL medication being authorized.
• Section B must be completed by a physician for any medication authorizations. This includes non-prescription medications.
• Each medication needs a separate authorization form. Multiple medications cannot be listed on one form.
• If diagnosed with asthma a inhaler with chamber and mask along with a separate action plan must accompany this document
• If a Epipen is prescribed, a separate action plan must accompany this document
• If the end date documented by the physician expires before school is out for the year, a new authorization form will be required.
Child’s first and last name
Child’s known allergies
I, authorize to administer this medication as (parent’s name) (program name)
specified in this medication form.
Parent’ signature
Date
SECTION A: To be completed by parent/guardian
SECTION B: To be completed by child’s physician
SECTION C: To be completed by parent/guardian
MCH 213 F revised 4/07 1
COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM
Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization
Part I – HEALTH INFORMATION FORM State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no longer than one year before your child’s entry into school.
Name of School: ____________________________________________________________________________________ Current Grade: _______________________
Student’s Name: _________________________________________________________________________________________________________________________ Last First Middle Student’s Date of Birth: _____/_____/_______ Sex: _______ State or Country of Birth: ________________________ Main Language Spoken: ______________
Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Zip: _______________
Name of Mother or Legal Guardian: ______________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Name of Father or Legal Guardian: ______________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Emergency Contact: __________________________________________________________ Phone: ______-______-________ Work or Cell: _____-_____-______
Condition Yes Comments Condition Yes Comments Allergies (food, insects, drugs, latex) Diabetes Allergies (seasonal) Head or spinal injury Asthma or breathing problems Hearing problems or deafness Attention-Deficit/Hyperactivity Disorder Heart problems Behavioral problems Hospitalizations Developmental problems Lead poisoning Bladder problem Muscle problems Bleeding problem Seizures Bowel problem Sickle Cell Disease (not trait) Cerebral Palsy Speech problems Cystic fibrosis Surgery Dental problems Vision problems
Describe any other important health-related information about your child (for example, feeding tube, oxygen support, hearing aid, etc.):
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
List all prescription, over-the-counter, and herbal medications your child takes regularly:
_______________________________________________________________________________________________________________________________________
Check here if you want to discuss confidential information with the school nurse or other school authority. Yes No
Please provide the following information:
Name Phone Date of Last Appointment Pediatrician/primary care provider
Specialist
Dentist
Case Worker (if applicable)
Child’s Health Insurance: ____ None ____ FAMIS Plus (Medicaid) _____ FAMIS _____ Private/Commercial/Employer sponsored I, ______________________________________ (do___) (do not___) authorize my child’s health care provider and designated provider of health care in the school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record. Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ __________
Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________
Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______
MCH 213 F revised 4/07 2
COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM
Part II - Certification of Immunization
Section I
To be completed by a physician, registered nurse, or health department official. See Section II for conditional enrollment and exemptions.
(A copy of the immunization record signed or stamped by a physician or designee indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form.) Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box. Certification of Immunization 11/06
Student’s Name: Date of Birth: |____|____|____|
Last First Middle Mo. Day Yr.
IMMUNIZATION
RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN
*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5
*Diphtheria, Tetanus (DT) or Td (given after 7 years of age)
1 2 3 4 5
*Tdap booster (6th grade entry) 1
*Poliomyelitis (IPV, OPV)
1 2 3 4
*Haemophilus influenzae Type b (Hib conjugate) *only for children <60 months of age
1 2 3 4
*Pneumococcal (PCV conjugate) *only for children <2 years of age
1 2 3 4
Measles, Mumps, Rubella (MMR vaccine)
1 2
*Measles (Rubeola)
1 2 Serological Confirmation of Measles Immunity:
*Rubella
1 Serological Confirmation of Rubella Immunity:
*Mumps
1 2
*Hepatitis B Vaccine (HBV) Merck adult formulation used
1 2 3
*Varicella Vaccine
1 2 Date of Varicella Disease OR Serological Confirmation of Varicella Immunity:
Hepatitis A Vaccine 1 2
Meningococcal Vaccine 1
Human Papillomavirus Vaccine
1 2 3
Other 1 2 3 4 5
Other 1 2 3 4 5
Other 1 2 3 4 5
* Required vaccine I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child care or preschool prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Minimum requirements are listed in Section III). Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):___/___/____
MCH 213 F revised 4/07 3
Student’s Name: Date of Birth: |____ |_ ___|___ _|
Section II Conditional Enrollment and Exemptions
Certification of Immunization 04/07
MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. DTP/DTaP/Tdap:[ ]; DT/Td:[ ]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[ ]; Rubella:[ ]; Mumps:[ ]; HBV:[ ]; Varicella:[ ] This contraindication is permanent: [ ], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|. Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|
RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).
CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next immunization due on __________________. Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):|___|___|___|
*Minimum Immunization Requirements for Entry into School and Day Care (requirements are subject to change)
3 DTP or DTaP – at least one dose of DTaP or DTP after 4th birthday unless received 6 doses before 4th birthday Tdap – booster required for entry into 6th grade if at least 5 years since last tetanus-containing vaccine 3 Polio – at least one dose after 4th birthday unless received 4 doses of all OPV or all IPV prior to 4th birthday Hib – 2-3 doses in infancy; 1 booster between 12-15 months; 1 dose between 15-60 months if unvaccinated, for children up to
60 months of age only Pneumococcal – 2-4 doses, depending on age at 1st dose for children up to 2 years of age only 2 Measles – 1st dose on/after 12 months of age; 2nd dose prior to entering kindergarten 1 Mumps – on/after 12 months of age 1 Rubella - on/after 12 months of age
Note: Measles, Mumps, Rubella requirements also met with 2 MMR – 1st dose on/after 12 months of age; 2nd dose prior to entering kindergarten
Hep B – 3 doses required (2 doses if Merck adult formulation given between 11 – 15 years of age; check the indicated box in Section I if this formulation was used)
1 Varicella – to susceptible children born on/after January 1, 1997; dose on/after 12 months of age * Additional Immunizations Required at Entry into 6th Grade
Tdap – booster required for entry into 6th grade if at least 5 years since last tetanus-containing vaccine For current requirements consult the Division of Immunization web site at http://www.vdh.virginia.gov/epidemiology/immunization
Section III Requirements
MCH 213 F revised 4/07 4
Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth Student’s Name: _______________________________________________ Date of Birth: _____/_____/__________ Sex: □ M □ F
Date of Assessment: _____/_____/_______
Weight: ________lbs. Height: _______ ft. ______ in.
Body Mass Index (BMI): ___________ BP____________
Age / gender appropriate history completed
Anticipatory guidance provided
TB Risk Assessment: □ No Risk □ Positive/Referred Mantoux results: __________________mm
Physical Examination
1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment
1 2 3 1 2 3 1 2 3
HEENT □ □ □ Neurological □ □ □ Skin □ □ □ Lungs □ □ □ Abdomen □ □ □ Genital □ □ □ Heart □ □ □ Extremities □ □ □ Urinary □ □ □
Hea
lth A
sses
smen
t
EPSDT Screens Required for Head Start – include specific results and date: Blood Lead:___________________________________________ Hct/Hgb ____________________________________________
Assessed for: Assessment Method: Within normal Concern identified: Referred for Evaluation Emotional/Social
Problem Solving
Language/Communication
Fine Motor Skills
Dev
elop
men
tal
Scre
en
Gross Motor Skills
Hea
ring
Sc
reen
Screened at 20dB: Indicate Pass (P) or Refer (R) in each box. 1000 2000 4000
R L
Screened by OAE (Otoacoustic Emissions): □ Pass □ Refer
□ Referred to Audiologist/ENT □ Unable to test – needs rescreen
□ Permanent Hearing Loss Previously identified: ___Left ___Right
□ Hearing aid or other assistive device
Vis
ion
Scre
en
With Corrective Lenses (check if yes) Stereopsis Pass Fail Not tested Distance Both R L Test used: 20/ 20/ 20/ Pass
Referred to eye doctor
Unable to test – needs rescreen
Den
tal
Scre
en
Problem Identified: Referred for treatment
No Problem: Referred for prevention
No Referral: Already receiving dental care
Rec
omm
enda
tions
to (P
re) S
choo
l , C
hild
Car
e, o
r E
arly
Inte
rven
tion
Per
sonn
el
Summary of Findings (check one): □ Well child; no conditions identified of concern to school program activities □ Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): _______________________ _____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
___ Allergy □ food: _____________________ □ insect: _____________________ □ medicine: _____________________ □ other: _________________ Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epi pen □ other: _______________________________
___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)
___ Restricted Activity Specify: _________________________________________________________________________________________________
___ Developmental Evaluation □ Has IEP □ Further evaluation needed for: ___________________________________________________________
___ Medication. Child takes medicine for specific health condition(s). □ Medication must be given and/or available at school.
___ Special Diet Specify: ______________________________________________________________________________________________________
___ Special Needs Specify: ______________________________________________________________________________________________________
Other Comments: _____________________________________________________________________________________________________________
Health Care Professional’s Certification (Write legibly or stamp): Name : _____________________________________ Signature: ________________________________________ Date: ____/_____/______
Practice/Clinic Name: __________________________________________ Address: ____________________________________________________________
Phone: _______-_______-____________________ Fax: _______-_______-_____________________ Email: _________________________________________