1. health and fitness

Full/Part Time Enrollment Contract Agreement
I/We _____________________________________________________am/are contracting with Jacquelyn Woodhams for childcare for the following
child/ren_________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Hours of Operation:
The program operates from 5:30am to 11 pm Monday-Sunday. A late fee of $1 per minute will be charged if your child is not picked up by the time
that is specified below. The late fee payment is expected at the time you pick up your child.
Hours of care needed:
You will be charged $_________per_______for
Full Time Part Time care for
Hourly/overnight rates are available only by special arrangement.
MON
Cash Payer
TUES
WED
over
THURS
under 3 years of age for ______ days per week.
FRI
SAT
SUN
CCAP
Payment Options (check one)
Weekly
Biweekly
Monthly (Fees are due before care is provided)
My First Payment will be in the amount of $_____________due on ________________
Monthly Parent Fee
CCAP pays $__________for _____children/wk. (Parent/Guardian is responsible for payment on any days CCAP does not pay)
A $25 late fee charge will be added for not making payment on time when it is due.
A $40 returned check fee will be added for any checks that do not clear my bank.
I understand that payment is based on the hours I agree to use childcare, not the actual hours of attendance. If I reserve a spot for additional
children, or my child to attend an additional day, I will be charged for that day regardless of actual attendance. I understand that I still have to pay
my regular daycare fees regardless of absent days, sick days, and/or vacation days. Appropriate party for any of the following must give a 2 week
written notice signed by both parties:
1. Termination of the agreement by either party
2. Increase in childcare fees
3. Vacation Periods
If no notice is given, and payment is not received, you will be billed for the amount due, your 2 weeks’ notice, plus any additional late charges,
court costs, and/or collection fees.
I acknowledge that I have received a copy of this policy book and enrollment contract of Jackie’s Daycare & I have read it and agree to its
conditions.
Parent or Guardian Signature ________________________________________________________________Date______________________
Parent or Guardian Signature ________________________________________________________________Date______________________
Provider’s Signature ______________________________________________________________________Date______________________
Enrollment Date: ____________________Withdraw Date: ____________________ 2week notice given____________________
ADMISSION AND REGISTRATION PROCEDURE
The following are required on or before the first day of the child’s attendance in my child care home:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
A pre-admission interview in person
A signed statement indicating that you have read, received, and understands my current policy and procedures.
Enrollment form filled out in full.
Immunization records or exemption
List of food allergy.
Emergency Medical Authorization form.
Release of children form.
Sun screen authorization form.
Written authorization for media use.
Must bring formula, wipes, diapers (if needed) change of clothes to be kept in your child/rens cubby along with
their sun screen.
11. Payment of childcare fees (must pay before care is given)
12. Approval notice for CCAP if on CCAP (can be emailed to [email protected] )
I will need within thirty (30) days after admission your child/rens Health & Medication consent forms and to be
signed and dated by a health care provider. It must have a statement on it that includes when the next visit is
required by the healthcare provider.
By signing the policies and procedures document, I __________________________________________ acknowledge
that I have received a copy of this policy book and enrollment contract of Jackie’s Childcare home. I have read it and
agree to follow, to accept the conditions, and to give authorization and approval for the activities described in the
policies.
