Home Address: City/State (if other than D.C.) Other HT IN CM. Body Mass Index (BMI) % HGB / HCT (Required for Head Start) Glasses Referred

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1 DISTRICT OF COLUMBIA UNIVERSAL HEALTH CERTIFICATE Part 1: Child s Personal Information Parent/Guardian: Please complete Part 1 clearly and completely & sign Part 5 below. Child s Last Name: Child s First & Middle Name: Date of Birth: Gender: Race/Ethnicity: White Non Hispanic Black Non Hispanic M F Hispanic Asian or Pacific Islander Other Parent or Guardian Name: Telephone: Home Cell Work Home Address: Ward: Emergency Contact Person: Emergency Number: City/State (if other than D.C.) Zip code: Home Cell Work School or Child Care Facility: Medicaid Private Insurance None Primary Care Provider (PCP): Other Part 2: Child s Health History, Examination & Recommendations Health Provider: Form must be fully completed. DATE OF HEALTH EXAM: WT LBS KG HT IN CM BP: (>3 yrs) NML ABNL Body Mass Index (BMI) % HGB / HCT (Required for Head Start) Vision Screening Right 20/ Left 20/ Glasses Referred Hearing Screening Pass Fail Referred HEALTH CONCERNS: REFERRED or TREATED HEALTH CONCERNS: REFERRED or TREATED Asthma Referred Under Rx Language/Speech YES Referred Under Rx NO YES NONE Seizure Referred Under Rx Development/ YES Referred Under Rx NO YES Behavioral NONE Diabetes Referred Under Rx Other YES Referred Under Rx NO YES NONE ANNUAL DENTIST VISIT: (Age 3 and older): Has the child seen a Dentist/Dental Provider within the last year? YES NO Referred A. Significant health history, conditions, communicable illness, or restrictions that may affect school, child care, sports, or camp. NONE YES, please detail: B. Significant food/medication/environmental allergies that may require emergency medical care at school, child care, camp, or sports activity. NONE YES, please detail: C. Long-term medications, over-the-counter-drugs (OTC) or special care requirements. NONE YES, please detail (For any medications or treatment required during school hours, a Physician s Medication Authorization Order should be submitted with this form) Part 3: Tuberculosis & Lead Exposure Risk Assessment & Testing: TB RISK ASSESSMENTS HIGH LOW Tuberculin Skin Test (TST) DATE: NEGATIVE POSITIVE LEAD EXPOSURE RISKS YES NO Part 4: Required Provider Certification and Signature YES NO If TST Positive CXR NEGATIVE CXR POSITIVE TREATED (>2 yrs) Health Provider: POSITIVE TST should be referred to PCP for evaluation. For questions, call T.B. Control: LEAD TEST DATE: RESULT: Health Provider: ALL lead levels must be reported to DC Childhood Lead Poisoning Prevention Program: Fax: This child has been appropriately examined & health history reviewed. At time of exam, this child is in satisfactory health to participate in all school, camp or child care activities except as noted above. YES NO This athlete is cleared for competitive sports. YES NO Age-appropriate health screening requirements performed within current year. If no, please explain: Print Name MD/NP Signature Date Address Phone Fax Part 5: Required Parental/Guardian Signatures. (Release of Health Information) I give permission to the signing health examiner/facility to share the health information on this form with my child s school, child care, camp, or appropriate DC Government Agency. Print Name Signature Date

