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Washington Virtual Academies 2601 S 35Th St, Suite 100 Tacoma, WA 98409 Ph: 866‐467‐8167 Fx: 866‐989‐0715 2012/2013 Enrollment Forms Fax Cover Sheet Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in the enrollment process. You can fax, scan and email, or mail the required paperwork. Important Note: Please send copies; do not mail the original documents. Fax (preferred): 1‐866‐989‐0715 Scan and Email: [email protected] Mail: Washington Virtual Academies 2601 S 35th Street, Suite 100 **All Students 18 Years and Older Must Sign ALL Enrollment Paperwork** Tacoma, WA 98409 Student Name: ______________________________________________________________________________________________________ Parent/Guardian Name: _______________________________________________________________________________________________ Number of pages including cover sheet: ___________ Date: ___________ New Student Enrollment Forms Checklist (Please check each form you are including in your fax) Birth Certificate (if enrolling in Kindergarten) Certificate of Immunizations‐Be sure to sign this form in the top Right Corner or the form will be Rejected, (please make sure Immunizations are transcribed onto the WA State form provided, parents are required to send this in at the time of enrollment) Proof of Residence (utility bill, if living with family, friends, or any other circumstances please include a letter stating you and your family are residing at their residence and a copy of their utility bill or signed Lease/Rental Agreement) Student Enrollment Registration Form WAVA Course Enrollment Form 12/13 School Year (this form is only if your student is attending WAVA Full Time or Part Time WAVA plus Part Time Home School Status in which you are providing on your own) WAVA Choice Form 12/13 School Year (this form is only if your student is attending WAVA Full Time or Part Time WAVA plus Part Time Home School Status in which you are providing on your own, this form is also provided to you by your PAL) WAVA Inter Local Attendance Shared Agreement (this form is only if your student is attending WAVA and your resident school which is provided to you by your PAL) Release of Student Records (this form is to be sent directly to WAVA and not turned into your resident school/school district, WAVA will send upon approval) Student Registration Form‐OSPI & ITHS 9Th Grade students most recent Report Card or Progress Report 10th‐12Th Grade students Unofficial or Official transcript If your student has a 504 Plan, please submit a copy If your student has an IEP, WAVA will request a copy Re‐Enrolling Student Enrollment Forms Checklist (Please check each form you are including in your fax) Proof of Residence if you have moved If your student is entering the 6Th grade please provide the date for the Tdap Booster Immunization (this is required to enter the 6th grade) Re‐Enrollment Registration Form Re‐Enrollment Course Enrollment Form WAVA Choice Form 12/13 School Year (this form is only if your student is attending WAVA Full Time or Part Time WAVA plus Part Time Home School Status in which you are providing on your own, this form is also provided to you by your PAL) WAVA Inter Local Attendance Shared Agreement (this form is only if your student is attending WAVA and your resident school which is provided to you by your PAL) New Student Enrollment Registration Form
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
School District Applying for:
Student Information:
Omak School District
Monroe School District
Grade Level Applying for: K-8
_______________________________________________________________________________________________
Legal Last Name
First Name
MI
Also known as:
_______________________________________________________________________________________________________________________________
(Physical Home Address)
Street
Apt. #
City
County
Has your student ever been promoted to a higher grade level? Yes
Washington Virtual Academies
Enrollment Processing Center
2601 South 35th Street, Ste 100
Tacoma, WA 98409
Ph. 1.866.467.6187
Fx. 1. 866.989.0715
www.k12.com/wava
9-12
___________________
Birthdate (mo/day/year)
_____________
_________________________
Grade
Home Telephone #
Zip
No If yes, when and where: ___________________________________
Has your student ever been retained a grade level? Yes No If yes, when and where: _____________________________________________
SPECIAL PROGRAM INFORMATION (please check your answers)
Has your child ever qualified for or been enrolled in any Special Education Program(s)? YES NO If yes, when and where: ___________________________
Has your child ever participated in:
TITLE 1/Chapter 1
IEP/Special Education
GIFTED
ESL
504
Does your student currently have an IEP? YES NO
If yes, where is it on file: ___________________________________________
Does your student currently have a 504 plan? YES
NO If yes, where: _______________________________________________
What is the primary language spoken in the home? ________________________________________________________
Is your child's first language a language other than English? YES NO If yes, what language? _____________________________
DISCIPLINE INFORMATION (please check your answers)
Has your child ever been suspended, or expelled? YES NO
Is your student currently under a suspension, expulsion, or Becca Bill/Truancy Petition?
