Pre-Enrollment SurveyCHARLES COUNTY PUBLIC SCHOOLS (CCPS)

La Plata, MD 20646

Updated May 2017

The purpose of this short questionnaire is to ensure your child is registering for school at the correct location. Please take a few minutes to answer these questions. If you answer yes to any of these questions, you may be redirected to another location to complete your child's school registration.

Date of Birth ______________

CCPS School ________________________________________________________________________________

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

1. Are you entering and/or transferring from a school or location outside the United States?

2. Is the student's native or home language a language other than English?

3. Is the preferred language for parent/guardian communication a language other than English?

4. Has the student previously received ESOL services or been enrolled in an ESOL program?

5. I am not the parent or legal guardian of the student.

6. Is the student currently suspended or expelled from a school?

7. Are you unable to produce two proofs of domicile in your name?

8. Are you currently building or purchasing a home and moving in Charles County prior to theend of the first quarter?

9. Are you living in a domicile outside of Charles County and requesting to enter into atuition contract?

Yes No

10. Is the student entering CCPS from instruction in the home (home schooling)? Yes No

If you answered Yes to any question (1 through 9), please start the student registration process at Jesse L. Starkey School Administration Building at 5980 Radio Station Road, La Plata MD 20646. Phone: 301-934-7326.

If you answered Yes to question 10, please start the student registration process at Robert D. Stethem Education Center at 7775 Marshall Corner Road, Pomfret, MD 20675. Phone: 301-753-1757.

Student Last Name __________________________ Student First Name ____________________________

Welcome to Charles County Public Schools! Enclosed you will find the required forms for enrolling your child in the Charles County Public Schools. You may also find these forms online and complete them using your computer and printer at http://www.ccboe.com/ss/how-to-register/. Bring the completed forms to your child’s local school.

Pre-Enrollment Survey Please complete this survey for ensuring that you are registering your child at the correct location. If you answer yes to any of the questions, please begin the enrollment process at the Jessie L. Starkey Administration Building at 5980 Radio Station Road, La Plata, MD. The phone number is 301-934-7326.

Enrollment Forms: 1. New Student Information2. Emergency Card3. DHMH896 Record of required immunizations4. Record of Physical Examination Part I completed by parents, Part II completed by a certified health professional5. Health Room Card6. Authorization to Request Student Records (for students transferring from another school system)7. Lead testing form for Pre-Kindergarten, Kindergarten and First Grade students only8. Pre-Kindergarten survey for Kindergarten students only

All children entering Charles County Public Schools must have the following: within

1. A physical examination by a physician or a certified practitioner (Physicals must be completed between ninemonths prior to and six months after entering school.)

2. Proof of required immunizations against communicable diseases(A DHMH896 Form showing the required immunizations can be obtained at any school.)

3. Proof that the student has completed the grade prior to the one in which the parent is seeking enrollment,such as a report card marked promoted.

4. Child's birth certificate or other acceptable proof of birth (e.g. passport/visa; physician's certificate; baptismalor church certification; hospital certificate; or birth registration).(If the child was born in Maryland, a copy of his/her birth certificate can be purchased from the Charles CountyHealth Department. Call 301-609-6900.)

5. Two proofs of Domicile (see lists of acceptable and unacceptable proofs on backside)*Note - Any proof of Domicile, bill, or other document must be in its entirety with parent/guardian name and boththe residence/service address as well as the mailing address including city, state, and current date

6. Students who are transferring from another school in Maryland should also have a copy of the StudentRecord Card 7 that is completed by the sending school. The Student Record Card 7 is also called theMaryland Student Withdrawal/Transfer Record

Guardianship All children must attend school in the county where the children's parent(s)/legal guardian(s) reside.

Students Entering from Non-US Schools Students entering from schools outside of the United States must begin the registration process at the Department of Student Services in the Jesse L. Starkey Administration Building, 5980 Radio Station Road, La Plata, MD. Please call 301-934-7334 for an appointment.