2 DISTRICT OF COLUMBIA UNIVERSAL HEALTH CERTIFICATE Student s Name: / / Date of Birth: / / Last First Middle Mo. /Day/ Yr. Sex: Male Female School or Child Care Facility: Section 1: Immunization: Please fill in or attach equivalent copy with provider signature and date. IMMUNIZATIONS RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN Diphtheria,Tetanus, Pertussis (DTP,DTaP) DT (<7 yrs.)/ Td (>7 yrs.) Tdap Booster Haemophilus influenza Type b (Hib ) Hepatitis B (HepB) Polio (IPV, OPV) Measles, Mumps, Rubella (MMR) Measles Mumps Rubella Varicella Chicken Pox Disease History: Yes When: Month Year Pneumococcal Conjugate Hepatitis A (HepA) (Born on or after 01/01/2005) Meningococcal Vaccine Human Papillomavirus (HPV) Influenza (Recommended) Rotavirus (Recommended) Verified by: (Health Care Provider) Name & Title Other Signature of Medical Provider Print Name or Stamp Date Section 2: MEDICAL EXEMPTION. For Health Care Provider Use Only. I certify that the above student has a valid medical contraindication to being immunized at the time against: (check all that apply) Diphtheria: ( ) Tetanus: ( ) Pertussis: ( ) Hib: ( ) HepB: ( ) Polio: ( ) Measles: ( ) Mumps: ( ) Rubella: ( ) Varicella: ( ) Pneumococcal: ( ) HepA: ( ) Meningococcal: ( ) HPV: ( ) Reason: This is a permanent condition ( ) or temporary condition ( ) until / /. Signature of Medical Provider Print Name or Stamp Date Section 3: Alternative Proof of Immunity. To be completed by Health Care Provider or Health Official. I certify that the student named above has laboratory evidence of immunity: (Check all that apply & attach a copy of titer results) Diphtheria: ( ) Tetanus: ( ) Pertussis: ( ) Hib: ( ) HepB: ( ) Polio: ( ) Measles: ( ) Mumps: ( ) Rubella: ( ) Varicella: ( ) Pneumococcal: ( ) HepA: ( ) Meningococcal: ( ) HPV: ( ) Signature of Medical Provider Print Name or Stamp Date

3 CONFIDENTIAL FORM- SIDE ONE Please review instructions on side two District of Columbia Oral Health (Dental Provider) Assessment Form Part 1. Child s Personal Information Child s Last Name Child s First & Middle Name Date of Birth Gender: M F School or Child Care facility: Parent/Guardian Name Telephone1: Home Cell Work Home Address: Ward Emergency Contact: Telephone2: Home Cell Work City/State (if other than D.C.) Zip code: Race/Ethnicity: White Non Hispanic Black Non Hispanic Hispanic Asian or Pacific Islander Other Primary Care Provider (Medical): Dentist/Dental Provider: Medicaid Private Insurance None Part 2. Child s Clinical Examination (to be completed by the Dental Provider) (Please use key to document all findings on line next to each tooth) Tooth # Tooth # Tooth # Tooth # 1 17 A K 2 18 B L 3 19 C M 4 20 D N 5 21 E O 6 22 F P 7 23 G Q 8 24 H R 9 25 I S J T Part 3. Clinical Findings and Recommendations (Please indicate in Finding column) Other Date of Exam S - Sealants Key (Check Appropriate) X - Missing teeth Restoration Non-restorable/ Extraction 1D-One surface decay UE- Unerupted Tooth 2D-Two surface decay 3D-Three surface decay 4D-More than three surface decay Findings 1. Gingival Inflammation Y N 2. Plaque and/or Calculus Y N 3. Abnormal Gingival Attachments Y N 4. Malocclusion Y N 5. Other (e.g. cleft lip/palate) Preventive services completed Yes No Part 4. Final Evaluation/Required Dental Provider Signatures Comments This child has been appropriately examined. Treatment is complete. is incomplete. Referred to DDS/DMD Signature Print Name Date Address Phone Fax Part 5. Required Parent/Guardian Signatures Parent or Guardian Release of Health Information. I give permission to the signing health examiner or facility to share the health information on this form with my child s school, childcare, camp, or Department of Health PRINT NAME of parent or guardian SIGNATURE of parent or guardian Date