YES
NO If yes, which one and when: ______________________
CUSTODY INFORMATION (please check your answers)
Is there a joint custody or parenting plan in effect? YES NO
Is there a restraining order in effect? YES NO
Restraining order is against? Mother Father Other: _________________ Begin Date: ______________________ Exp Date: ________________
*Please note if there is a restraining order or parenting plan in affect you will need to send in a copy*
Ethnicity and Race Data Collection
Question 1. Is your child of Hispanic or Latino origin? (Check all that apply)
Mexican/Mexican American/Chicano
Not Hispanic/Latino
Latin American
Puerto Rican
Cuban
Other/Hispanic/Latino
Central American
Spaniard
Question 2. What race(s) do you consider your child? (Check all that apply)
African American/Black Indonesian
Taiwanese
Guamanian or Chamorro
Alaska Native
Makah
Dominican
South America
White
Japanese
Thai
Mariana Islander
Chehalis
Muckleshoot
Asian Indian
Korean
Vietnamese
Melanesian
Nooksack
Nisqually
Chinese
Laotian
Other Asian
Samoan
Native Hawaiian
Spokane
Sohal Water
Snoqualmie
Sauk-Suiattle
Tongan
Cowlitz
Puyallup
Filipino
Malaysian
Colville
Samish
Quinalut
Port Gamble Klallam
Hmong
Singaporean
Fijian
Kalispel
Lower Elwha
Quileute
Pakistani
HOH
Jamestown
Swinomish
Tulalip
Yakama
Squaxin Island
Stillaguamish
Suquamish
Other Pacific Islander
Lummi
Other Washington Indian: ______________________________ Other American Indian/Alaska Native: __________________________
The McKinney-Vento Act defines homeless children as “individuals who lack a fixed, regular, and adequate nighttime residence”
Notice: Only students who reside in the state of Washington may be enrolled in Washington Virtual Academies.
(Resting their head at night in a Washington State Residence)
*Recognizing this legal requirement, I hereby verify that the student named above physically resides within Washington State and all of the above
provided information is true and correct.*
Legal Parent/Guardian Signature ____________________________________________________________
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
Date ____________
New Student Course Enrollment Form
Washington Virtual Academies
Enrollment Processing Center
2601 South 35th Street, Ste 100
Tacoma, WA 98409
Ph. 1.866.467.6187
Fx. 1. 866.989.0715
www.k12.com/wava
*Washington Virtual Academies is a Public School*
Student Name: ____________________________________________________________ Grade: _______ Date of Birth: _____________
1. Will your student be Full Time with WAVA? Yes___ No___ If yes, please complete the bottom portion of this form.
2. Will your student be Part Time with Home School status (aside from WAVA)? Yes___ No___ If yes, please sign the Declaration to
provide Home Based Instruction.
3. Will your student be attending any courses at their resident school while attending WAVA? Yes___ No___ If yes, please complete
the Intra Local Attendance Agreement. (This form is provided by your PAL.)
Kindergarten (ONLY)
WAVA Courses
Grades 1-8 (ONLY)
Please
check
Kinder
Hours
Kinder
FTE
Math & Science
6.66
.25
Language Arts
3.33
.25
WAVA Courses
Grades
1-3
Hours
4.6
Grades
1-3
FTE
.25
Grades
4-8
Hours
5.75
Grades
1-8
FTE
.25
4.6
.25
5.75
.25
Math
□
Language Arts
□
□
□
4.6
.25
5.75
.25
5.40
.25
6.75
.25
□
.8
-
1.0
-
Science
Total Courses, Hours, & FTE
Please
Check
History & Art (This is one
course)
PE (must take at least one core
class)
Total Courses, Hours, &
FTE
Grades 9-12(only)
st
1 Semester Course Titles
Credits
Total Credits & FTE
FTE
nd
2 Semester Course Titles
Credits
FTE
Total Credits & FTE
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
_______________________________________________________________________________________________________________
Parent/Guardian/Student Name
First
Last
______________________________________________________________________________
Parent/Guardian/Student Signature
__________
Date
For Administrator Use Only:
This letter is to provide notice that the parent is exercising the option to enroll his or her child in another school district under Washington interdistrict choice (RCW 28A.225.220). The above listed student will enroll in courses offered through the Washington Virtual Academies in the
______________________________________________________________, public school district.
Washington Virtual Academies
Enrollment Processing Center
2601 South 35th Street, Ste 100
Tacoma, WA 98409
Ph. 1.866.467.6187
Fx. 1. 866.989.0715
www.k12.com/wava
Resident School District__________________________
2012-2013 Request for Release-CHOICE (One form per student- If the student is 18 years or older they must sign this form.)