Students Entering from Parent Teaching/Home Schooling Students entering from instruction by the parent (home schooling) must begin the enrollment process at the Robert D. Stethem Educational Center. Please call 301-932-1003 for an appointment.

Page 1

Kindergarten To be eligible for kindergarten for the 2017-18 school year, a child must be five years old on or before Sept. 1, 2017. Kindergarten registration for the 2017-2018 school year will begin on Tuesday, April 18, 2017. Contact your home school for specific times and to find out if an appointment is necessary.

Early Entrance into Kindergarten Charles County Public Schools has procedures and guidelines for early entrance into the kindergarten program. Children who will turn five years old between September 2 and October 15, 2017, are eligible to apply. The deadline for current county residents to apply for early entrance to kindergarten for the 2017-18 school year is June 15, 2017. Families who move to Charles County between June 15 and August 1 may obtain an early entrance application by calling the Office of Early Childhood at 301-934-7380 and must provide documentation of the move-in date.

Proofs of DomicileWhen registering their children in the Charles County Public Schools, parents or guardians are required to show two proofs of domicile. One proof must be submitted from each of the below listed categories.

• Deed• Current verifiable lease or rental agreement (with

appropriate signatures and contact information)• Settlement papers (within 45 days and with

appropriate signatures)• Foster care placement letter/McKinney-Vento

documentation• Assignment of Ownership Agreement (for properties

in cooperative homeowner's associations (e.g.,Potomac Heights)

• Most recent property tax bill for domicile or MarylandDepartment of Assessment and Taxation Form

Unacceptable Proofs of Domicile

• Most recent utility bill (within 45 days) that includes nameand service address (examples are electric, water/sewer,trash, oil, gas, cable, security system,and solar bills

• Current verification of service statement for above utilities• Current wage statement (within 45 days) that

includes name, and address of employee and employer• Most recent W2, 1098 or 1099• One of the following issued statements with name

and address (within 45 days):o Documentation of benefits from Social

Security Administrationo Documentation of benefits from the

Department of Social Serviceso Official correspondence on letterhead

mailed from local, state, or federal court

• Driver’s License• Voter Registration• Car Registration• Credit card statement/bill• Cellular or telephone bill• Cable bill• General mail, advertising mail, mail to occupant• Letters or notes from individuals other than a staff

pupil personnel worker or school administrator,whether notarized or not

Note-Parent(s)/guardian(s) are responsible for promptly notifying the school system of any change in address. Failure to do so may result in the student being immediately transferred to the school zoned for the student's correct address and/or incur tuition charges.

Page 2

Category 1Category 2

• Any mail/bills with no resident named and/or address• P.O. Box addresses and no street or road address• Lot numbers and property numbers• Termination of service notices• Deeds, titles, or tax bills to property with no dwelling on

it. The property must be lived on by the party to qualifyas a residence

Acceptable Proofs of Domicile

New Student Information Updated July 2017 CHARLES COUNTY PUBLIC SCHOOLS

La Plata, Maryland 20646

INSTRUCTIONS: This form is to be completed by parent/guardian or eligible student. For all students, new to or reentering CCPS, verification of the following must be presented at the time of enrollment: Charles County domicile, age and immunizations, unless homeless. PRIOR SCHOOL EXPERIENCE Has the student ever been enrolled in a Charles County Public School? Yes No

Last Attended School Name Public Private Home Schooling

School Address ______________________________________ Date of withdrawal Last Grade Completed _______

STUDENT INFORMATION Information provided must match birth certificate or other evidence of birth.

