STUDENT SERVICES

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WELCOME TO GLOUCESTER COUNTY PUBLIC SCHOOLS
Student Registration Form
School's Name:_____B_e_t_h_el__E_le_m__e_n_ta_r_y_________________

FOR OFFICE USE ONLY Student ID#________________________________ Entry Date:________________________________ YOG:____________________________________ Entry Code:______PK Code_______ PK Time____ Homeroom #:______________________________ Counselor/Teacher__________________________ Team:____________________________________ Bus #:____________________________________

PLEASE PRINT ALL INFORMATION
Are you a resident of Gloucester County?  Yes  No Items accepted as proof of residency: lease/deed and current utility bill Has your student ever attended a Gloucester County Public School?  Yes  No If yes, which school did your child attend?  Abingdon  Achilles  Bethel  Botetourt  Petsworth  T. C. Walker  Page Middle  Peasley Middle  High School

Student's Legal Name:_____________________________________________________________________________________

LAST

FIRST

MIDDLE

NICKNAME

Gender:  Male  Female  Non-Binary Student's Ethnicity: SEE ATTACHED FORM

Student's Birth Date:____/____/____ Place of Birth:______________________ Birth Certificate #____________________

Student's Grade Level:__________ If kindergarten, did your child have any pre-kindergarten education?  Yes  No If yes, please provide brief description (i.e., licensed daycare provider, head start)______________________________________

What is the primary language used in the home, regardless of the language spoken by the student? ___________________ What is the language most often spoken by the student? _______________________________________________________ What is the language that the student first acquired? _________________________________________________________ Student's Mailing Address:_________________________________________________________________________________

Student's 911 Address-required: ____________________________________________________________________________

(if different than mailing):

Number

Street Name

City

Zip Code

Student's Home Phone Number: ______________________

Does your child currently receive special services?  YES  NO If yes, please check all that apply:  Speech  Special Education  504  Gifted  ESL  Occupational Therapy/Physical Therapy  Other____________
Is the student connected to the military?  Yes  No If yes, please check the appropriate box listed below:
 Active Duty ­ the student is a dependent of a member of the active duty forces (full time) (Army, Air Force, Coast Guard, Marine Corps, Navy)
 National Guard or Reserves ­ the student is a dependent of a member of the National Guard or Reserve Forces (Army, Air Force, Coast Guard, Marine Corps, Navy)

Student Resides With:  Mother & Father  Mother only  Father only  Grandparents  Foster Parent(s)  Mother & Stepfather  Father & Stepmother  Guardian/Custodian  Other___________

Name:__________________________________________________ Name:__________________________________________________

Address (if different from student):__________________________ ________________________________________________________ Place of Employment:_____________________________________ Work Phone #:___________________________________________ Cell Phone #:____________________________________________ Email address:___________________________________________

Address (if different from student):_________________________ _______________________________________________________ Place of Employment:____________________________________ Work Phone #:__________________________________________ Cell Phone #:___________________________________________ Email address:__________________________________________

If the student is NOT residing with BOTH biological/adoptive parents, please list other parent's information (i.e., name, address, etc.)

EMERGENCY CONTACT INFORMATON OTHER THAN PARENT
(Our schools attempt to contact the parent/guardian first ­ the following information is for OTHER than parent/guardian) Contact Person 1:_______________________________________ Phone #:_______________ Relationship to Student:__________________
Contact Person 2:_______________________________________ Phone #:_______________ Relationship to Student:__________________
Contact Person 3:_______________________________________ Phone #:_______________ Relationship to Student:__________________

Student Services Form - Revised 08/22/2018

Name of Student:_________________________________________________________________________________________________________________
STUDENT REGISTRATION FORM (continued)
New Federal legislation, the No Child Left Behind Act, requires that all school divisions report student information regarding the areas listed below. Please read each statement, or have the registrar read the statements for you, and answer each question as requested.
Your child is considered to be Neglected/Delinquent if one of the following is true:
In order to be eligible to be counted as neglected/delinquent, a child age 5 through 17 must live in an "institution for neglected children and youth," which means a public or private residential facility, other than a foster home, that is operated primarily for the care of children and youth who (a) have been committed to the institution or voluntarily placed in the institution under applicable State law due to abandonment, neglect, or death of their parents or guardians; and (b) have had an average length of stay in the institution of at least 30 days; OR Must live in an "institution for delinquent children and youth," which means a public or private residential facility that is operated for the care of children and youth who (a) have been adjudicated to be delinquent or in need of supervision and (b) have had an average length of stay in the institution of at least 30 days.
Is your child Neglected/Delinquent? Yes_____ No_____
Your child is considered to be Homeless if one of the following is true:
1) Shares the housing of others due to loss of housing, economic hardship or similar reason; 2) Lives in motels, hotels, trailer parks or camping grounds due to lack of alternative adequate accommodations; 3) Lives in emergency or transitional shelters; 4) Abandoned in hospitals; 5) Awaits foster care placement; 6) Has a primary residence that is a public place or a place not designed for or ordinarily used as regular
accommodation; 7) Lives in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations or similar
settings.
Is your child Homeless? Yes_____ No_____ If yes, which item above applies to your situation?_____
Your child is considered to be a Migratory Child if one of the following is true:
The term "migratory child" means a child who is, or whose parent or spouse is, a migratory agricultural worker, including a migratory dairy worker, or a migratory fisher, and who, in the preceding 36 months, in order to obtain, or accompany such parent or spouse, in order to obtain temporary or season employment in agricultural or fishing work: (a) has moved from one school district to another; (b) in a State that is comprised of a single school district, has moved from one administrative area to another within
such district; or (c) resides in a school district of more than 15,000 square miles, and migrates a distance of 20 miles or more to a
temporary residence to engage in a fishing activity.
Is your child a Migratory Child? Yes______ No______
1

Name of Student:_______________________________________________________________________________________
Your child is considered to be a refugee if the following is true:
An individual who is outside his/her country and is unable or unwilling to return to that country because of a wellfounded fear that she/he will be persecuted because of race, religion, nationality, political opinion, or membership in a particular social group. This does not include persons displaced by natural disasters or persons who, although displaced, have not crossed an international border or persons commonly known as "economic migrants," whose primary reason for flight has been a desire for personal betterment rather than persecution.
Is your child a Refugee? Yes_____ No_____

Your child is considered to be an Immigrant if ALL of the following are true:
The term "immigrant children and youth" means individuals who: (a) are aged 3 through 21; (b) were not born in any State; and (c) have not been attending one or more schools in any one or more States for more than 3 full academic years.
Is your child an Immigrant? Yes_____ No_____

I have willfully and knowingly provided you with the correct information. I will provide you any new information concerning my child as it occurs.

__________________________________________________ Parent/Legal Guardian Signature

___________________________________ Date

No student can be prevented from participation in any program solely because of his/her race, color, national origin,

gender, age, religion, or disability. A procedure for resolving complaints alleging discrimination on the basis of race,

color, national origin, gender, age religion, or disability may be found in the manual for Policies and Regulations of the

Gloucester County Public Schools. The Section 504 and Title IX Coordinator for the Gloucester County Public Schools

is: Mr. Bryan Hartley, Coordinator ­ Section 504 and Title IX ­ Gloucester County Public Schools ­ 6099 T. C. Walker

Road ­ Gloucester, VA 23061 ­ (804) 693-7856.

Last updated 7-9-14

2

GLOUCESTER COUNTY PUBLIC SCHOOLS Bethel Elementary School
2991 Hickory Fork Road Gloucester VA 23061 Eileen Kersmarki, Principal Phone: 804-693-2360 Fax: 804-693-0403

Last School Attended: Name: _______________________________________________________________

Mailing address:________________________________________________________

_________________________________________________________

Phone #:________________________

Fax#:____________________________

Name of Student:______________________________ Date of Birth:________________ Grade:________
By signing below I authorize the release of all scholastic records to include the following:  Health, including immunization record  Discipline  Special Education  504  Gifted  Virginia SOL scores  Virginia State Testing ID Number  any other pertinent records
to Gloucester County Public Schools. I have willfully and knowingly provided the correct information. I will provide Gloucester County Public Schools any new information concerning my child as it occurs.