Note: If the FTE of the student will be shared between districts, the CHOICE law does not apply. The sharing of FTE requires an
Inter-District Agreement.
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
New Request
Annual Renewal
Student Name: ___________________________________________Grade 2012-13:_____Date of Birth: ___________
Parent/Guardian Name: _____________________________________________________________________________
Address: ____________________________________________________________City:__________________________
Zip Code: _______________ Home Telephone: ___________________ Work Telephone: _________________________
Resident School District: _____________________________________________________Currently Enrolled? Y
School District Requested:
Monroe
Please check all that apply:
Omak
Special Ed
504
School Program Requested:
Discipline Issues
Grade K-8
N
Grade 9-12
Regular Ed
BASIS FOR REQUEST OF RELEASE
A financial, educational, safety or health condition affecting the student would be reasonably improved as a result of the
transfer.
Attendance at the school requested is more accessible to the parent’s place of work or childcare.
There is some other special hardship or detrimental condition affecting the student or the student’s immediate family
that would be alleviated as a result of the transfer.
PLEASE EXPLAIN. USE BACK OF PAGE, IF NECESSARY
________________________________________________________________________________________
________________________________________________________________________________________
DURATION OF RELEASE (School Year, release is only good for 1 year, must be renewed every year):_____________________________
Parent/Guardian Signature: _______________________________________________________Date:________________
**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**
CERTIFICATION OF RELEASE FROM ____________________________________________________________
Approved
Denied
(Name of school district)
Student Name___________________________________________
Releasing School District Authorized Signature______________________________________________________
Date_________________
Title____________________________________________________
CERTIFICATION OF NON-RESIDENT SCHOOL ACCEPTANCE FROM _____________________________________
Approved
Denied
(Name of school district)
Non-Resident, accepting School District Authorized Signature_______________________________________________
Date__________
Title_________________________________________________________________________
Program Implementation Guidelines for Alternative Learning Experience
Office of Superintendent of Public Instruction
Washington Virtual Academies 2601 S 35Th St, Suite 100 Tacoma, WA 98409 Ph: 866‐467‐8167 Fx: 866‐989‐0715 Learning Coach/Adult Student (18+) Waiver Form Student Name: ____________________________________________________ Grade 12/13: _________ Brithdate: _________________ Parent/Guardian Name: _________________________________________________________ Phone: ____________________________ Address: _______________________________________________________ City: ______________________________ Zip: __________ Assigned Learning Coach/Liaison Name: _______________________________________________________________________________ Assigned Learning Coach/Liaison Email Address: ____________________________________________ Phone: _____________________ I ________________________________________ give permission and consent for ________________________________to Parent/Guardian/Adult Student Assigned Learning Coach/Liaison be the learning coach and liaison for _______________________________________. All conversations and requests may be Student Name discussed with the Learning Coach/Liaison I have assigned. The Learning Coach/Liaison _________________________________ Assigned Learning Coach/Liaison I have assigned is the main point of contact for ________________________________________ in regards to any questions Student Name or concerns with __________________________________ education with Washington Virtual Academies for the 2012/2013 Student Name school year. I understand and agree that all documents requiring Parent/Guardian/Adult Student signature will be signed by myself. I also understand and agree that I the Parent/Guardian/Adult Student must comply with monthly contacts with the teacher(s) as scheduled regarding my student. _____________________________________________________________ _____________________ Parent/Guardian/Adult Student Signature Date I, _____________________________________________, as the requested and assigned Learning Coach/Liaison do agree to Assigned Learning Coach/Liaison be the main point of contact for _______________________________________ regarding school work, grades, or any Student Name information requested on my behalf. _____________________________________________________________ _____________________ Assigned Learning Coach/Liaison Signature Date Washington Virtual Academies Enrollment Processing Center 2601 South 35th Street, Ste 100 Tacoma, WA 98409 Ph. 1.866.467.6187 Fx. 1. 866.989.0715 www.k12.com/wava Student Registration Form OSPI & ITHS Statement of Understanding In accordance with the Alternative Learning Experience Implementation Standards, reference WAC 392‐121‐182 (3)(e), prior to enrollment parent(s) or guardians shall be provided with, and sign, documentation attesting to the understanding of the difference between home‐based instruction an enrollment in an alternative learning experience (ALE). Summary Description Home‐Based Instruction (Home School not using WAVA Program