Legal First Name

Suffix Previous Name

Gender Male Female Social Security Number (not required) ## - ## - ####

State City ETHNICITY Check the box that indicates this student's heritage. Is the student Hispanic or Latino? Yes No

RACE DESIGNATION Check the boxes that indicate the student's race. Select at least one race, regardless of ethnicity designation. More than one response can be selected. American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

DOMICILE OF STUDENT AND ENROLLING PARENT/GUARDIAN

Last Name________________________ First Name _________________ Middle _______________ Suffix __________

Mother Father Guardian Caregiver Self Other

City State Zip Code

City State Zip Code

Home Work

Email OTHER PARENT OR GUARDIAN Lives with Student Yes No, if no provide address below

Last Name ________________________ First Name _________________ Middle _______________ Suffix __________

Mother Father Guardian Caregiver Other

City State Zip Code

City State Zip Code

Street Address

Mailing Address

Cell Home _________________________ Work

Employer________________________________________ Email

LANGUAGE OF WRITTEN COMMUNICATION (OF PARENTS/GUARDIANS) Native or primary language spoken at home English Other, specify: ____Preferred parent/guardian communication language English Other, specify: ______________________

__________________

What language(s) are spoken the most in the home? ____________________________________________

(mm/dd/yyyy)

Legal Last Name

Legal Middle Name

Date of Birth (mm/dd/yyyy)

Place of Birth Country

Indicate relationship Must provide official document

Street Address

Mailing Address

Employer

Indicate relationship Must provide official document

Page 3

Cell

Apartment Camper Condominium Duplex Motel Single Family Home Shelter Townhouse Trailer

STUDENT HOME LANGUAGE SURVEY In accordance with federal and state requirements, the Home Language Survey will be administered to all students and used only for determining whether a student needs English language support services and will not be used for immigration matters or reported to immigration authorities. If a language other than English is indicated on two or more of the three questions below, the student will be assessed for English language support services. Additional criteria for testing may be considered. What language(s) did the student first learn to speak? ___________________________________________ What language(s) does the student use most often to communicate? ________________________________

SIBLINGS ATTENDING CHARLES COUNTY PUBLIC SCHOOLS Charles County Public Schools siblings domiciled in household with student

Student Name Gender Grade CCPS School

Charles County Public Schools siblings not domiciled with student Street Address City State Zip Code

Student Name Gender Grade CCPS School

AM TRANSPORTATION (check one) Bus Walker Car Before-Care

PM TRANSPORTATION (check one) Bus Walker Car After-Care

OTHER INFORMATIONThroughout the year photographs, audio, and video may be taken of CCPS students and used or published for educational purposes or to promote school or school system activities, unless consent is withheld. Mark no to withhold consent.

Yes No

Does the student have an IEP? Yes NoDoes the student have a 504 plan? Yes NoHas the student been in an ESOL program? Yes NoIs the student currently suspended from a school? Yes NoIs the student currently expelled from a school? Yes No

PARENT VERIFICATION OF INFORMATION STATEMENT The information submitted on this form and on any attachment is accurate, complete and true to the best of my knowledge. I understand that falsification of any information submitted shall be cause for denial of enrollment. Furthermore, I understand I am responsible for reporting to the school principal any change in domicile or if the student becomes a non-resident of this county and that I am liable for tuition for any periods that the student may be a non-resident, unless homeless. If student has an IEP I understand that an IEP team must determine student’s placement.

_ _ Signature, Parent/Legal Guardian or Eligible Student Today's date (mm/dd/yyyy)

INFORMATION IN THIS SECTION WILL BE COMPLETED BY CCPS STAFF Staff name verifying documents Enrolling School . Enrollment Date: ___/___/______ Entry Code _______ CCPS ID# ___________ SR7 (if MD public school student)Proof of Age Proof of age requires a copy of the following: Birth Certificate Passport/Visa Physician's Certificate Baptismal or Church Certificate Hospital Certificate Parent's Affidavit Birth Registration Other ____________________________

Proof of Domicile Proof of domicile requires a copy of two of the following (1 from each category): 1.Deed 1.Lease 1.Mortgage statement 1.Property title record or tax bill 1.Settlement document w/ signature 1.Foster Care 1.Ownership Agreement 2.W2,1098,etc. 2.Government Issued Document PPW Statement 2.Current wage statement 2.Service provider statement 2.Entire utility bill (<45 days)

days)________________________Proof of Immunizations Proof of immunization compliance requires a copy of one of the following: Maryland Department of Health and Mental Hygiene Immunization Certificate 896 Computer-generated printout from doctor’s office Other

Special Circumstances (if applicable) Out-of-Boundary Enrollment, Reason: IEP School Change Request Administrative Placement Displaced (complete CCPS McKinney-Vento application, notify Youth in Transition Coordinator and school PPW) Foster Care (complete CCPS Foster Care Enrollment Form, notify Foster Care Coordinator) Tuition (out-of-county resident) Migrant Kinship Care Custody Documents

International Registration (if applicable, completed by International Registration Office) For the purposes of determining eligibility for support services and/or exemption from certain tests, please provide the following information if the student was born outside the U.S.