Parent or Guardian Signature______________________________________________Date___________
Parent or Guardian Signature______________________________________________Date___________
Provider’s Signature_____________________________________________________Date___________
Enrollment Date____________________
1
CHILDREN’S ENROLLMENT RECORD
Date of Enrollment_________________
*Child’s Name_____________________________________________________Nickname_________________________
Home Address______________________________________________________________Zip Code_________________
Home Phone___________________________________Sex M F Age___________Date of Birth____________________
Family Members:____________________________________________________________________________________
*Mother or Guardians Name__________________________________________________________________________
Address if different from childs________________________________________________________________________
Home Phone_______________________Cell Phone_______________________Email____________________________
Name of employment (mother/guardian)________________________________________________________________
Address of employment________________________________Zip Code_____________work phone________________
*Father or Guardians Name___________________________________________________________________________
Address if different from childs________________________________________________________________________
Home Phone_______________________Cell Phone_______________________Email____________________________
Name of employment (father/guardian)________________________________________________________________
Address of employment________________________________Zip Code_____________work phone________________
Special instructions for reaching the parent or guardian____________________________________________________
EMERGENCY CONTACTS
1. Name__________________________________________________Home Phone__________________________
Address_____________________________________________________________________________________
Work Phone______________________________________Relationship to child__________________________
2. Name__________________________________________________Home Phone__________________________
Address_____________________________________________________________________________________
Work Phone______________________________________Relationship to child__________________________
2
CHILD PICK UP INFORMATION
Persons authorized to pick up your child from Jackie’s Childcare (note: must show photo ID)
Name _____________________________________________________________________________________________
Home Phone______________________Work Phone_______________________Cell Phone_______________________
Name _____________________________________________________________________________________________
Home Phone______________________Work Phone_______________________Cell Phone_______________________
Name _____________________________________________________________________________________________
Home Phone______________________Work Phone_______________________Cell Phone_______________________
Persons NOT authorized to pick up your child from Jackie’s Childcare
Name _____________________________________________________________________________________________
Home Phone______________________Work Phone_______________________Cell Phone_______________________
Name _____________________________________________________________________________________________
Home Phone______________________Work Phone_______________________Cell Phone_______________________
Name _____________________________________________________________________________________________
Home Phone______________________Work Phone_______________________Cell Phone_______________________
NOTES____________________________________________________________________________________________
__________________________________________________________________________________________________
3
HEALTH CARE QUESTIONS
Name, address and phone number of your child’s doctor___________________________________________________
__________________________________________________________________________________________________
Name, address and phone number of your child’s dentist___________________________________________________
__________________________________________________________________________________________________
Food Allergies_______________________________________________________________________________________
Other Allergies______________________________________________________________________________________
Chronic Medical conditions____________________________________________________________________________
Does your child have a health care plan? Y/N If yes, the health care plan must be provided on or before the first day.
Is your child fully immunized? Y/N Completed immunization records must be provided on or before the first day.
Operations or serious injuries__________________________________________________________________________
Is the child on any medications? (Explain) ________________________________________________________________
If yes, please describe________________________________________________________________________________
Physical limitations _________Describe if yes_____________________________________________________________
Dietary limitations __________Describe if yes_____________________________________________________________
Vision___________________________________________Hearing____________________________________________
Are there any activities that you prefer that your child NOT participate in? ___________
If so please list: _____________________________________________________________________________________
ALLERGIES (Nature of Reaction)
Hay Fever_____________________________________
Plant Poising___________________________________
Insect stings___________________________________
Penicillin______________________________________
Other drugs____________________________________
Animals_______________________________________
Food _________________________________________
Other_________________________________________
_____________________________________________
_____________________________________________
HEALTH HISTORY (Chronic or recurring)
Ear Infections__________________________________
Diabetes______________________________________
Heart dises/defect ______________________________
Convulsion/seizures_____________________________
Asthma_______________________________________
Nosebleeds____________________________________
Measels ______________________________________
Mumps _______________________________________
Chicken Pox___________________________________
Flu or Flu shot _________________________________
4
EMERGENCY MEDICAL CARE
Hospital of Preference: (Please Check one)
Mckee Medical Center
2000 Boise Avenue
Loveland, Co 80538
(970) 669-4640
Medical Center Of The Rockies
2500 Rocky Mountain Ave
Loveland, CO 80538
(970) 624-2500
Other
Closest Available
Authorization for Emergency Medical Care I hereby give my permission to Jackie’s Childcare to call a doctor or
emergency medical service and for the doctor, hospital or medical service to provide emergency medical or surgical
care for my child, _________________________________________________________________________________
It is understood that the child care provider will make a conscientious effort to locate the parent/guardians and
emergency contacts listed on the registration document before any action will be taken. If it is not possible to
locate emergency contacts listed treatment will not be delayed. I/we will accept the expense of emergency
transportation, medical, or surgical treatment.
By signing this I also understand that my enrollment record must be updated annually and the physicals must be
updated 2, 4, 6, 9, 12, 15, 18, & 24 months, and age 3, 4, 5, 6, 8, 10, & 12 years of age.