 Is provided by the parent or guardian as authorized under RCW 28A.200 and 28A.225.010.  Students are not enrolled in Public Education.  Students are not subject to the rules and regulations governing public schools, including course, graduation, and assessment requirements.  The public school is under no obligation to provide instruction or instructional materials, or otherwise supervise the student’s education. Alternative Learning Experience‐Washington Virtual Academies
 Is authorized under WAC 392‐121‐182.  Students are enrolled in public education either full time or part time.  Students are subject to the rules and regulations governing public school students including course, graduation, and assessment requirements for all portions of the ALE.  Learning experiences are:  Supervised, monitored, assessed, and evaluated by certified staff.  Provided via a written student learning plan.  Provided in whole, or part outside the regular classroom. Part –time Enrollment of Home‐Based Instruction Students Home‐based instruction students may enroll in public school programs, including ALE programs, on a part‐time basis and retain their home‐based instruction status. In the case of part‐time enrollment in ALE, the student will need to comply with the requirements of the ALE written student learning plan, but not be required to participate in state assessments or meet state graduation requirements. *Please note Part‐Time Enrollment of Home‐Based Instruction is aside from Washington Virtual Academies as we are an ALE Program and a Public School.* I have read the descriptions of home‐based instruction and alternative learning experiences provided and understand the difference between home‐based instruction and the alternative learning experience program in which my child is enrolling. Parent/Guardian/Student Signature: ___________________________________________________________________________ Date_____________________ Name(s) of Student(s) __________________________________ ______________________________________ ___________________________________ **All Students 18 Years and Older Must Sign ALL Enrollment Paperwork** Declaration of Intent to Provide Home School Instruction *This section is intended for students who are not Full Time Public School Students* A Parent who intends to cause his/her child or children to receive home school instruction in lieu of attendance or enrollment in a public school, approved private school, or an extension program of an approved private school must file an annual declaration of intent to do so in the format prescribed below: Note: Washington Virtual Academies is a Public School I do hereby declare that I am the parent, guardian, or legal custodian of the child(ren) listed below; that said child(ren) is (are) between 5 and 17 and as such are subject to the requirements found in chapter 28A.225 RCW Compulsory Attendance; I intend to cause said child(ren) to receive home school instruction as specified in RCW 28A.225.010(4); and if a certificated person will be supervising the instruction, I have indicated this by checking the appropriate space. Child(ren)’s Name(s) Birthdate _______________________________________________________________ ________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ **All Students 18 Years and Older Must Sign ALL Enrollment Paperwork** ____________________________________________________ ___________________________ Parent/Guardian/Student Signature Date ____________________________________________________ ___________________________ Street Address State ____________________________________________________ ____________________________ City Zip Code This statement must be filed annually by September 15 or within two weeks of the beginning of any public school quarter, trimester, or semester with the superintendent of the public school district within which the parent resides along with a copy to Washington Virtual Academies. www.k12.com/wava
 STUDENT INFORMATION:
Last Name:
Student ID:
First Name:
Address:
Parent/LG Name:
Email:
 SY 12-13 ENROLLMENT INFORMATION:
Please let us know how your student will be
enrolling for SY12-13 by answering questions
1 through 6. Check the appropriate box and
provide the information requested.
1. Will student be a Full Time student
(taking all courses with WAVA)? Yes No
2. Will student be a Part Time Shared
Student (taking some courses at another
Public School)?
Yes No If yes, please provide school
name and contact information:
3.
Will student be a Part Time Home
School student (taking some courses in a
home school program)? Yes No If yes,
please provide school name and contact
information:
4. Will student be a Part Time Private
School student (taking a course with WAVA
not offered at the Private School)? Yes
No If yes, please provide school name and
contact information:
5.
Will student be attending a Running
Start Program? Yes No If yes, please
provide school name and contact information:
6. Will student be attending a Skill
Center?