4 Instructions For Completion of Oral Health Assessment Form: District of Columbia Child Health Certificate This Form replaces the Dental Appraisal Form used for entry into DC Schools, all Head Start programs, Childcare providers, camps, after school programs, sports or athletic participation, or any other District of Columbia activity requiring a physical examination. The form was developed by the DC Department of Health and follows the American Academy of Pediatric Dentistry (AAPD) Guidelines on Mandatory School-Entrance Oral Health Examinations. AAPD recommends that a child be given an oral health exam within 6 months of eruption of the child s first tooth and no later than his or her first birthday. The DC Department of Health recommends that all children 3 years of age and older have an oral health examination performed by a licensed dentist and have the DC Oral Health Assessment Form completed. This form is a confidential document. Confidentiality is adherent to the Health Insurance Portability and Accountability Act of 1996 (HIPPA) for the health providers, and the Family Education Rights and Privacy Act (FERPA) for the DC schools and other providers. General Instructions: Please use black ball point pen when completing this form. Part 1: Child s Personal Information Please complete all sections including child s race or ethnicity. Please indicate the ward of your home address. List primary care provider, dental provider, and type of dental insurance coverage. If child has no dental provider and is uninsured, then please write None in each box. This form will not be complete without Parent or Guardian signature in Part 5. Part 2: Child s Clinical Examination: Dental Provider: Form must be fully completed. The Universal Tooth Numbering System is used. Please use key to document all findings for each tooth. An X signifies a missing tooth (teeth) with no replacement; non-restorable/extraction; UE: unerupted tooth; S: Sealants; Restoration; 1D: one surface decay; 2D: two surface decay; 3D: three surface decay; 4D: more then three surface decay - The Key should be used to designate status for each tooth at time of examination on the Oral Health Assessment Form. - If a portion of an existing restoration is defective or has recurrent decay, but part of the restoration is intact, the tooth should be classified as a decayed tooth. If one surface has decay, then mark as 1D; if two surface has decay then mark as 2D. - Key UE: unerupted, does not apply to a missing primary tooth when a permanent tooth is in a normal eruption pattern. Part 3: Clinical Findings and Recommendations - Circle Yes or No in Findings Column - For Yes, please explain in the Comments Section. 1- Advance periodontal conditions (pockets etc., will be noted under gingival inflammation). 1- Gingival inflammation adjacent to an erupting tooth is NOT noted. 1- Inflammation adjacent to orthodontically banded teeth or a dental appliance whether fixed or removable is noted. 2- Indicate if there is sub and/or supra gingival plaque and or calculus and areas where present. 3- All gingival tissues must be free of inflammation e.g. gingiva is pale pink in color and firm in texture for a finding of 'NO' to be recorded. 3- Frenum attachments labial, sublingual, etc., will be noted under the Abnormal Gingival Attachment Indicator Code if they are the cause of a specific problem- e.g., spacing of central incisors, speech impediment, etc. 4- Status of orthodontic condition should be noted under Malocclusion. Classification of occlusion is: Class I, Class II, Class III, an overbite, over jet, cross-bite or end to end. 5- Other is to be used, together with comments, for conditions such as cleft lip/palate. - Indicate whether oral health preventive services such as prophylaxis, sealant and or fluoride treatment have been administered. Part 4. Final Evaluation/Required Dental Provider Signature; Indicate whether the child has been appropriately examined and if treatment is complete. If treatment is incomplete refer patient for follow up care. Dentist must sign, date, and provide required information. Part 5 Required Signatures. This Form Will Not Be Complete Without Parent or Guardian Signature & Date The parent or guardian must print, sign, and date this part. By signing this section the parent or guardian gives permission to the dentist or facility to share the oral health information on this form with the child s school, childcare, camp, Department of Health, or the entity requesting this document. All information will be kept confidential.

5 PLEASE TYPE OR PRINT TRAVEL AND ACTIVITY AUTHORIZATION Special 1-time permission for this activity only Blanket permission for all given activities I, parent/guardian of Name of Parent/Guardian give my permission to Name of Child for my child to participate in the following activities: Trips in the van/automobile (facility or parent -owned) Explain planned activity where and when Field trips away from the facility Explain planned activity where and when I understand that the facility will use the appropriate child restraint devises and abide by all District of Columbia safety rules when my child is transported in a vehicle. The facility will also notify me each time that my child is to participate in an activity that would involve transportation. In addition, if the facility has planned activities outside the fenced area of the facility, I will allow my child to play outside the fenced area; or I will not allow my child to play outside the fenced area. This authorization is valid from / / to / / Parent/Guardian Signature Date Signed NOTE: Place on file in child s folder/record 810 First Street, NE, 4th floor, Washington, DC Phone: Fax:

6 PLEASE TYPE OR PRINT AUTHORIZATION FOR CHILD S EMERGENCY MEDICAL TREATMENT If my child, born on, becomes ill or involved in an accident and I cannot be contacted, I authorize the following hospital or physician to give the emergency medical treatment required: Hospital: Address: or: Physician: M.D. Telephone No: Address: (Area Code) I give permission to, located at Name of Facility or Caretaker, to take my child for treatment. I accept responsibility for any necessary expense incurred in the medical treatment of my child, which is not covered by the following: Health Insurance Company: Name of Policy Holder: Policy Number: Relationship to Child: Coverage: Medicaid Number: State: DC MD VA Child s Known Allergies or Physical Conditions: Signature: Relationship to Child: Address: Telephone No: Home Business Pager/Cell Phone Date: Month/Day/Year Date Updated: Month/Day/Year 810 First Street, NE, 4th floor, Washington, DC Phone: Fax:

7 Medication Authorization Release and Indemnification Agreement Please read information & procedures on reverse side Part I Parent or Guardian to Complete I hereby request School Age Child Care / Summer Camp personnel to administer medication as directed by this authorization. I agree to release,, indemnify, and hold harmless YMCA and any of their staff members, or directors from lawsuits, claims, expenses, demands, or actions, etc against them for helping this student use medication, provided School Age / Summer Camp staff members comply with the physician, parent or guardian orders set forth in accordance with the provision of Part II below. I have read the procedures outlined on the back of this form and assure responsibility as required. Has the student taken this medication before? Yes No (If no, the first full dose must be given at home to ensure that the student doesn t a negative reaction.) First dose was given: Date: Time: Student Name (Last, First, Middle) Date of Birth School Name School Year Grade No YMCA staff shall administer medication or treatment, unless the Program Director or his or her designee has personally reviewed all the required clearances. Parent or Guardian Signature Daytime Phone Number Date Part II Parent or Guardian to complete and sign for over-the counter medications for relief of symptoms for headache, muscle ache, orthodontic pain, or menstrual cramps and for antibiotics and antiviral medication. Physicians must complete and sign for all other medications. The YMCA discourages the use of medication by students in the program/camp during the day. Any necessary medication that possible can be taken before or after the program/camp should be so prescribed. Injectable medications are not administered in the program/camp except in specific emergency situations. YMCA staff will, when it is absolutely necessary, administer medication during the program and while participating in programs, camps, or field trips and situations according to the procedures outlined on the back of this form. Information should be written in lay language with no abbreviations. Diagnosis Medications If medication is given on an as-needed basis, specify the symptoms or conditions when medication is to be taken and the time at which it may be given again. Dosage to be given at School Age/Summer Camp (e.g. mg, ml, or cc) Time(s) or interval between times to be given Effective date: Current School Year From: to If the student is taking more than one medication, list sequence in which medications are to be taken Physicians Name (Print or Type) Physician Signature Telephone Number or Fax Date Parent or Guardian Name (Print or Type) Parent or Guardian Signature Telephone Number Date (Not Required of Physician signs) Part III School Age/Summer Camp Director to Complete Check box as appropriate Parts I & II above are complete and including signature. (It is appropriate if all items in part II are written on the physician s stationary or a prescription pad.) Medication is appropriately labeled. Date by which any unused medication is to be collected by the parent. (Within one week after expiration of the physcian order or on the last day of school.) School Age/Summer Camp Director Signature Date Form must be updated yearly. School Age / Summer Camp calendar runs from 9/1 to 8/30.