Is the student an asylee? Yes No

Date entered a U.S. School for the first time ___/___/_____ Date entered the U.S. for the first time __/___/__ ___ Is the student a refugee? Yes No ( mm/dd/yyyy) (mm/dd/yyyy)

Page 4

EMERGENCY INFORMATION CARD Updated 30 MAY 2017

CHARLES COUNTY PUBLIC SCHOOLS La Plata, Maryland 20646 School Year _____________

INSTRUCTIONS: This form is to be completed by parent/guardian or eligible student STUDENT Last Name ___________________________________ First Name _______________________________ Middle Initial ____ Homeroom ___________________________________ Grade ______ Student Birth Date _____________ Bus # _____

PARENT/GUARDIAN

Is English the primary language spoken at home Yes No If no, list primary language __________________________

Mother/Guardian’s Name ________________________________ Cell phone __________________ Street Address _______________________________________ City______________________ State ____ Zip Code ____

Mailing Address ______________________________________ City_______________________ State ____ Zip Code ____(i f different from street address )

Email Address _________________________________________ Home phone _____________________________

Employer ____________________________________________ Work phone _____________________________

Father/Guardian’s Name ________________________________ Cell phone __________________ Street Address _______________________________________ City______________________ State ____ Zip Code ___

(i f different from above address )Mailing Address ______________________________________ City_______________________ State ____ Zip Code ___

(i f different from above address)

Email address _________________________________________ Home phone _____________________________

Employer ____________________________________________ Work phone _____________________________ SIBLINGS LIVING IN THE SAME HOUSEHOLD ATTENDING CHARLES COUNTY PUBLIC SCHOOLS Student Name Birth date Grade CCPS School

Please list below two emergency contacts that have permission to assume temporary care of your child if the above parent/guardian(s) cannot be reached. Listing an emergency contact does not allow the individual to pick up a student at any given time in a non-emergency situation without prior written authorization from the parent/guardian. Name Relationship Home Phone Work Phone Cell Phone

PARENT VERIFICATION OF INFORMATION STATEMENT The student will not be released to any individual except the primary caregiver or individual(s) identified above.

I understand that, by providing the phone numbers above, I am consenting to receiving direct and automated phone calls at these numbers from the school system with emergency and other information related to the school setting. In case of an accident or serious illness, I request the school to contact me. If the school is unable to reach me in a timely manner, I hereby authorize the school system to arrange transportation to and treatment of my child at the emergency room of the nearest hospital, or a facility where medical treatment is available. I agree that it is my obligation to notify the school if I have any changes to the information on this form.

Throughout the year, photographs, audio and video may be taken of CCPS students and used or published for educational purposes or to promote school or school system activities, unless consent is withheld. To withhold consent, the parent or guardian must contact the school in writing.

_____________________________________ ___/___/______ Signature, Parent/Legal Guardian or Eligible Student Today's date Page 5

Charles County Public Schools La Plata, MD

Release of Student Information

Date: __________________

TO: Guidance Office/ Registrar FROM:

___________________________________

___________________________________

___________________________________

This to request the records for:

_______________________________________________ ____ __________ Name of Student (first, middle, last) Grade Date of Birth

who entered _____________________________________ on _____________. School Name Date of Entry

This parent has full knowledge that such records are being requested and hereby grants authority to release them. Parental permission is no longer required when records are requested by authorized school personnel. (Family Educational Rights and Privacy Act, Final Rule on Education Records, Federal Register, June 17, 1976, Vol. 41, No. 118, Page 24673.)