Yes No If yes, please provide school
name and contact information:
Enrollment Processing Center
2601 S 35th Street, Ste 100
Tacoma, WA 98409
Phone: 1.866.467.6187
Fax: 1.866.989.0715
WAVA HIGH SCHOOL
PREFERENCE FORM
Omak WAVA HS
Birth Date:
Middle Name:
City:
County:
(H) Phone:
State:
Zip Code:
(W) Phone:
 SY 12-13 ELECTIVE COURSE PREFERENCE:
Using the Course Catalogue as a guide, rank the top 5 Elective
Courses the student is interested in taking by placing numbers 1, 2, 3,
4 and 5 in the box provided, where 1 is the first choice:
ART010: Fine Art
ART020: Music Appreciation
BUS030: Personal Finance*
BUS040: Introduction to
Entrepreneurship
ENG010: Journalism
ENG020: Public Speaking
ENG: Creative Writing
HST020: Psychology
SCI010: Environmental Science
SCI030: Forensic Science
OTH010: Skills for Health
OTH020: Physical Education*
OTH040: Reaching Your
Academic Potential*
OTH050: Achieving Your Career
and College Goals*
OTH070: Life Skills
OTH060: Family and Consumer
Science
TCH010: Computer Literacy*
TCH030: Image Design &
Editing
TCH040: Web Design
TCH060: C++ Programming
TCH070: Game Design
TCH017: 3D Art I—Modeling
TCH027 Green Design &
Technology
MTH322 Consumer Math
MTH332 Transition Algebra
WLG100: Spanish I
WLG200: Spanish II
WLG300: Spanish III
WLG110: French I
WLG210: French II
WLG310: French III
WLG120: German I
WLG220: German II
WLG300: German III
WLG400: German IV
WLG500: AP® Spanish
Language
NOTE: *Required courses
Though these courses will probably be available each year, course offerings are dependent upon student enrollment and
staffing.
WAVA HS technology courses are designed for PC-IBM compatible computers only. Macintosh computers are not supported
 All WAVA HS freshman are required to take one semester each of TCH010 Computer Literacy and WAH100.
All grade levels have one additional required elective per semester to serve as a homeroom.
www.k12.com/wava
 STUDENT INFORMATION:
Last Name:
Student ID:
First Name:
Address:
Parent/LG Name:
Email:
 SY 12-13 ENROLLMENT INFORMATION:
Please let us know how your student will be
enrolling for SY12-13 by answering questions
1 through 6. Check the appropriate box and
provide the information requested.
1. Will student be a Full Time student
(taking all courses with WAVA)? Yes No
2. Will student be a Part Time Shared
Student (taking some courses at another
Public School)?
Yes No If yes, please provide school
name and contact information:
3.
Will student be a Part Time Home
School student (taking some courses in a
home school program)? Yes No If yes,
please provide school name and contact
information:
4. Will student be a Part Time Private
School student (taking a course with WAVA
not offered at the Private School)? Yes
No If yes, please provide school name and
contact information:
5.
Will student be attending a Running
Start Program? Yes No If yes, please
provide school name and contact information:
6. Will student be attending a Skill
Center?
Yes No If yes, please provide school
name and contact information:
Enrollment Processing Center
2601 S 35th Street, Ste 100
Tacoma, WA 98409
Phone: 1.866.467.6187
Fax: 1.866.989.0715
WAVA HIGH SCHOOL
PREFERENCE FORM
Monroe WAVA HS
Birth Date:
Middle Name:
City:
County:
(H) Phone:
State:
Zip Code:
(W) Phone:
 SY 12-13 ELECTIVE COURSE PREFERENCE:
Using the Course Catalogue as a guide, rank the top 5 Elective
Courses the student is interested in taking by placing numbers 1, 2, 3,
4 and 5 in the box provided, where 1 is the first choice:
ART010: Fine Art
ART020: Music Appreciation
BUS030: Personal Finance*
BUS040: Introduction to
Entrepreneurship
ENG010: Journalism
ENG020: Public Speaking
ENG: Creative Writing
HST020: Psychology
SCI010: Environmental Science
SCI030: Forensic Science
OTH010: Skills for Health
OTH020: Physical Education*
OTH040: Reaching Your
Academic Potential*
OTH050: Achieving Your Career
and College Goals*
OTH070: Life Skills
OTH060: Family and Consumer
Science
TCH010: Computer Literacy*
TCH030: Image Design &
Editing
TCH040: Web Design
TCH060: C++ Programming
TCH070: Game Design
TCH017: 3D Art I—Modeling
TCH027 Green Design &
Technology
MTH322 Consumer Math
MTH332 Transition Algebra
WLG100: Spanish I
WLG200: Spanish II
WLG300: Spanish III
WLG110: French I
WLG210: French II
WLG310: French III
WLG120: German I
WLG220: German II
WLG300: German III
WLG400: German IV
WLG500: AP® Spanish
Language
NOTE: *Required courses
Though these courses will probably be available each year, course offerings are dependent upon student enrollment and
staffing.