8 Parent Information about Medication Procedures 1. Medications should be taken at home whenever possible. Any medication taken in School Age/Summer Camp must have a parent or guardian-signed authorization: some medications also require physician s orders. Medication must be turned in at School Age/Summer Camp desk prior to the start of the day. The parent or guardian must transport medication to and from site. 2. No medication will be accepted by School Age/Summer Camp personnel without receipt of completed and appropriate medication forms. Form must be updated yearly. School Age / Summer Camp calendar runs from 9/1 to 8/ A physician may use office stationary or a prescription pad in lieu of completing Part II. Include the following information written in lay language with no abbreviations: Name of student Date of birth Reason for medication or diagnosis Name of medication Exact dosage to be taken, (e.g. milligrams per tablet, milligrams per ml/cc) as applicable Time to take medication a to be administered and frequency or exact time interval dosage Sequence in which the medications should be taken in cases where more than one medication is prescribed If medication in given on an as needed basis, specify the exact conditions or symptoms when medication is to be taken and the time at which it may be given again. ( repeat as necessary is unacceptable.) Duration of medication order or effective dates Physician s signature Date 4. All prescription medications, including physician s prescription drug samples, must be in their original containers and labeled by a physician or pharmacist. An over-the-counter medication must be in the original container with the name of the medication visible. The parent or guardian must label the original container with the following: Name of student Exact dosage to be taken in school age/summer camp (e.g. milligram tablet, milligrams per ml/cc) Frequency or time interval dosage is to be administered 5. The first dose of any medication must be given at home. 6. The parent or guardian is responsible for submitting a new form to the School Age/Summer Camp at the time of registration or the start of the program. 7. Medication will be stored in a locked area accessible only to authorized personnel. 8. Within one week after expiration of the effective date on the physician order, or on the last day of the program, the parent or guardian must personally collect any unused portion of the medication. Medications not claimed within that period will be destroyed. 9. Medication can be given no more than one half hour before or after the prescribed time. 10. YMCA Fairfax County Reston School Age/Summer Camp program does not assume responsibility for authorized medication taken independently by the student. 11. In no case may any School Age and Summer Camp staff or member administer any medication outside the framework of the procedures outlined here.

9 PLEASE TYPE OR PRINT Medication Authorization Form Pursuant to Title 29 of the District of Columbia Municipal Regulations (DCMR), Section 377.1; No Child Development Facility may provide medicine or treatment, with the exception of emergency first aid, to any child, unless the Facility has obtained a written medical order or prescription from the child s licensed health care practitioner and the written consent of the child s parent (s) or guardian (s). Pursuant to Title 29 of the District of Columbia Municipal Regulations (DCMR), Section 377.4; The Facility shall maintain a medication log, on a form approved by the Director, on which the Facility shall record the date, time of day, medication, medication dosage, method of administration, and the name of the person administering the medication, each time any medication is administered to a child. Part I: To be completed by the parent/guardian and child s physician: I do hereby give permission to to administer the Name of Facility below noted prescribed medication to my child born on. Name of Medication Time/Frequency Dosage Effective Dates From: To: From: To: Signature of Physician Date Signature of Parent/Guardian Date Part II: To be completed by the Center Director or designee: Name of Medication Date Time Given Reactions Staff Initials PLEASE RETAIN A COPY FOR YOUR FILE 810 First Street, NE, 4th floor, Washington, DC Phone: Fax:

10 EMERGENCY FORM INSTRUCTIONS TO PARENTS: (1) Complete all items on this side of the form. Sign and date where indicated. (2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child s health practitioner review that information. NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY. When parents cannot be reached, list at least one person who may be contacted to pick up the child in an emergency: 1. Name Telephone (H) (W) Last First Address 2. Name Telephone (H) (W) Last First Address 3. Name Telephone (H) (W) Last First Address Child s Physician or Source of Health Care Telephone Address In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital. Signature of Parent/Guardian Date Child s Name Last First Birth Date Enrollment Date Hours & Days of Expected Attendance Child s Home Address Mother s Name Last First Home Telephone Mother s Employer/School Name Address Mother s Home Address (If different from above) Work Telephone Cellular Phone Beeper Father s Name Last First Home Telephone Father s Employer/School Name Address Father s Home Address (If different from above) Work Telephone Cellular Phone Beeper Name of Person Authorized to Pick Up Child (daily) Last First Relationship to Child Address ANNUAL UPDATES (Initials/Date) (Initials/Date) (Initials/Date) (Initials/Date) OCC 1214 (Revised 7/05) - Side 1 of 2 - All previous editions are obsolete.