_________________________________________ __________________________ Signature of Parent/Guardian Date The following information is needed to determine correct placement:

• Official School Records (send originals if Maryland Public School) to include attendance,date of withdrawal, exact titles of subjects taken, grades and/or credits earned to date, key tograding system if letter grades are not used, copy of current report card.

• Special Educational Records, including current IEP• ESOL ACCESS SCORES both Literacy and Composite• Health/Medical Records• Legal Records• Record of individual or group testing• Psychological and Educational information• 504/SST Records• Discipline Records• Other (please specify) ________________________________________________________Sincerely, Guidance Office ____________________________________

School Name

Signature & Title ______________________________________________________________

First Request: ____________

Second Request ____________

Third Request: ____________

School staff place address sticker here

HEALTH ROOM EMERGENCY INFORMATION Updated 16 MAY 2017

CHARLES COUNTY PUBLIC SCHOOLS La Plata, Maryland 20646

INSTRUCTIONS: This form is to be completed by parent/guardian or eligible student. For all students, new to or reentering CCPS. This form will be kept in the Health Room of the school and treated confidentially. STUDENT

Last Name ___________________________________ First Name _______________________________ Middle Initial ____

Street Address _______________________________________ City______________________ State ____ Zip Code ___

Date of Birth / / Sex Male Female Age ____

Child’s Physician’s Name______________________________ Physician’s Phone ___________________ SCHOOL Grade _____ Homeroom ________________________________________ Bus # _____

PARENT/GUARDIAN Is English the primary language spoken at home Yes No If no, list primary language __________________________

Mother/Guardian’s Name ________________________________ Employer ____________________________________

Cell: _____________________ Home _____________________ Work __________________________

Father/Guardian’s Name ________________________________ Employer ____________________________________

Cell: _____________________ Home ______________________ Work __________________________ SIBLINGS ATTENDING CHARLES COUNTY PUBLIC SCHOOLS Student Name Grade CCPS School

List at least three neighbors or nearby relatives with transportation who have your permission to assume temporary care of your child IF YOU CANNOT BE REACHED or YOU ARE UNAVAILABLE TO PICK UP YOUR CHILD WITHIN 30 MINUTES OF NOTIFICATION.

HEALTH INFORMATION (Note: THE SCHOOL HEALTH PROGRAM TREATS THIS INFORMATION CONFIDENTIALLY) Drug Allergy(s) Medication(s) taken at Home Medication(s) taken at School

Please make sure you list and discuss the following conditions and reactions with your child’s school Nurse Food Allergies with reaction Insect Allergies with reaction

Check all health conditions that apply to your child ADHD Diabetes Orthopedic Condition Other _________________________________ Asthma Heart Condition Seizure Disorder Other _________________________________ Anaphylaxis Mental Health Condition Other Chronic Condition ___________________________________________

PARENT VERIFICATION OF INFORMATION STATEMENT In case of an accident or serious illness, I request the school contact me. I hereby authorize the school to arrange transportation to and treatment of my child at the emergency room of the nearest hospital, or if outside of the county, to the nearest appropriate facility where medical treatment is available.

_____________________________________ __/__/____ Signature, Parent/Legal Guardian or Eligible Student Today's date

Name Relationship Home Number Work Number Cell Number

Health Page 1

MARYLAND SCHOOLS RECORD OF PHYSICAL EXAMINATION

To Parents or Guardians:

In order for your child to enter a Maryland public school for the first time, the following are required:

• A physical examination by a physician or certified nurse practitioner must be completed within nine monthsprior to entering the public school system or within six months after entering the system. A physicalexamination form designated by the Maryland State Department of Education and the Department of Health andMental Hygiene must be used to meet this requirement.

• Evidence of complete primary immunizations against certain childhood communicable diseases is requiredfor all students in preschool through the twelfth grade. A Maryland Immunization Certification form for newlyenrolling students may be obtained from the local Department of Health and Human Services or from schoolpersonnel. The form and the required immunizations must be completed before a child may attend school. (FormDHMH 896).