Parent/Guardian signatures
____________________________________________________________________Date__________________________
____________________________________________________________________Date__________________________
5
EMERGENCY INFORMATION & AUTHORIZATION FOR TREATMENT & TRANSPORTATION
Child’s Name _______________________________________ Nickname _______________________Date of Birth _____________
Last
First
Home Address ________________________________________________________________ Home Phone____________________
Street
City/State
Zip
Parent/Guardian Name ________________________________________ Cell Phone/Pager _________________________________
Last
First
Employer / School ____________________________________________________________________________________________
Employer/School Address________________________________________________________ Phone__________________ Ext. ___
Street
City/State
Zip
Parent/Guardian Name ________________________________________ Cell Phone/Pager _________________________________
Last
First
Employer / School ____________________________________________________________________________________________
Employer/School Address________________________________________________________ Phone__________________ Ext. ___
Street
City/State
Zip
Alternate Emergency Contact:
(1)_________________________________________________________________________________________________________
Name
Relationship
Phone Number
Cell Phone
Pager
Address ___________________________________________________________________________________________
(2)_________________________________________________________________________________________________________
Name
Relationship
Phone Number
Cell Phone
Pager
Address ___________________________________________________________________________________________
(Front of Card)
Additional Person Authorized to Pick up Child:
(1)_________________________________________________________________________________________________________
Name
Relationship
Phone Number
Cell Phone
Pager
Address ___________________________________________________________________________________________
(2)_________________________________________________________________________________________________________
Name
Relationship
Phone Number
Cell Phone
Pager
Address ___________________________________________________________________________________________
Health Care Facility__________________________________________________________________________________________
Name
Address (if known)
Phone Number
Pager
Allergies/Reactions ___________________________________________________________________________________________
Chronic Illnesses/Special Needs ________________________________________________________________________________
Medications _________________________________________________________________________________________________
Insurance Information _______________________________________________________________________________________
Authorization for emergency medical care and transportation:
In the event of an emergency I hereby give my permission for child care staff to access emergency medical services for my child,
including transport to the nearest health care facility, to receive emergency medical or surgical care and treatment.
It is understood that a conscientious effort will be made to locate me, and I accept the expense of care and transport.
____________________________________________________ _____________________________________________________
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Child Care Facility___________________________________________________________________________________________
Name
Address
Phone
Cell Phone
ANN UAL AUTHORIZATION FORMS
Authorization for Emergency Medical Care
I,
hereby give my permission to
-----------------~
_ __ _ _ __ __ _ __ _ _ __ _to call for medical or surgical care for
my child,
, should an emergency arise. It is understood that a
conscientious effort wi ll be made to locate me before emergency action will be taken, but if th is is not
possible the expenses of emergency medical treatment or care w ill be accepted/paid by me.
Hospital of choice:
Permission fo r Trips
I give permission for my child to go on trips away from the premises of the Family Child Care facility,
in the company of a responsible adult, whether on foot or by vehicle.
, . ,
Permission for Transportation to and from School
I give permission to_____ _ _ __ _ _ _ _ Family Child Care Provider to transport
(n ame of provider)
my child to and from _ _ _ _ _ _ __ _ _ _ _ School.
(name of school)
Permission for Participatio n in Activities
I give permi ssion for my child to participate in program activities except for the following:
I give my permission fo r sunsc reen to be applied to my ch ild before going outside. The sunscreen will be
provided by me _ _ or by the provider_ or both_ _ (please check one).
My ch ild may participate in the use of media as listed in the contract and also including, any provider deemed
appropriate computer games or video games. There will be no higher rating than E/PG for any of these.
YES
NO
Parent/Guardian -------------------~ Date----------~
Parent/Guardian
-------------------~
Parent/Guardian
-------------------~
Date
- ---------Date
----- ------
Additional comments/parameters. Use the back of this sheet if needed.
GENERAL HEALTH APPRAISAL FORM
PARENT please complete AND SIGN
Child’s Name:_______________________________________________________ Birthdate: _____________________
Allergies: q None or Describe___________________________________________________________________________________________
Type of Reaction ____________________________________________________________________________________________________
Diet: q Breast Fed q Formula _______________________ qAge Appropriate
qSpecial Diet ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
q Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding.