11 REGISTRATION RECORD FOR CHILD RECEIVING CARE AWAY FROM HOME Child: Sex: Male Female Date of Birth: Home #: Language Spoken At Home Home Address: Father: Home # Business # Home Address: Business Address: Mother: Home # Business # Home Address: Business Address: Relative or Guardian: Home # Business # Home Address: Business Address: Person to be contacted in case of an emergency (other than parent/guardian): Address: Relationship to child: Phone # Designated individual authorized to receive child at end of session: Signature: Relationship to child: Date: TO BE COMPLETED BY THE FACILITY Date of Admission: Date of Withdrawal: Reason: 810 First Street, NE, 4th floor, Washington, DC Phone: Fax:

12 YMCA of Metropolitan Washington Summer Day Camp 2014 Inclusion Form The YMCA of Metropolitan Washington is committed to living out our value of inclusiveness which guarantees nondiscrimination and equal access for all in our programs, services, and activities, and will provide reasonable accommodations upon request. Inclusion information for children with special needs must be provided at the time registration & directly to the child s Camp Director on the first day of each camp. Parents must submit Medication Authorization Forms for any medications (including OTC medications, epipens, insulin or foods that treat medical conditions). 1) Name of the Child: 2) Age of the Child: 3) Camp(s) & Week(s) Attending: 4) Name and phone numbers for the parent/legal guardian(s): Parent/Legal Guardian 1: Name: Phone: Parent/Legal Guardian 2: Name: Phone: 5) Describe the characteristics of your child s special needs: 6) What type of support do you feel your child needs? 7) Does the child have any triggers that staff should be aware of? 8) Are there any other special concerns that staff should be aware of? 9) Does the parent have any tips or suggestions on how to address special concerns? 10) Does the child have any favorite books, toys or security items that would be appropriate to send to camp? (Must be approved by the Camp Director.) 11) Does the child exhibit severe emotional or physical reactions? 12) When should staff call the parent/guardian? (Parents/legal guardians will always be called if medical attention is required.) 13) Does the child require medications? 14) Other pertinent information/concerns. All children with special needs or developmental disabilities must consult with camp staff prior to camp before registration can be considered complete. The YMCA will make accommodations to the fullest extent possible based on available resources. One-on-one assistance is not guaranteed. Parent s Name (Please Print) Parent s Signature Date Internal Use: A copy of this form has been provided to the Camp Director. Registrar Signature Date YMCA of METROPOLITAN WASHINGTON

13 YMCA of Metropolitan Washington Summer Day Camp 2014 Inclusion Form The YMCA of Metropolitan Washington is committed to living out our value of inclusiveness which guarantees nondiscrimination and equal access for all in our programs, services, and activities, and will provide reasonable accommodations upon request. Inclusion information for children with special needs must be provided at the time registration & directly to the child s Camp Director on the first day of each camp. Parents must submit Medication Authorization Forms for any medications (including OTC medications, epipens, insulin or foods that treat medical conditions). 1) Name of the Child: 2) Age of the Child: 3) Camp(s) & Week(s) Attending: 4) Name and phone numbers for the parent/legal guardian(s): Parent/Legal Guardian 1: Name: Phone: Parent/Legal Guardian 2: Name: Phone: 5) Describe the characteristics of your child s special needs: 6) What type of support do you feel your child needs? 7) Does the child have any triggers that staff should be aware of? 8) Are there any other special concerns that staff should be aware of? 9) Does the parent have any tips or suggestions on how to address special concerns? 10) Does the child have any favorite books, toys or security items that would be appropriate to send to camp? (Must be approved by the Camp Director.) 11) Does the child exhibit severe emotional or physical reactions? 12) When should staff call the parent/guardian? (Parents/legal guardians will always be called if medical attention is required.) 13) Does the child require medications? 14) Other pertinent information/concerns. All children with special needs or developmental disabilities must consult with camp staff prior to camp before registration can be considered complete. The YMCA will make accommodations to the fullest extent possible based on available resources. One-on-one assistance is not guaranteed. Parent s Name (Please Print) Parent s Signature Date Internal Use: A copy of this form has been provided to the Camp Director. Registrar Signature Date YMCA of METROPOLITAN WASHINGTON