WAVA HS technology courses are designed for PC-IBM compatible computers only. Macintosh computers are not supported
 All WAVA HS freshman are required to take one semester each of TCH010 Computer Literacy and WAH100.
All grade levels have one additional required elective per semester to serve as a homeroom.
Washington Virtual Academies Enrollment Processing Center 2601 South 35th Street, Ste 100 Tacoma, WA 98409 Ph. 1.866.467.6187 Fx. 1. 866.989.0715 www.k12.com/wava Release of Student Records Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, health and immunization records). Please do not send any records unless this form has been sent to you directly by a Washington Virtual Academies school official. Student Information Student’s Full Name: _____________________________________________________________________________________________________________________ First Middle Legal Last Also known as: Student’s Date of Birth: ________________________________ Home Phone: ____________________________ Student’s Legal Address: __________________________________________________________________________________________________________________ Street Apt # _______________________________________________________________________________________________________________________________________ City County State Zip Code Homeschooled or Never Previously Enrolled in School (fill out only if applicable) Check Below if Applicable: □ Student was always previously homeschooled □ Student is enrolling in Kindergarten □ Has your student ever attended a public school, private school, home school program, or any other accreditated program during his/her education time period? Yes __ No___ If yes, please complete below portion. Prior School Information Current School of Attendance: ____________________________________________________________________________________________________ School Address: _________________________________________________________________________________________________________________________ Street _______________________________________________________________________________________________________________________________________ City County State Zip Code Attended from: _____________________________ School Phone: ____________________________ School Fax: __________________________ Previous School of Attendance (if differs from above):_________________________________________________________________________________ School Address: _________________________________________________________________________________________________________________________ Street _______________________________________________________________________________________________________________________________________ City County State Zip Code Attended from: _____________________________ School Phone: ____________________________ School Fax: __________________________ Recognizing this legal requirement, I hereby verify that the student named above physically resides within Washington State and all of the above provided information is correct. Print name of Parent/Guardian/Student : ____________________________Parent/Guardian/Student Signature: ________________________Date:____________ **All Students 18 Years and Older Must Sign ALL Enrollment Paperwork** SCHOOL OFFICIALS ONLY: Send Records to: Washington Virtual Academies Official Student Records 2601 South 35th Street, Ste 100 Tacoma, WA 98409 Office Use Only:
Certificate of Immunization Status (CIS)
DOH 348-013
Reviewed by:
Date:
Signed Cert. of Exemption on file? 0 Yes 0 No
January 2010
Please print. See back for instructions on how to fill out this form or get
it printed from the Immunization Registry.
First Name:
Middle Initial:
Birthdate (mm/dd/yyyy): Sex:
I certify that the information provided on
Child’s Last Name:
this form is correct and verifiable.
Symbols below:
Vaccine
+ Required for School and Child Care/Preschool
• Required for Child Care/Preschool Only
Dose
Date
Month
Day
Vaccine
Year
+ Hepatitis B (Hep B)
1
2
3
Parent/Guardian Name (please print):
Parent/Guardian Signature Required
Dose
Month
Date
Day
Year
+ Polio (IPV, OPV)
option 1, 2, 3, OR 4 below – see, back #5.
1) 0
Chickenpox disease verified by printout from
CHILD Profile Immunization Registry
Must be marked by printout (not by hand) to be valid.
1
2
3
2) 0 Chickenpox disease verified by Health
Care Provider (HCP)
If you choose this box, mark 2A OR 2B below.
2A)
0 Signed note from HCP attached OR
2B)
0 HCP signed here and print name below:
4
or Hep B - 2 dose alternate schedule for teens
1
2
Rotavirus (RV1, RV5)
1
2
3
+ Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
1
2
3
4
5
+ Tetanus, Diphtheria, Pertussis (Tdap, Td)
1
2
• Haemophilus influenzae type b (Hib)
1
2
3
4
• Pneumococcal (PCV, PPSV)
1
2
3
4
Date
If the child named on this CIS had chickenpox disease (and
not the vaccine), disease history must be verified. Mark
Influenza (flu, most recent)
Licensed health care provider (HCP) Signature
Date
(MD, DO, ND, PA, ARNP)
+ Measles, Mumps, Rubella (MMR)
HCP Printed Name:
1
3) 0 Chickenpox disease verified by school staff
from CHILD Profile Immunization Registry
If you choose this box, staff must initial that parent or
guardian approves:
(initial)
(date)
2
+ Varicella (chickenpox) or verify disease 1-4 
1
2
4) 0 Chickenpox disease verified by parent*
If you choose this box, fill in the date or child’s age when
he or she had the disease:
Age/Date of disease:
*Can ONLY verify for some grades, see back #5 (4).
Hepatitis A (Hep A)
If the child can show immunity by blood test (titer) and
hasn’t had the vaccine, ask your HCP to fill in this box.
1
2
Documentation of Disease Immunity
Meningococcal (MCV, MPSV)
I certify that the child named on this CIS has laboratory
evidence of immunity (titer) to the diseases marked.
Signed lab report(s) MUST also be attached.
1
Human Papillomavirus (HPV)
1
2
3
Office Use Only: Immunization information updated
and verified with parent/guardian permission:
0
0
0
0
0
Diphtheria
Hepatitis A
Hepatitis B
Hib
Measles
0
0
0
0
0
Date
Printed Staff Name
Date
0
Other:
Licensed health care provider (HCP) Signature
(MD, DO, ND, PA, ARNP)
Printed Staff Name
Mumps
Polio
Rubella
Tetanus
Varicella
HCP Printed Name:
Date
Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand.
#1 To print with info filled in: First, ask if your health care provider’s office puts vaccination history into the CHILD Profile Immunization Registry (Washington’s
statewide database). If they do, ask them to print the CIS from CHILD Profile and your child’s information will fill in automatically. Be sure to review all the information, sign
and date the CIS in the upper right hand box, and return it to school or child care. If your provider’s office does
not use CHILD Profile, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):
EXAMPLE
#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box.
#3 Write each vaccine your child received under the correct disease. Write the vaccine type under the “Vaccine”
column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as mm/dd/yyyy). For
example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here 
#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the
Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus,
Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.
Vaccine
Date
Dose
Month
Day
Year
+ Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)
DTaP
01
12
2011
1
DTaP
03
20
2011
2
DTaP
06
01
2011
3
#5 If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS:
1) 0 If your child’s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease verification is
found, box 1 is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand).
2) 0 If your health care provider (HCP) can verify that your child has had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your
HCP, or 2B if your HCP signs and dates in the space provided. Be sure your HCP’s full name is also printed.
3) 0 If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box 3. Then,
they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS.
4) 0 If your child started kindergarten in the 2008-2009 school year or later, you CANNOT use this box. If your child started kindergarten before the 08-09
school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child had chickenpox.
To find out which grades require chickenpox vaccine (or history), visit: http://www.doh.wa.gov/cfh/immunize/schools/vaccine.htm
#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider
(HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.
#7 Be sure to sign and date the CIS in the upper right hand box, and return to school or child care.
#8 If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval.
Vaccine Trade Names in alphabetical order
Trade Name
ActHIB
Adacel
Afluria
Boostrix
Cervarix
Comvax (Cmvx)
Daptacel
Decavac
Vaccine
Hib
Tdap
Flu (TIV)
Tdap
HPV2
Hep B + Hib
DTaP
Td
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Trade Name
Vaccine
Engerix-B
Fluarix
FluLaval
FluMist
Fluvirin
Fluzone
Gardasil
Havrix
Hep B
Flu (TIV)
Flu (TIV)
Flu (LAIV)
Flu (TIV)
Flu (TIV)
HPV4
Hep A
Ipol
Infanrix
Kinrix (Knrx)
Menactra
Menomune
Pediarix (Pdrx)
PedvaxHIB
Pentacel (Pntcl)
IPV
DTaP
DTaP + IPV
MCV or MCV4
MPSV or MPSV4
DTaP + Hep B + IPV
Hib
DTaP + Hib + IPV
Pentavalente
Pneumovax
Prevnar
ProQuad (PrQd)
Quadracel (Qdrcl)
Recombivax HB
Rotarix
RotaTeq
DTaP + Hep B + Hib
PPSV or PPV23
PCV or PCV7 or PCV13
MMR + Varicella
DTaP + IPV
Hep B
Rotavirus (RV1)
Rotavirus (RV5)
TriHIBit
Tripedia
Twinrix (Twnrx)
Vaqta
Varivax
DTaP + Hib
DTaP
Hep A + Hep B
Hep A
Varicella
Vaccine Abbreviations in alphabetical order
Abbreviations
Full Vaccine Name
DT
Diphtheria, Tetanus
DTaP
DTP
(For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)
Trade
Name
Diphtheria, Tetanus,
acellular Pertussis
Diphtheria, Tetanus,
Pertussis
Abbreviations
Hep A (HAV)
Hep B (HBV)
Hib
HPV
Flu
(TIV or LAIV)
Influenza
IPV
HBIG
Hepatitis B Immune
Globulin
MCV or MCV4
(For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)
Full Vaccine Name
Hepatitis A
Hepatitis B
Haemophilus influenzae
type b
Abbreviations
Full Vaccine Name
Meningococcal
Polysaccharide Vaccine
Measles, Mumps, Rubella /
with Varicella
Abbreviations
Rota
(RV1 or RV5)
Td
Tetanus, Diphtheria
Human Papillomavirus
OPV
Oral Poliovirus Vccine
Tdap
Tetanus, Diphtheria, acellular
Pertussis
Inactivated Poliovirus
Vaccine
Meningococcal
Conjugate Vaccine
PCV or PCV7 or
PCV13
Pneumococcal Conjugate
Vaccine
Pneumococcal Polysaccharide
Vaccine
TIG
Tetanus immune globulin
VAR or VZV
Varicella
MPSV or MPSV4
MMR / MMRV
PPSV or PPV23
If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388).
Full Vaccine Name
Rotavirus
DOH 348-013 January 2010
CertificateofExemption
For School, Child Care and Preschool Immunization Requirements1
DIRECTIONS: All exemptions must have a licensed health care provider sign & date Box 1 (‘Provider Statement’).
Exception: Box 1 is not required for religious exemptions when Box 2 (‘Demonstration of Religious Membership’) is completed. All exemptions must also have a
parent/guardian sign & date Box 3 (‘Parent/Guardian Statement’).
Child’s Last Name:
First Name:
Middle Initial:
Birthdate (mm/dd/yyyy): Sex:
2
Parent/Guardian Name (please print):
Parent/Guardian, please choose the exemption(s) that apply to your child below.
0 Temporary Medical Exemption
0 Permanent Medical Exemption
0 Personal/Philosophical Exemption (see Box 1)
0 Religious Exemption (see Box 1)
0 Religious Membership Exemption (see Box 2)
Until
Vaccine(s)
Date (or Permanent)
Print Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)
X
Signature of Licensed Health Care Provider
X
Date
I do not want my child to get the following vaccine(s):
0 Diphtheria
0 Measles
0 Pneumococcal
0 Tetanus
0 Other (indicate):
Box 1
2
Provider Statement : “I,
, am
a qualified provider (MD, DO, ND, PA, ARNP) licensed under Title 18
RCW. I confirm that the parent or guardian signing in Box 3
(Parent/Guardian Statement) has received information on the benefits
and risks of immunization to their child as a condition for exempting
their child for medical, religious, personal, or philosophical reasons.”
X
Signature of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)
X
Date
0 Hepatitis B
0 Hib
0 Mumps
0 Pertussis (whooping cough)
0 Polio
0 Rubella
0 Varicella (chickenpox)
Box 2
Parent/Guardian Demonstration of Religious Membership: “I am a
member of a church or religious body whose beliefs or teachings do not allow
for medical treatment from a health care practitioner. By supplying the
information requested below, no further proof or signed provider statement in
Box 1 is required for this religious exemption.”
X
Name of Church or Religious Body
X
Signature of Parent or Guardian
X
Date
Box 3
Parent/Guardian Statement: “I certify that all the information provided on this certificate is correct and verifiable. I understand that if there is an
outbreak of a vaccine-preventable disease my child has not been fully immunized against (as indicated above, for medical, personal/philosophical or
religious reasons), my child may be at risk for disease and can be excluded from school, child care, or preschool until the outbreak is over.”
X
Signature of Parent or Guardian
X
Date