I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to
discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school, child care
or camp personnel. FAX #: _____________________________ DATE: _____________________________
Parent/Guardian Signature___________________________________________________________________
HEALTH CARE PROVIDER: Please Complete After Parent Section Completed
Date of Last Health Appraisal: _____________________________ Weight @ Exam: _______________________________________
Physical Exam: q Normal q Abnormal (Specify any physical abnormalities)_____________________________________________________
Allergies: q None or Describe__________________________ Type of Reaction __________________________________________________
Significant Health Concerns: qSevere Allergies qReactive Airway Disease qAsthma qSeizures qDiabetes qHospitalizations
qDevelopmental Delays qBehavior Concerns qVision qHearing qDental qNutrition q Other ________________________________
Explain above concern (if necessary, include instructions to care providers): ______________________________________________________
Current Medications/Special Diet: q None or Describe ______________________________________________________________________
Separate medication authorization form is required for medications given in school, child care or camp
For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT
OR
qAcetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed
Dose ____________________ or see the attached age-appropriate dosage schedule from our office
qIbuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
Dose ____________________ or see the attached age-appropriate dosage schedule from our office
Immunizations: qUp-to-Date q See attached immunization record qAdministered today: _____________________________________________
Health Care Provider: Complete if Appropriate
**ONLY REQUIRED BY EARLY HEAD START AND HEAD START PROGRAMS PER STATE EPSDT SCHEDULE**
** Height @ Exam _____ ** B/P _____ **Head Circumference (up to 12 months) _______ **
** HCT/HGB _____ ** Lead Level qNot at risk or Level _____
**TB qNot at risk or Test Results q Normal q Abnormal
**Screenings Performed: qVision: qNormal qAbnormal qHearing: qNormal qAbnormal qDental: qNormal qAbnormalRecommended Follow-up________________________________________________________________________________________
Provider Signature
Next Well Visit: q Per AAP guidelines* or q Age__________
This child is healthy and may participate in all routine activities in school sports, child care or camp
program. Any concerns or exceptions are identified on this form.
Office Stamp
Or write Name, Address, Phone, #
_____________________________________________________
Signature of Health Care Provider (certifying form was reviewed)
Date: _______________
The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07
*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months, and age 3, 4, 5, 6, 8, 10 and 12
years.
Copyright 2007 Colorado Chapter of the American Academy of Pediatrics
COLORADO LAW REQUIRES THAT THIS FORM BE COMPLETED FOR EACH STUDENT ATTENDING COLORADO SCHOOLS
Name_________________________________________________________________ Date of Birth _______________________________________
Parent/Guardian __________________________________________________________________________________________________________
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT—CERTIFICATE OF IMMUNIZATION
Vaccine
Enter the month, day and year each immunization was given
Hep B
Hepatitis B
DTaP
Diphtheria, Tetanus, Pertussis (pediatric)
DT
Diphtheria, Tetanus (pediatric)
Tdap
Tetanus, Diphtheria, Pertussis
Td
Tetanus, Diphtheria
Hib
Haemophilus influenzae type b
IPV/OPV
Polio
PCV
Pneumococcal Conjugate
MMR
Measles, Mumps, Rubella
Varicella
Chickenpox
Healthcare Provider
Documentation Date _________________________________
Lab Verification Date_________________________________
Vaccines recorded below this line are recommended. Recording of dates is encouraged.
HPV
Human Papillomavirus
Rota
Rotavirus
MCV4/MPSV4
Meningococcal
Hep A
Hepatitis A
TIV/LAIV
Influenza
Other
THIS SECTION CAN BE COMPLETED BY CHILD CARE/SCHOOL/HEALTH CARE PROVIDER
A) Child Care Up to Date
______________________________________________________________
B) Child Care Up to Date
______________________________________________________________
C) Child Care/Pre-school/Pre-K*
______________________________________________________________
D) Complete for K–5th Grade
______________________________________________________________
Up to date through 6 months of age for Colorado School Immunization Requirements
Up to date through 18 months of age for Colorado School Immunization Requirements
Up to date for Child Care/Pre-School/Pre-K for Colorado School Immunization Requirements
Up to date for K–5th Grade for Colorado School Immunization Requirements
Update Signature
Date
Update Signature
Date
Update Signature
Date
Update Signature
Date
* If age 4 years and fulfills Requirements for Pre-School & Kindergarten, check BOTH Boxes C and D.
HAS MET ALL IMMUNIZATION REQUIREMENTS FOR COLORADO SCHOOLS (6TH GRADE OR HIGHER)
Signed ____________________________________________ Title _____________________________________ Date ________________________
(Physician, nurse, or school health authority)
STATEMENT OF EXEMPTION TO IMMUNIZATION LAW (DECLARACIÓN RESPECTO A LAS EXENCIONES DE LA LEY DE VACUNACIÓN)
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS MAY BE SUBJECT TO EXCLUSION FROM SCHOOL AND TO QUARANTINE.