• Evidence of blood testing is required for all students who reside in a designated at risk area when firstentering Pre-kindergarten, Kindergarten, and 1st grade. The blood-lead testing certificate (DHMH 4620) (oranother written document signed by a Health Care Practitioner) shall be used to meet this requirement.

Exemptions from a physical examination and immunizations are permitted if they are contrary to a student’s or family's religious beliefs. Students may also be exempted from immunization requirements if a physician/nurse practitioner or health department official certifies that there is a medical reason not to receive a vaccine. Exemptions from Blood-Lead testing is permitted if it is contrary to a family’s religious beliefs and practices. The Blood-Lead certificate must be signed by a Health Care Practitioner stating a questionnaire was done.

The health information on this form will be available only to those health and education personnel who have a legitimate educational interest in your child.

In order to assist your child in gaining the most from their educational experience, please complete Part I of this Physical Examination form. Part II must be completed by a physician or nurse practitioner, or attach a copy of your child’s physical examination to this form. If your child requires medication and or a treatment to be administered in school, you must have the physician complete a medication and or treatment administration form for each medication and or treatment to be administered.

These forms can be obtained from your child’s school or online from the Charles County Public Schools (CCPS) website: Authorization to Provide Medically Prescribed Treatment, Release and Indemnification Agreement, Authorization to Administer Prescribed Medication, Release and Indemnification Agreement, , Emergency Care for the Management of a Student with a Diagnosis of Anaphylaxis, Release and Indemnification Agreement for Epinephrine Auto Injector. If you do not have access to a physician or nurse practitioner or if your child requires a special individualized health procedure, please contact the principal and/or nurse in your child’s school.

Please complete this Physical Examination form and return it to your child’s school as quickly as possible.

Student Health FormMaryland State Department of Education

Maryland State Department of Health

CHARLES COUNTY PUBLIC SCHOOLS (CCPS) La Plata, Maryland

Student Health Form updated January 2017

Health Page 2

PART 1 HEALTH ASSESSMENT

To be completed by parent/guardian CCPS ID#

Student's Name (Last, First, Middle) Birthdate Name of School Grade

Address (Number, Street, City, State, Zip) Phone No.

Parent/Guardian Names

Phone No.Address:

When was the last time your child had a physical exam? Month Year

When was the last time your child had a dental exam? Month YearPhone No.Where do you usually take your child for dental care?

Name: Address:

ASSESSMENT OF STUDENT HEALTHTo the best of your knowledge, has your child had any problem with the following? Please check

Yes No CommentsAnaphylaxisAllergies (Food, Insects, Drugs, Latex)Allergies (Seasonal)Asthma or Breathing Problems

Behavior or Emotional ProblemsBirth DefectsBleeding ProblemsCerebral PalsyDentalDiabetesEar Problem or DeafnessEye or Vision ProblemsHead Injury/ConcussionHeart ProblemsHospitalization (When, Where, Why)Lead Poisoning/ExposureLearning problems/disabilitiesLimits on Physical ActivityMeningitisPrematurityProblem with BladderProblem with BowelsProblem with CoughingSeizuresSerious Allergic ReactionsSickle Cell DiseaseSpeech ProblemsSurgeryOtherDoes your child take any medication? □ No □ YesName(s) of Medications: ___________________________________________________________________________ Will your child require any medication to be administered in school? □ No □ YesName(s) of Medications:_______________________________________________________________________ Will your child require any emergency medications (epinephrine auto-injectors, inhalers, glucagon, Diastat, nebulized medication) to be administered in school? □ No □ Yes, please list ________________________________________

Will your child require any special treatments (G-tube feedings, catheterizations, etc.) to be administered in school? □ No □ Yes

Parent/Guardian Signature:______________________________________ Date __________________

Where do you usually take your child for routine medical care? Name:

Health Page 3

PART II SCHOOL HEALTH ASSESSMENT

PAGES 4 AND 5 TO BE COMPLETED ONLY BY PHYSICIAN OR NURSE PRACTIONERCCPS ID#

Student's Name (Last, First, Middle) Birthdate(Mo/Day/Yr)

Name of School Grade

1. Does the child have a diagnosed medical condition? □ No □ YesSpecify ____________________________________________________________________________________________________________________________________________________________________________________________2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is at school? (e.g.,seizure, severe allergic reaction anaphylaxis to food or insect sting, asthma, bleeding problem, diabetes, heart problem,or other problem) If yes, please DESCRIBE. Additionally, please “work with the school nurse to develop an emergencyplan”. No Yes, Specify:______________________________________________________________________________________________________________________________________________________________3. Are there any abnormal findings on evaluation for concern? N Yes, Specify:__________________________

_____________________________________________________________________________________________

EVALUATION FINDINGS/CONCERNS

PHYSICAL EXAM WNL ABNL Area of Concern HEALTH AREA OF CONCERN Concern Yes No

Head Attention Deficit/HyperactivityEyes Behavior/AdjustmentENT DevelopmentDental HearingRespiratory ImmunodeficiencyCardiac Lead Exposure/Elevated LeadGI Learning Disabilities/ProblemsGU MobilityMusculoskeletal/Orthopedic NutritionNeurological Physical Illness/ImpairmentSkin PsychosocialEndocrine Speech/LanguagePsychosocial Vision

OtherREMARKS: (Please explain any abnormal findings/health concerns.)

4. RECORD OF IMMUNIZATIONS: DHMH 896 is required to be completed and attached by a health care provideror a computer generated immunization.5. Is the child on medication? If yes, indicate medication and diagnosis. No Yes_______________________________________________________________________________________________________ CCPS Authorization to Administer Prescribed Medication Form, Release and Indemnification Agreement, must be completed for medication administration in school.6. Should there be any restriction of physical activity in school? If yes, specify nature and duration of restriction. No Yes__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________7. Screenings Tuberculin Test Results Date Taken

Blood Pressure

Height

Weight

BMI %tile

Lead Test DHMH 4620OptionalHealth Page 4

PART II SCHOOL HEALTH ASSESSMENT (continued)To be completed ONLY by Physician/Nurse Practitioner

(Student Name) _________________________________________ has had a complete physical examination and has:

□ No evident problem that may affect learning or full school participation □ Problems noted above

Additional Comments:

Physician/Nurse Practitioner (Type or Print) Phone No. Physician/Nurse Practitioner Signature Date

Health Page 5

DHMH Form 896 Center for Immunization Rev. 2/14 www.dhmh.maryland.gov

How To Use This Form The medical provider that gave the vaccinations may record the dates (using month/day/year) directly on this form (check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be listed individually, by each component of the vaccine. A different medical provider, local health department official, school official, or child care provider may transcribe onto this form and certify vaccination dates from any other record which has the authentication of a medical provider, health department, school, or child care service.

Only a medical provider, local health department official, school official, or child care provider may sign ‘Record of Immunization’ section of this form. This form may not be altered, changed, or modified in any way.

Notes:

1. When immunization records have been lost or destroyed, vaccination dates may be reconstructed for all vaccinesexcept varicella, measles, mumps, or rubella.

2. Reconstructed dates for all vaccines must be reviewed and approved by a medical provider or local healthdepartment no later than 20 calendar days following the date the student was temporarily admitted or retained.

3. Blood test results are NOT acceptable evidence of immunity against diphtheria, tetanus, or pertussis(DTP/DTaP/Tdap/DT/Td).

4. Blood test verification of immunity is acceptable in lieu of polio, measles, mumps, rubella, hepatitis B, orvaricella vaccination dates, but revaccination may be more expedient.

5. History of disease is NOT acceptable in lieu of any of the required immunizations, except varicella.

Immunization Requirements The following excerpt from the DHMH Code of Maryland Regulations (COMAR) 10.06.04.03 applies to schools:

“A preschool or school principal or other person in charge of a preschool or school, public or private, may not knowingly admit a student to or retain a student in a: (1) Preschool program unless the student's parent or guardian has furnished evidence of age appropriate immunity

against Haemophilus influenzae, type b, and pneumococcal disease;(2) Preschool program or kindergarten through the second grade of school unless the student's parent or guardian has

furnished evidence of age-appropriate immunity against pertussis; and(3) Preschool program or kindergarten through the 12th grade unless the student's parent or guardian has furnished

evidence of age-appropriate immunity against: (a) Tetanus; (b) Diphtheria; (c) Poliomyelitis; (d) Measles (rubeola);(e) Mumps; (f) Rubella; (g) Hepatitis B; (h) Varicella; (i) Meningitis; and (j) Tetanus-diphtheria-acellular pertussisacquired through a Tetanus-diphtheria-acellular pertussis (Tdap) vaccine.”

Please refer to the “Minimum Vaccine Requirements for Children Enrolled in Pre-school Programs and in Schools” to determine age-appropriate immunity for preschool through grade 12 enrollees. The minimum vaccine requirements and DHMH COMAR 10.06.04.03 are available at www.dhmh.maryland.gov. (Choose Immunization in the A-Z Index)

Age-appropriate immunization requirements for licensed childcare centers and family day care homes are based on the Department of Human Resources COMAR 13A.15.03.02 and COMAR 13A.16.03.04 G & H and the “Age-Appropriate Immunizations Requirements for Children Enrolled in Child Care Programs” guideline chart are available at www.dhmh.maryland.gov. (Choose Immunization in the A-Z Index)

Health Page 6

DHMH Form 896 Center for Immunization Rev. 2/14 www.dhmh.maryland.gov

MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE

CHILD'S NAME__________________________________________________________________________________________ LAST FIRST MI

SEX: MALE □ FEMALE □ BIRTHDATE___________/_________/________

COUNTY _________________________________ SCHOOL_______________________________________ GRADE_______

PARENT NAME ______________________________________________ PHONE NO. _____________________________ OR GUARDIAN ADDRESS ____________________________________________ CITY ______________________ ZIP________

To the best of my knowledge, the vaccines listed above were administered as indicated. Clinic / Office Name Office Address/ Phone Number

1. _____________________________________________________________________________Signature Title Date

(Medical provider, local health department official, school official, or child care provider only) 2. _____________________________________________________________________________ Signature Title Date 3. _____________________________________________________________________________ Signature Title Date

Lines 2 and 3 are for certification of vaccines given after the initial signature.

RECORD OF IMMUNIZATIONS (See Notes On Other Side) Vaccines Type

Dose # DTP-DTaP-DT Mo/Day/Yr

Polio Mo/Day/Yr

Hib Mo/Day/Yr

Hep B Mo/Day/Yr

PCV Mo/Day/Yr

Rotavirus Mo/Day/Yr

MCV Mo/Day/Yr

HPV Mo/Day/Yr

Dose #

Hep A Mo/Day/Yr

MMR Mo/Day/Yr

Varicella Mo/Day/Yr

History of Varicella Disease

1 1 Mo/Yr

2 2

3 Td Mo/Day/Yr

____________

Tdap Mo/Day/Yr

________

FLU Mo/Day/Yr

________

Other Mo/Day/Yr

__________

4

5

COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM VACCINATION ON MEDICAL OR RELIGIOUS GROUNDS. ANY VACCINATION(S) THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE. MEDICAL CONTRAINDICATION:

Please check the appropriate box to describe the medical contraindication.

This is a: □ Permanent condition □ Temporary condition until _______/________/________

The above child has a valid medical contraindication to being vaccinated at this time. Please indicate which vaccine(s) and the reason for the

contraindication,

Signed: _____________________________________________________________________ Date _______________________ Medical Provider / LHD Official

RELIGIOUS OBJECTION: I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any vaccine(s) being given to my child. This exemption does not apply during an emergency or epidemic of disease.

Signed: _____________________________________________________________________ Date: _______________________

Date OR

Health Page 7

CHARLES COUNTY