Before enrolling your child in Gloucester County Public Schools, you must provide the following:
_____Proof of Residency (notarized lease or deed or mortgage statement AND current utility bill)
_____Original Birth Certificate _____Updated Immunization Record _____Physical Exam Report _____Transcript From Former School -can be unofficial (HIGH SCHOOL ONLY) _____IEP and/or 504 (if applicable) _____Legal Papers Referencing Student (if applicable)

__________________________________________________________ Parent/Legal Guardian Signature

_______________________________ Date

No student can be prevented from participation in any program solely because of his/her race, color, national origin, sex, age, religion or disability. A procedure for resolving complaints alleging discrimination on the basis of race, color, national origin, gender, age, religion, or disability may be found in the manual for Policies and Regulations of the Gloucester County Public Schools. The Section 504 and Title IX Coordinator for the Gloucester County Public Schools is Mr. Bryan Hartley, Section 504 and Title IX Coordinator - Gloucester County Public Schools - 6099 T.C. Walker Road ­ Gloucester, VA 23061 ­ (804) 693-7856.
Student Services Form - Revised 03/16/16

Gloucester County Public Schools
Bethel Elementary School Federal Ethnicity and Race

(Please Print)

Student Name: ________________________________________ Grade Level:_____

Last

First

Middle

Ethnicity: Is the student Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race?
 Yes
 No
Race: What is the student's race? Please select all that apply.
 American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.
 Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
 Black or African American: A person having origins in any of the Black racial groups of Africa.
 White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
 Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

____________________________________

Parent/Guardian Signature

DATE

INTERNET & DEVICE ACCESS
FOR REMOTE LEARNING
Student's Name:______________________________________________
School:  Abingdon Elementary  Achilles Elementary  Bethel Elementary  Botetourt Elementary  Petsworth Elementary
 Page Middle  Peasley Middle  Gloucester High School
Internet access for remote learning:
 Internet access at home allows for live streaming, classroom instruction, real time interaction with teachers and classmates
 Internet access at home is available but too slow for live streaming or real time interaction  Public connection NOT at home (coffee shop, fast food restaurant, recreation center, etc.)  Other  No internet connection available
Device access for remote learning:
 School provided (desktop, laptop, Chromebook, tablet)  Personal (desktop, laptop, Chromebook, tablet)  Shared with family members (desktop, laptop, Chromebook, tablet)  Smartphone only  Any public device (i.e, at public library, coffee shop, recreation center, etc.)  No device access
------------------------------------------------------------------------------------------------------------------------------FOR OFFICE USE ONLY
 Hybrid
 Full-Time Virtual

Gloucester County Public Schools Home Language Survey

(Please Print)

Student Name: ________________________________________

Last

First

Middle

Date of Birth ___________ (Ex., 04/20/2002 or MM/DD/YYYY)

1. What is the primary or main language used in the home by parents/guardians, regardless of language spoken by the

student? ______________________________

2. What language is most often spoken by the student? ________________________

3. What is the first language the student learned to speak?

_______________________________________________________

4. Does the student currently speak or understand a language other than English?

_____ Yes

_____ No

If yes, which language(s)? _______________________________________________

5. In which language would the family prefer to receive information? _____________________________

6. Where was the student born? (select one)

 United States (Go to #7)

 Other Country (Print the Name of the Country): ____________________________ (Please answer #6: A-E)

A. Last grade or level completed in country of birth _________________________ B. Date of Entry to United States __________________________ C. Date student entered Virginia schools ____________________ D. Circle all grades completed in United States schools:

None PK K 1 2 3 4 5 6 7 8 9 10 11 12

E. If applicable, student is:  Immigrant  Migrant

 Refugee

7. Has the student ever received ELL (English Language Learners) or ESOL (English Speakers of Other Languages)

services?

 Yes  No  Not sure

If yes, please provide dates and locations:

Dates

School District/State

School maintains original form in the student's cumulative file. A copy is sent to the ELL teacher. Revised 11/25/19
Under provisions of the Civil Rights Act of 1964, each student's dominant language must be identified. This information is essential for schools to provide meaningful instruction. Your cooperation in meeting this requirement is appreciated. Please answer the questions accurately and completely.

GLOUCESTER COUNTY PUBLIC SCHOOLS
6099 T. C. Walker Road Gloucester, VA 23061
804-693-5300
AFFIRMATION STATEMENT
Virginia law requires that, prior to admission to any public school of the Commonwealth, a school board shall require the parent, guardian, or other person having control or charge of a child of school age to provide, upon registration, a sworn statement or affirmation indicating whether the student has been expelled from school attendance at a private school or in a public school division of the Commonwealth or in another state for an offense in violation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury to another person. Any person making a materially false statement or affirmation shall be guilty upon conviction of a Class 3 misdemeanor. The registration document shall be maintained as part of the student's scholastic record. (Code of Virginia 22.1-3.2)
PLEASE COMPLETE AND SIGN THE APPLICABLE STATEMENT BELOW
I, _____________________________________, affirm that ____________________________ has not been expelled from school attendance at a private school or public school in Virginia or another state for an offense in violation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury to another person.
________________________________________________ Parent, guardian, or person having control or charge of child
________________________________________________ Date

I, _____________________________________, affirm that ____________________________ has been expelled from school attendance at a private school or public school in Virginia or another state for an offense in violation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury to another person.

________________________________________________ Parent, guardian, or person having control or charge of child

SS-93 (6/30/2014)

________________________________________________ Date

Gloucester County Public Schools Broadcast Contacts

Student Name:_____________________________________ School:_________________________________

Parent/Guardian:___________________________________________________________________________

Gloucester County Public Schools use a broadcast system to communicate with students and parents for various reasons. While attendance, lunch charges and emergencies are its primary purpose, broadcasts can have other uses. A broadcast can be used to communicate academic reminders such as upcoming standardized testing, requests for parent volunteers, special events like open houses, or even holiday reminders.

The contact information below will be used for broadcast messages. Phones 1, 2, and 3 will be used during an emergency broadcast. The 4th phone number is provided as an additional primary number for all broadcasts. Its intended use is for parent/guardian contacts not residing with the student. The other contact information you provide is optional, like SMS (cell phone text messages) or emails.

Phone numbers cannot have an extension. You must include the area code.

Primary Numbers:

Emergency Numbers:

Phone 1: __________________ Phone 4: __________________

Phone 2: __________________ Phone 3: __________________

Optional:
SMS 1: __________________

SMS 2: __________________

Email 1: _________________________________

Email 2: ________________________________

New Student School Bus Registration Form

Date:

School: 381

BETHEL

Grade: K 1 2 3 4 5
circle one

Student ID#:

Date of Birth:

Student Name:

Ethnic Code: 0 1 2 3 4 5 6
circle one

Will the student be riding the bus?

Yes

No

If the student will be going to a baby sitter, complete the Dual Ridership Form.

Parent Name:

Telephone #:

911 Address:
Mailing Address:
If different from 911 address Shaded area indicate required data.

GLOUCESTER COUNTY PUBLIC SCHOOL
Student Health History Form

School Year 20____ - 20___ Teacher:_______________

___________________________/__________________________/_______________

STUDENT Name: Last

First

Middle Initial

DOB: ___/____/_____

Does your child have 504? Yes / No

IEP? Yes / No

Grade:_______

1. Check if your child has history of OR is currently experiencing any of the following; explain (?) answers in #2 below:

? Allergy to food(s)

? Concussion/head injury (Mo/Year)

Juvenile Rheumatoid Arthritis

?Allergy to medication(s)

Cystic Fibrosis

Migraines (diagnosed by MD)

? Environment/stinging insect allergy

Dental Problems / Braces

? Muscle/Back injury

ADD/ADHD (circle)

Diabetes

? Chronic Pain

Anxiety / Depression (circle)

? Eating Disorder (what type)

Scoliosis

? Asthma that is treated with inhaler

Eczema/Chronic Skin Condition

Seizure Disorder/Epilepsy/Tics

Autism Spectrum

? Emotional/Mental Health (what)

Sickle Cell Disease

? Bladder/Kidney disease

? Endocrine Disorder (what)

? Sleep problems

? Bleeding/Clotting Disorder

? Fainting/Blacking out (frequency)

Smoker

Broken bones/Dislocations

Frequent Headaches

? Stomach/Bowel problems

? Cancer (type/location if applicable)

Hearing/Speech/Vision Problems (circle)

? Surgery (type)

Celiac Disease

? Heart Condition

? Weight concerns

Cerebral Palsy

High/Low Blood Pressure

? Other Illness/Injury

Chronic diarrhea/constipation (circle)

? Impaired Mobility/ Device (what)

*NOTE: An Emergency Action Plan is required for a student who has Diabetes, Asthma treated with inhaler (including

exercise-induced asthma), Seizures and/or Life-threatening Allergies that require an Epi-Pen. Forms are available in the

school clinic, online on the Health and Safety page of the GCPS website, or from your child's health care provider.

2. Briefly explain (?) checked answers here (include month and year for history of a problem): __________________________________________________________________________________________ __________________________________________________________________________________________ 3. Is your child currently undergoing medical care or psychological treatment? Briefly explain here__________ __________________________________________________________________________________________ __________________________________________________________________________________________

4. ASTHMA and/or ALLERGIES (food, medicine, environmental, seasonal), FILL in the BACK of this form.

5. MEDICATION taken at home (daily or as needed basis), to treat the above noted health issues: _______________________________________________________________________________________ _______________________________________________________________________________________
6. Does your child have a health condition that restrict participation in Physical Education? If yes, provide a note from your child's health care provider stating the health condition and what restrictions are required, and effective to date(s).
7. Does your child have a DENTIST? YES / NO Provider Name:__________________________________________ Phone: ______________________

8. Does your child have a HEALTH CARE Doctor? YES / NO Provider Name: __________________________________________ Phone:______________________

9. HEALTH INSURANCE (Check One): FAMIS MEDICAID PRIVATE TRICARE

NONE

Continued on back

CHECK THE APPROPRIATE BLANKS FOR ALL THREE CONDITIONS: Please send documentation
from your child's physician if a previously reported health condition no longer requires medication at school.
ASTHMA
____ My child does NOT have asthma and does NOT use an inhaler.
____ My child DOES have asthma. I will bring in the medication and the completed Asthma Action Plan to school. It must be in the school clinic no later than the last Friday of September.
_____ My child DOES have asthma but will not have an Asthma Action Plan or inhaler at school. I understand that if my child has a severe asthma attack while at school/school functions, that NO medicine is available at the school and 911 will be called. I take full responsibility for the outcome.
-------------------------------------------------------------------------------------------------
ALLERGIES
____ My child does NOT have a food, environmental or insect/bee sting allergy that requires an EpiPen.
____ My child DOES need medication available at school, and I will bring an Allergy Action Plan and Epipen (AND Benadryl if ordered by the healthcare provider) to the school clinic no later than the last Friday in September.
____ My child DOES have a food, environmental or insect/bee sting life threatening allergy but will not have an Allergy Action Plan or EpiPen at school. I understand that if my child has a severe allergic reaction at school or a school function that NO medicine is available at school, and 911 will be called. I take full responsibility for the outcome.
My child's reaction to ________________________________________________________________________________ is:________________________________________________________________________________________________ __________________________________________________________________________________________________
-------------------------------------------------------------------------------------------------
SEIZURES
____ My child does NOT have a seizure disorder.
____ My child DOES have a seizure disorder, and I will bring a Seizure Action Plan and medication (if ordered by doctor) to the school clinic no later than the last Friday in September.
____ My child DOES have a seizure disorder but will not have a Seizure Action Plan or medication at school. I understand that if my child has a seizure at school/school functions, that NO medication is available and 911 will be called. I take full responsibility for the outcome.
------------------------------------------------------------------------------------------------- PARENT/GUARDIAN SIGNATURE
I understand that per GCPS policy, medications/inhalers are not to be at school or carried by the student without proper paperwork being filed in the school clinic; this includes all over-the-counter and prescription medicines and inhalers.
Consent to Share Information: The school nurse has my permission to share my child's confidential health information, on a need-to-know basis, with appropriate members of the educational staff and healthcare providers for use in meeting the educational and health needs of my student while in school. I agree to notify the school nurse of any changes in medication (to include dosage/frequency), and change in the health status of my child to include new medical diagnosis by a doctor and injuries acquired (concussion, etc.), or if any of the above information changes.
Parent/Guardian PRINTED Name Signature:____________________________/______________________________
Date Signed:_____________________________ Daytime Phone/Contact Number:___________________________

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

Allergies (food, insects, drugs, latex)

Allergies (seasonal)

Asthma or breathing problems

Attention-Deficit/Hyperactivity Disorder

Behavioral problems

Developmental problems

Bladder problem

Bleeding problem

Bowel problem

Cerebral Palsy

Cystic fibrosis

Dental problems

Comments

Condition

Yes

Diabetes

Head injury, concussions

Hearing problems or deafness

Heart problems

Lead poisoning

Muscle problems

Seizures

Sickle Cell Disease (not trait

Speech problems

Spinal injury

Surgery

Vision problems

Comments

Describe any other important health-related information about your child (for example, feeding tube, hospitalizations, 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:

Pediatrician/primary care provider

Name

Phone

Date of Last Appointment

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 G revised 10/2010

1

COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM
Part II - Certification of Immunization
Section I To be completed by a physician or his designee, 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, registered nurse, or health department official 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.

Student's Name: Last
IMMUNIZATION
*Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1

Date of Birth: |____|____|____|

First

Middle

Mo. Day Yr.

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

2

3

4

5

*Diphtheria, Tetanus (DT) or Td (given after 7 1

2

3

4

5

years of age)

*Tdap booster (6th grade entry)

1

*Poliomyelitis (IPV, OPV)

1

2

3

4

*Haemophilus influenzae Type b

1

2

3

4

(Hib conjugate)

*only for children <60 months of age

*Pneumococcal (PCV conjugate)

1

2

3

4

*only for children <2 years of age

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)

1

2

3

 Merck adult formulation used

*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

I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child *caRreeqour iprreedscvhaococlinperescribed 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: Certification of Immunization 11/06

Date (Mo., Day, Yr.):___/___/____

MCH 213 G revised 10/2010

2

Student's Name:

Date of Birth: |____ |_ ___|___ _|

Section II Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

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.):|___|___|___|

Section III Requirements

For Minimum Immunization Requirements for Entry into School and Day Care, consult the Division of Immunization web site at
http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published by the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)). (requirements are subject to change.)

Certification of Immunization 10/2010

MCH 213 G revised 10/2010

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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: _____/_____/_______

1 = Within normal

Physical Examination 2 = Abnormal finding 3 = Referred for evaluation or treatment

Health Assessment

Weight: ________lbs. Height: _______ ft. ______ in.

1 2 3

1 2 3

1 2 3

Body Mass Index (BMI): ___________ BP____________  Age / gender appropriate history completed  Anticipatory guidance provided
TB Risk Assessment:  No Risk  Positive/Referred Mantoux results: __________________mm

HEENT Lungs Heart

   Neurological    Skin   

   Abdomen

   Genital   

   Extremities    Urinary   

EPSDT Screens Required for Head Start ­ include specific results and date:

Blood Lead:___________________________________________

Hct/Hgb ____________________________________________

Developmental Screen

Assessed for: Emotional/Social Problem Solving Language/Communication Fine Motor Skills Gross Motor Skills

Assessment Method:

Within normal

Concern identified:

Referred for Evaluation

Hearing Screen

 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

Vision Screen

 With Corrective Lenses (check if yes)

Stereopsis  Pass

 Fail

Distance

Both

R

L

20/

20/

20/

 Pass

 Referred to eye doctor

 Not tested Test used:
 Unable to test ­ needs rescreen

Dental Screen

 Problem Identified: Referred for treatment  No Problem: Referred for prevention  No Referral: Already receiving dental care

Recommendations to (Pre) School , Child Care, or Early Intervention Personnel

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: _________________________________________

MCH 213 G revised 10/2010

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