SI SE PRESENTA UN BROTE DE LA ENFERMEDAD, ES POSIBLE QUE A LAS PERSONAS EXENTAS SE LES PONGA EN CUARENTENA O SE LES EXCLUYA DE LA ESCUELA.
MEDICAL EXEMPTION: The physical condition of the above named person is such that immunization would endanger life or health or is medically
contraindicated due to other medical conditions.
EXENCIÓN POR RAZONES MÉDICAS: El estado de salud de la persona arriba citada es tal que la vacunación significa un riesgo para su salud o incluso su vida; o
bien, las vacunas están contraindicadas debido a otros problemas de salud.
Medical exemption to the following vaccine(s):
La exención por razones médicas aplica a la(s) siguiente(s) vacuna(s):
Signed (Firma) _________________________________
Date (Fecha) ____________
Physician (Médico)
Hep B
DTaP
Tdap
Hib
IPV
PCV
MMR
VAR
RELIGIOUS EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a religious belief opposed
to immunizations.
EXENCIÓN POR MOTIVOS RELIGIOSOS: El padre o tutor de la persona arriba citada, o la persona misma, pertenece a una religión que se opone a la inmunización.
Religious exemption to the following vaccine(s):
Exención por motivos religiosos de la(s) siguiente(s) vacuna(s):
Signed (Firma) _________________________________
Date (Fecha) ____________
Parent, guardian, emancipated student/consenting minor
(Padre, tutor, estudiante emancipado o consentimiento del menor)
Hep B
DTaP
Tdap
Hib
IPV
PCV
MMR
VAR
PERSONAL EXEMPTION: Parent or guardian of the above named person or the person himself/herself is an adherent to a personal belief opposed
to immunizations.
EXENCIÓN POR CREENCIAS PERSONALES: Las creencias personales del padre o tutor de la persona arriba citada, o la persona misma, se oponen a la
inmunización.
Personal exemption to the following vaccine(s):
Exención por creencias personales de la(s) siguiente(s) vacuna(s):
Signed (Firma) _________________________________
Date (Fecha) ____________
Parent, guardian, emancipated student/consenting minor
(Padre, tutor, estudiante emancipado o consentimiento del menor)
Hep B
DTaP
Tdap
Hib
IPV
PCV
MMR
VAR
CDPHE-IMM CI RC Rev. 2/12
Table 1. MINIMUM NUMBER OF DOSES REQUIRED FOR CERTIFICATE OF IMMUNIZATION
Level of School/Age of Student
VACCINE a
Child Care
2–3 mos
Child Care
4–5 mos
Hepatitis B l
1
2
Pertussis/Tetanus/
Diphtheria
1
2
Haemophilus
influenzae type b (Hib) j
1
2
Pneumococcal
Conjugate k
1
2
1
2
Polio
e
Child Care
6–7 mos
Child Care
8–11 mos
Child Care
12–14 mos
Child Care
15–18 mos
see
footnote b
4
3/2
3/2/1
Pre-school
2–4 yrs
3
3
2
3/2
3/2
Grades
K to 5
5–10 yrs
K Entry
4–6 yrs
Grades
6 to 12
11–18+yrs
3
3
3
5/4 b
5/4 b c
5/6 c d
4/3 f
4/3 f
4/3 f
see footnote g
2h
2h
2h
see footnote n
n
3/2/1
College
3/2/1
4/3/2 see footnote k
3
Measles/Mumps/
Rubella g
Varicella
Child Care
19–23 mos
1
m
1
2
2/1
n
2/1
2 hi
n
o
Meningococcal
a: Vaccine doses administered no more than 4 days
before the minimum interval or age are to be
counted as valid.
b: Five doses of pertussis, tetanus, and diphtheria
vaccines are required at school entry in Colorado
unless the 4th dose was given at 48 months of age
or older (i.e., on or after the 4th birthday) in which
case only 4 doses are required. There must be at
least 4 weeks between dose 1 and dose 2, at least
4 weeks between dose 2 and dose 3, at least 6
months between dose 3 and dose 4 and at least 6
months between dose 4 and dose 5. The final dose
must be given no sooner than 4 years of age (dose
4 may be given at 12 months of age provided there
is at least 6 months between dose 3 and dose 4). If
a child has received 6 doses of DTaP before the
age of 4 years, no additional doses are required.
