The following steps are required to complete re-enrollment:
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1 RE-ENROLLMENT PACKET The following steps are required to complete re-enrollment: Complete IP Re-Enrollment Forms (Online only Information provided in letter and on page 2) Submit updated health documents (Online or in-person See pages 3-6) Complete D.C. Residency Verification Faster options this year for some families (In-person only See page 7) Sign Re-Enrollment Confirmation (In-person only) Your student is officially enrolled for the school year at Ingenuity Prep! Deadline: May 1, 2019
2 Re-Enrollment Form 1: Go to ingenuityprep.schoolmint.com and sign in with the username provided and your password from last year. If you forgot your password, click Forgot Password? 2: Edit student forms for each returning student 3: Complete forms You may Save Progress at any time after completing your profile. Be sure to click Submit Forms when you are ready to submit. Deadline: May 1, 2019
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4 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): Name/ID Number Part 2: Child s Health History, Examination & Recommendations DATE OF HEALTH EXAM: WT LBS KG HGB / HCT (Required for children under age 6) Vision Screening Right 20/ Left 20/ HT IN CM Glasses Referred Attempted Health Practitioner: Form must be fully completed. BP: (>3yrs) NML Body Mass Index ABNL Hearing Screening Pass Fail (BMI) % Device Referred Attempted HEALTH CONCERNS: REFERRED or TREATED HEALTH CONCERNS: REFERRED or TREATED Asthma Referred Under Rx Language/Speech YES Referred Under Rx NO YES NONE Seizures Referred Under Rx Development/ YES Referred Under Rx NO YES Behavioral NONE Diabetes NO YES Referred Under Rx Other NONE YES Referred Under Rx ANNUAL DENTIST VISIT: Has the child seen a Dentist/Dental Provider within the last year? YES NO Referred Fluoride Varnish Date: A. Significant health history, conditions, communicable illness, or restrictions that may affect school, child care, sports, or camp. NONE YES, please provide details: B. Significant food/medication/environmental allergies that may require emergency medical care at school, child care, camp, or sports activity. NONE YES, please provide details: C. Long-term medications, over-the-counter-drugs (OTC) or special care requirements. NONE YES, please provide details. (For any medications or treatment required during school hours, a Licensed Health Practitioner s Medication Plan or Medication Authorization Order should be submitted with this form). Part 3: Tuberculosis & Lead Exposure Risk Assessment & Testing: TB RISK ASSESSMENTS HIGH Tuberculin Skin Test NEGATIVE (TST) DATE: POSITIVE If TST Positive CXR NEGATIVE CXR POSITIVE TREATED (>2 yrs) Health Practitioner: POSITIVE TST should be referred to PCP for evaluation. For questions, call T.B. Control: LOW LEAD EXPOSURE RISKS LEAD TEST DATE: RESULT: Health Practitioner: ALL lead levels must be reported to DC Childhood Lead and Healthy Housing Program: Fax: Part 4: Required Licensed Health Practitioner s Certification and Signature YES NO This child has been appropriately examined & health history reviewed and recorded in accordance with the items specified on this form. At time of the 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/APRN/NP Signature Date Address Phone Fax Part 5: Required Parental/Guardian Signatures. (Release of Health Information/civil liability waiver) 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. In addition, I hereby acknowledge and agree that the District, the school, its employees and agents shall be immune from civil liability for acts or omissions under DC Law , except for criminal acts, intentional wrongdoing, gross negligence, or willful misconduct. Print Name Signature Date
5 DISTRICT OF COLUMBIA UNIVERSAL HEALTH CERTIFICATE Section 1: Immunization: Please fill in or attach equivalent copy with Licensed Health Practitioner s signature and date. IMMUNIZATIONS RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN 5 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 5 1 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 Practitioner) Name & Title Other Signature of Licensed Health Practitioner Print Name or Stamp Date Section 2: MEDICAL EXEMPTION. For Licensed Health Practitioner 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 Licensed Health Practitioner Print Name or Stamp Date Section 3: Alternative Proof of Immunity. To be completed by Licensed Health Practitioner 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 Licensed Health Practitioner Print Name or Stamp Date
6 District of Columbia Immunization Requirements 1 School Year All students attending school in the District of Columbia must present proof of appropriately spaced immunizations by the first day of school. A Child 2 years or older entering Preschool or Head Start 4 Diphtheria/Tetanus/Pertussis (DTaP) 3 Polio 1 Varicella (chickenpox) if no history of disease 2 1 Measles, Mumps & Rubella (MMR) 2 Hepatitis A 3 or 4 Hib (Haemophilus Influenza Type B) 3 4 PCV (Pneumococcal) A student 4 years old entering Pre-Kindergarten 5 Diphtheria/Tetanus/Pertussis (DTaP) 4 Polio 2 Varicella (chickenpox) if no history of disease 2 2 Measles, Mumps & Rubella (MMR) 2 Hepatitis A 3 or 4 Hib (Haemophilus Influenza Type B) 3 4 PCV (Pneumococcal) A student 5 10 years old entering Kindergarten thru Fifth Grade 5 Diphtheria/Tetanus/Pertussis (DTaP) 4 Polio 2 Varicella (chickenpox) if no history of disease 2 2 Measles, Mumps & Rubella (MMR) 2 Hepatitis A (if born on or after 01/01/05) A student 11 years & older entering Sixth thru Twelfth Grade 5 Diphtheria/Tetanus/Pertussis (DTaP/Td) 1 Tdap (if five years since last dose of DTP/DTaP/Td) 4 Polio 2 Varicella (chickenpox) if no history of disease 2 2 Measles, Mumps & Rubella (MMR) 1 Meningococcal 3 Human Papillomavirus Vaccine (HPV) Students in grades 6 thru 10 or parent may sign approved vaccine refusal form available at 1 At all ages and grades, the number of doses required varies by a child s age and how long ago they were vaccinated. Please check with your child s school nurse or health care provider for details. 2 All Varicella/chickenpox disease histories MUST be verified/diagnosed by a health care provider (MD, NP, PA, RN) and documentation MUST include the month and year of disease. 3 The number of doses is determined by brand used.
7 D.C. Residency Verification Guide School Year How can I show my D.C. Residency? 1. Collect documentation of your address. The document(s) must have your current address and your name. The documents must belong to the same person (i.e., both belong to Mom or Dad, not one from each parent). 2. The person whose name is on the documents must bring them in-person to the school. 3. When you bring the documents to the school, you will sign a simple form stating that you are the legal caregiver for your student and that you have not falsified any of the documents. What documents can I use for residency verification? Choose one from List A or two from List B. Special Note: If you receive DC financial assistance, such as TANF, Medicaid, food stamps, or housing assistance, you may not need to submit documents. Please ask to speak with Ms. Amanda for more information. I don t have the right documents. What should I do? Call Ingenuity Prep at (202) as soon as possible for additional assistance. We are not able to extend the enrollment deadline for missing residency documents. List A Provide one of these documents Pay stub from the last 45 days, showing your D.C. address AND D.C. taxes Financial assistance from D.C. Government such as TANF, Medicaid, or housing assistance from the last 12 months Supplemental Security Income showing current benefits, dated in the last 12 months Tax information authorization form D-40 for the previous tax year List B Provide two of these documents D.C. car registration that has not expired Lease agreement AND receipt of rent payment with the receipt dated within the last two months D.C. Driver s License or government-issued ID One utility bill with separate proof of payment dated in the last 2 months Military Housing Orders or DEERS statement, as long as the student s name is on the form Proof that the student is a ward of D.C. Embassy letter dated on or after April 1, 2018
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