c: For students 7 years of age or older who have
not had the required number of pertussis doses, no
new or additional doses are required. Any student 7
years of age or older at school entry in Colorado
who has not completed a primary series of 3 appropriately spaced doses of tetanus and diphtheria vaccine may be certified after the 3rd dose of tetanus
and diphtheria vaccine (or tetanus, diphtheria, and
pertussis vaccine if 10 or 11 years) if it is given 6
months or more after the 2nd dose.
d: The student must meet the minimum prior
requirement for the 4th or 5th doses of diphtheria,
tetanus, and pertussis vaccine and have 1 tetanus,
diphtheria, and pertussis vaccine dose.
requirement is met. For students who began the
series before 12 months of age, 3 doses are
required of which at least 1 dose must have been
administered at 12 months of age or older (i.e., on or
after the 1st birthday). If the 1st dose was given at
12 to 14 months of age, 2 doses are required. If the
current age is 5 years of age or older, no new or
additional doses are required.
k: The number of pneumococcal conjugate vaccine
(PCV) doses required depends on the student’s current age and the age when the 1st dose was administered. If the 1st dose was administered before 6
months of age, the child is required to receive 3
doses 2 months apart and an additional dose
between 12–15 months of age. If started between
7–11 months of age, the child is required to receive
2 doses, two months apart and an additional dose
between 12–15 months of age. For any student who
received the 3rd dose on or after the first birthday, a
4th dose is not required. If the 1st dose was given at
12 to 23 months of age, 2 doses are required. If any
dose was given at 24 months of age through 4
years of age, the PCV vaccine requirement is met. If
the current age is 5 years or older, no new or additional doses are required.
l: For hepatitis B, in lieu of immunization, written evidence of a laboratory test showing immunity is
acceptable. The second dose is to be administered
at least 4 weeks after the first dose, and the third
dose is to be administered at least 16 weeks after
the first dose and at least 8 weeks after the second
e: For polio, in lieu of immunization, written evidence of a laboratory test showing immunity is
acceptable.
f: Four doses of polio vaccine are required at school
entry in Colorado unless the 3rd dose was given at
48 months of age or older (i.e., on or after the 4th
birthday) in which case only 3 doses are required.
There must be at least 4 weeks between dose 1 and
dose 2, at least 4 weeks between dose 2 and dose
3 and at least 6 months between dose 3 and dose
4. The final dose must be given no sooner than 4
years of age. Minimum age/interval does not apply if
4th dose of polio (3rd dose if given after 4th birthday) was administered prior to July 1, 2009.
g: For measles, mumps, and rubella, in lieu of
immunization, written evidence of a laboratory test
showing immunity is acceptable for the specific disease tested. The 1st dose of measles, mumps, and
rubella vaccine must have been administered at 12
months of age or older (i.e., on or after the 1st birthday) to be acceptable.
h: The 2nd dose of measles vaccine or measles,
mumps, and rubella vaccine must have been administered at least 28 calendar days after the 1st dose.
i: Measles, mumps, and rubella vaccine is not required
for college students born before January 1, 1957.
j: The number of Hib vaccine doses required
depends on the student’s current age and the age
when the vaccine was administered. If any dose was
given at 15 months of age or older, the Hib vaccine
dose. The final dose is to be administered at 24
weeks of age (6 months of age) or older and is not
to be administered prior to 6 months of age. Minimum age/interval does not apply to those students
who had 3 doses of the vaccine administered prior
to July 1, 2009.
m: For varicella, written evidence of a laboratory
test showing immunity or a documented disease
history from a health care provider is acceptable.
The 1st dose of varicella vaccine must have been
administered at 12 months of age or older (i.e., on
or after the 1st birthday) to be acceptable.
n: If the second dose of varicella vaccine was
administered to a child before 13 years of age, the
minimum interval between dose 1 and dose 2 is
three months, however, if the second dose is administered at least 28 days following the first dose, the
second dose does not need to be repeated. For a
child who is 13 years of age or older, the second
dose of varicella vaccine must have been administered at least 28 calendar days after the 1st dose.
See Table 2 for the school years/grade levels that
the 1st and 2nd doses of varicella will be required.
o: Information concerning meningococcal disease
and the meningococcal vaccine shall be provided to
each new student or if the student is under 18
years, to the student’s parent or guardian. If the student does not obtain a vaccine, a signature must be
obtained from the student or if the student is under
18 years, the student’s parent or guardian indicating
that the information was reviewed
Table 2. TIMETABLE FOR IMPLEMENTATION OF REQUIREMENTS FOR
SELECTED IMMUNIZATIONS FOR GRADES K TO 12
Refer to Table 1 for the minimum number of doses required for a particular grade level. Table 2 shows the year of implementation for a requirement from
Table 1 and is restricted to varicella vaccine dose 1 (Var1) and dose 2 (Var2) and tetanus, diphtheria, and pertussis vaccine (Tdap). Requirements and
effective dates for other vaccines are listed in Table 1. In this table, after a vaccine is required for grades K to 12, it is no longer shown, but the
requirements listed in Table 1 continue to apply.
Grade Level
School Year
K
1
2
3
4
5
6
7
8
9
10
11
2007–08
Var2
Var1
Var1
Var1
Var1
Var1
Tdap
Var1
Var1
2008–09
Var2
Var2
Var1
Var1
Var1
Var1
Tdap
Var1
Tdap
Var1
Var1
2009–10
Var2
Var2
Var2
Var1
Var1
Var1
Tdap
Var1
Tdap
Var1
Tdap
Var1
2010–11
Var2
Var2
Var2
Var2
Var1
Var1
Tdap
Var1
Tdap
Var1
2011–12
Var2
Var2
Var2
Var2
Var2
Var1
Var1
2012–13 (Var1 required
for grades K to 12)
Var2
Var2
Var2
Var2
Var2
Var2
Var1
2013–14
Var2
Var2
Var2
Var2
Var2
Var2
Var2
2014–15
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
2015–16
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
2016–17
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
2017–18
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
2018–19
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
2019–20 (Var2 required
for grades K to 12)
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
Var2
12
Tdap
Tdap
Tdap
Var1
Tdap
Tdap
Tdap
Tdap
Var1
Tdap
Var1
Tdap
Var1
Tdap
Tdap
Var1
Var1
Var1
Var1
Var1
Var1
Var1
Var1
Var1
Var1
Var1
Var2
SWIMMING PERMISSION FORM
CHILD’S NAME: ________________________________________ DATE: _________
I give permission for my child to swim at the following location:
________________________________________________________________________
For the purpose of:
 Swimming instruction
 Swimming - recreational
There will be a Red Cross certified life guard on duty at all times.
Please give us information regarding your child’s water skills:
 No experience with water
 Has been in water with no formal instruction
 Has taken the following classes: ______________________________
Does your child usually wear floatation devices while in water? ___________
(This would include water wings.)
Any other information you would like to provide:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________
Parent or Guardian Signature
_________________________
Date
____________________________________
Parent or Guardian Signature
_________________________
Date
TOPICAL PREPARATIONS (PREVENTIVE) PERMISSION FORM
This form covers a variety of preventive topical preparations that may be applied to the skin with
parent/guardian permission
Child’s Name
Parent/Guardian’s Name:
_
DIAPER OINTMENT/CREAM
I give my permission for the staff at
to apply over the counter diaper rash
ointment/cream to my child. I understand that I may only provide diaper ointment or cream, free of
antibiotic, antifungal or anti-inflammatory components without a written prescription from my doctor. I
understand I must provide the ointment/cream in the original over the counter container labeled with my
child’s name. Ointment/cream will not be applied to any broken skin or if a skin reaction has been
observed. Any skin reaction observed by staff will be reported promptly to the parent/guardian.
Name of product:
Special instructions:
My child may NOT use any other diaper ointment/cream than the one he or she brings
Parent/Guardian Signature:
Date:
MOISTURIZING LOTION/CREAM/BALM
I give my permission for the staff at
to assist with applying or apply skin
lotion/cream to my child. I understand I must provide the lotion/cream/balm in the original over the counter
container labeled with my child’s name. It is my responsibility to check the ingredients of this product to
ensure my child is not allergic to it. Skin lotion/cream/balm will not be applied to any broken skin or if a
skin reaction has been observed. Any skin reaction observed by staff will be reported promptly to the
parent/guardian.
Name of product:
Special instructions: My child may NOT use any other skin lotion/cream/balm than the one he or she brings
Parent/Guardian Signature:
Date: