2015 YMCA OF BOULDER VALLEY REGISTRATION FORM: PAGE 1 General and Emergency Pickup Information Must be completed annually and updated as needed.

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1 2015 YMCA OF BOULDER VALLEY REGISTRATION FORM: PAGE 1 General and Emergency Pickup Information Must be completed annually and updated as needed. Please print clearly. One form is required for each child. Additional copies are available at ymcabv.org or at the Arapahoe or Mapleton Ys. Fully complete all forms. All fields are required. form to reg@ymcabv.org or mail to or drop off at: YMCA of Boulder Valley, Registration 2800 Dagny Way, Lafayette, CO For registration questions, contact stacie.hoffmann@ymcabv.org or call x3996. REGISTRATION CHECKLIST. DON T MISS A STEP! General Information Emergency Pickup & Authorization Health History Information & Immunization Medical Authorization & Release Supplemental Health Forms (Camp Santa Maria Only) Program and Payment Option Sign Parent/Guardian Agreement Sign All Agreements Review the Parent/Guardian Handbook available online GENERAL INFORMATION Child s Name Returning Participant New Participant Address City State Zip Gender Birthdate Age at Camp Grade Entering in 2015 School Parental Custody Child Lives With: Mom Dad Both Other Parent/Guardian 1 Name Gender DOB Relationship to Child Address City State Zip Home Phone Cell Phone Place of Employment Phone Address (All updates sent by . Please print clearly.) Parent/Guardian 2 Name Gender DOB Relationship to Child Address City State Zip Home Phone Cell Phone Place of Employment Phone Address (All updates sent by . Please print clearly.) EMERGENCY CONTACTS AND PICKUP AUTHORIZATIONS In addition to parents, ONLY those on the below list will be allowed to pickup a child from a Y program. I understand that the following contacts must be at least 18 years old and have photo ID. Myself or one of the below listed contacts will be available to pick up my child and/or assume emergency responsibility within a half an hour should an emergency or illness occur. I accept responsibility for informing the YMCA, in writing, when the information changes. If you want to limit the contacts below to emergency contact only, please check the box below: EC=Emergency Contact Only Name Address Age Relationship Home Phone Cell Phone Work Phone EC Name Address Age Relationship Home Phone Cell Phone Work Phone EC Name Address Age Relationship Home Phone Cell Phone Work Phone EC PARTICIPATION AGREEMENT AND RELEASE: Please read very carefully and sign. Please contact the Y with any questions. I am aware of all Y program activities and allow my child to participate fully unless otherwise noted on this form. I allow and hereby certify that my child named herein is capable of safely participating in Y program activities including field trips and swimming. I indemnify and hold harmless the YMCA, any officer, volunteer or employee of the YMCA and all involved with YMCA programs from liability for any harm that befalls my child as a result of participation in YMCA program. I consent, unless noted, that photographs and video taken of him or her are the property of the YMCA of Boulder Valley and may be reproduced and publicized for program and marketing purposes, free of claims on my part. I agree to allow my child to be transported by BVSD or other district bus, YMCA vehicles, RTD bus or walking. I understand that children in day programs must be signed in and out every day by an authorized adult 18 years and older. Parents and any of my emergency pick up/contacts must have a photo ID available to show staff every day. I agree to adhere to all program policies published by the Y. Signature Printed Name Date

2 2015 YMCA OF BOULDER VALLEY REGISTRATION FORM: PAGE 2 Health History and Medical Release Information Child s Name CAMPER HEALTH HISTORY INFORMATION May participate in all activities Please restrict from these activities: Current medical, mental or psychological condition pertinent to routine care of child including any current treatment/care (i.e. interests, guidance techniques, current chronic illnesses, current fears, life impacting events): Additional information you feel helpful: ne Yes: Routine Medications: Include prescription, holistic/over the counter, vitamins, lotions, lip balms, etc. 1. Times: For: 2. Times: For: Must fill out a YMCA medication release form signed by physician and parent if medications are needed during program times. Pick up at either Y or download at ymcabv.org. Please refer to Parent Handbook for specific regulations. IMMUNIZATION RECORDS: You must provide an immunization record on a form approved by the Colorado Department of Health and Human Services (a print out from your child s school, physician s office or immunization card completed and signed). ne Yes: ALLERGIES/ASTHMA Type: Reactions if exposed: Treatment: You must also complete a YMCA allergy/asthma treatment form for any condition requiring medication or emergency treatment. Pick up at either Y or download at ymcabv.org. ne Yes: DIETARY RESTRICTIONS: Reason: Reaction: You may be required to provide healthy snacks which accommodate your child s dietary restrictions. Does your child have an I.E.P. with his/her school: NO YES (Please attach a copy if applicable to your child s care with the Y) Any special need/accommodation/restriction must be determined with the parents/guardian, program director and VP of program and approved at least 4 weeks prior to start date. Attendance for children who require additional staffing is dependent on availability of staff and may be at family s expense. Please refer to Special Needs Policy in Parent Handbook. MEDICAL CONTACTS/INFORMATION Physician Address Phone Dentist Address Phone Hospital Preference Address Phone Insurance Co. Policy # ID# MEDICAL AUTHORIZATION AND LIABILITY RELEASE: Please read very carefully and sign. Please contact the Y with any questions. In case of illness or emergency, as parent/legal guardian, I authorize the Y program director or trained and certified personnel to provide care or secure the services of a doctor if necessary. I hereby hold harmless the YMCA staff, volunteers and all involved with YMCA programs from liability for any accidents resulting from participation and consent to the YMCA to secure emergency care as needed or prescribed for my child, at my expense. This care may be given under whatever conditions are necessary to preserve life, limb or well being of my child. I also give permission to the YMCA to provide transportation as needed for my child in case of an emergency, at my expense. I understand that it is my responsibility to inform the YMCA of any changes to my child s health. I understand that medical information and personal data will be used only in Y programs, when necessary, to protect a child s well being. Parent/Guardian Signature: Deep Water Swim: If you would like your child to take a test to participate in deep water swim (above his/her nipple line) on YMCA swim field trips, please sign below. te: All campers attending Camp Santa Maria will be swim tested. Parent/Guardian Signature: Person(s) restricted from contact with RESTRAINING ORDER/photo attached: Please provide any of the information below which is available. In the event that this person should try to pick up child, the staff will contact the police, contact you and do everything possible to prevent them from taking your child, without risking the safety of the participants and staff. Name: Age: Relationship to child: Last Known Address City State Zip Home Phone: Cell Phone: Work Phone: Court Order Date I understand that if the 2nd parent/legal guardian is not available to sign this form, I take full responsibility in informing him/her of all policies. 1ST PARENT/LEGAL GUARDIAN Print Name: Signature: Date: 2ND PARENT/LEGAL GUARDIAN Print Name: Signature: Date:

3 2015 YMCA OF BOULDER VALLEY/ CAMP SANTA MARIA REGISTRATION FORM: PAGE 3 Supplemental Health History INSTRUCTIONS: Supplemental health forms must be fully completed. A copy of a physical exam completed within the last 12 months must be submitted to attend camp. Immunization records or exemption must be included. For any questions, review form with your child s health care provider. Child s Name Returning Participant New Participant Address City State Zip Gender Birthdate Age at Camp Grade Entering in 2015 School 1st Parent/Guardian to be contacted in case of illness Phone 2nd Parent/Guardian to be contacted in case of illness Phone GENERAL HEALTH HISTORY (Select answer. Explain yes answers below.) 11. Had fainting or dizziness?... YES / NO 1. Ever been hospitalized?... YES / NO 12. Passed out/had chest pain during exercise? YES / NO 2. Ever had surgery? YES / NO 13. Had mononucleosis (mono) during past 12 months? YES / NO 3. Have recurrent/chronic illness? YES / NO 14. If female, problems with periods/menstruation? YES / NO 4. Had a recent infectious disease? YES / NO 15. Have problems with falling asleep/sleepwalking? YES / NO 5. Had a recent injury? YES / NO 16. Ever had back/joint problems? YES / NO 6. Have asthma/wheezing/shortness of breath? YES / NO 17. Have a history of bedwetting? YES / NO 7. Have diabetes? YES / NO 8. Had seizures? YES / NO 18. Have problems with disrrhea/constipation? YES / NO 9. Had headaches? YES / NO 19. Have any skin problems? YES / NO 10. Wear glasses, contacts or protective eyewear? YES / NO 20. Traveled outside the country in the last 9 months? YES / NO Please explain Yes answers, noting the number of the questions. For travel outside of the country, please name countries visited and dates of travel. Additional information you feel helpful: MENTAL, EMOTIONAL AND SOCIAL HEALTH HISTORY (Select answer. Explain yes answers below.) 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? YES / NO 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? YES / NO 3. During the past 12 months, seen a professional to address mental/emotional health concerns? YES / NO 4. Had a significant life event that continues to affect the camper s life? YES / NO Please explain Yes answers, noting the number of the questions. Additional information you feel helpful: NON-PRESCRIPTION MEDICATIONS: The following medications are commonly stocked in the camp Health Center and are used on an as needed basis to manage illness or injury. Select or cross out those items the camper should not be given. If your camper requires any routine medications at camp, to include vitamins, the medical authorization on page 4 must be completed and signed by a physician. Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Phenylephrine (Sudafed PE) Pseudoephedrine (Sudafed) Chlorpheneramine maleate Guaifenesin Dextromethorphan Diphenhydramine (Benadryl) Generic cough drops Chloraseptic (Sore throat spray) Lice shampoo or scabies cream (Nix or Elimite) Calamine lotion Bismuth subsalicylate (Pepto-Bismol) Laxatives for constipation (Ex-Lax) Hydrocortisone 1% cream Topical antibiotic cream Aloe 1ST PARENT/LEGAL GUARDIAN Print Name: Signature: Date: 2ND PARENT/LEGAL GUARDIAN Print Name: Signature: Date:

4 2015 YMCA OF BOULDER VALLEY/CAMP SANTA MARIA REGISTRATION FORM: PAGE 4 Supplemental Health History PARENT/GUARDIAN: Complete top section and give this form (page 4) and a copy of your completed Supplemental Health History form (page 3) to your child s health-care provider for review. Camper Name: Gender Age On Arrival At Camp: DOB: Parent/Guardian: DOB: Home Phone: Cell Phone: Work Phone: HEALTH CARE PROVIDER: Please review the Supplemental Health History form (page 3) and complete all remaining sections of this form (page 4). Attach additional information if needed. If physical exam is not completed during office visit please provide a signed copy of the most recent physical completed with in the last 12 months. PHYSICAL EXAM (ACA accreditation standards specify physical exam completed within last 12 months.) Physical exam completed today: YES / NO...If, date of last physical (mm/dd/yr.): Weight (lbs): Height (ft, in): Blood Pressure ALLERGIES/ASTHMA: ne Known / Yes Allergy (list foods, medications, environment, other): Symptoms which occur: Recommended Treatment: Asthma Health Care Plan (list trigggers, medications, inhaler use): MEDICATIONS: daily medications / Yes, will take the following medication(s) while at camp (name, dose, frequency-describe below) NON-PRESCRIPTION MEDICATIONS: The following medications are commonly stocked in the camp Health Center and are used on an as needed basis to manage illness or injury. Select or cross out those items the camper should not be given. Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Phenylephrine (Sudafed PE) Pseudoephedrine (Sudafed) Chlorpheneramine maleate Guaifenesin Dextromethorphan Diphenhydramine (Benadryl) Generic cough drops Chloraseptic (Sore throat spray) Lice shampoo or scabies cream (Nix or Elimite) Calamine lotion Bismuth subsalicylate (Pepto-Bismol) Laxatives for constipation (Ex-Lax) Hydrocortisone 1% cream Topical antibiotic cream Aloe MEDICAL TREATMENTS: ne / Yes, the camper is undergoing treatment at this time for the following condition (describe below) Other treatments/therapies to be continued at camp: ne RESTRICTIONS: restrictions / Yes, the camper will require limitations or restrictions to the following activities while at camp (describe below) I have reviewed the Supplemental Health History form (page 3) and have discussed the camp program with the camper s parent(s)/guardian(s). It is in my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above). NAME OF LICENSED PROVIDER Print Name: Signature: Date: Office Address: Phone :

5 2015 YMCA OF BOULDER VALLEY/ CAMP SANTA MARIA REGISTRATION FORM: PAGE 5 Camp Options Fully complete all forms. All fields are required. Y Member / n-member CAMPER INFORMATION (Please fill out one form for each camper.) Camper Name: School Grade Entering: DOB: Parent/Guardian: DOB: Home Phone: Cell Phone: Work Phone: Y Member: YES / NO Card# Please complete the following if you have not registered online. CAMPS (Check the camp session and date you are registering for. Camp session weeks are Sunday-Saturday.) Pathfinders: Ages 7-10 year olds PATHFINDERS (One Week s) S1* 6/7 S2* 6/14 S3 6/21 S4 6/28 S5 7/5 S6 7/12 S7 7/19 S8 7/26 S9 8/2 Rates: (M/NM): $640/$665 *session rates (M/NM): $620/$645 Horseback Riding: Fee: $45 Weekend Stayover: $50 May select only if registering for multiple consecutive sessions Trekkers: Ages year olds TREKKERS (One Week s) S1* 6/7 S2* 6/14 S3 6/21 S4 6/28 S5 7/5 S6 7/12 S7 7/19 S8 7/26 S9 8/2 Rates: (M/NM): $640/$665 *session rates (M/NM): $620/$645 BASE CAMP Rates: (M/NM): $640/$665 *session rates (M/NM): $620/$645 Horseback Riding: Fee: $45 Rafting: Fee: $65 Weekend Stayover: $50 May select only if registering for multiple consecutive sessions TREKKERS (Two Week s) S1/2* 6/7-6/20 S3/4 6/21-7/4 S5/6 7/5-7/18 S7/8 7/19-8/1 Rates: (M/NM): $1,240/$1,290 * Rates 1/2: (M/NM): $1,140/$1,190...W Horseback Riding: Fee: $45 Rafting: Fee: $65 Weekend Stayover: $50 May select only if registering for multiple consecutive sessions Mini Camp: Ages 6-8 year olds MINI CAMP Sunday, August 9 - Wednesday, August 12 Rate: (M/NM): $405/$430 Mini-Camp is a four-day, three night session ESSION RATE OFFICE USE ONLY: Intake Name: Intake Date: Entry Date: Member#: Copied:

6 2015 YMCA OF BOULDER VALLEY/ CAMP SANTA MARIA REGISTRATION FORM: PAGE 6 Camp Options Continued and Payment Information Child s Name Y Member / n-member Teen Camps: Ages (Check the session date of the camp you are registering for. Only multiple consecutive sessions require weekend stayover.) TEEN ADVENTURE: AGES (Weekend Stayover Yes) SESSION DATE 6/7* 7/5 6/14 7/12/ 7/26 6/28 7/19 6/7 6/21 7/19 SKILL Climbing Kayaking Wilderness Survival Backpacking FEE (M/NM) $670/$695 (*$635/$660) $670/$695 $670/$695 $670/$695 OUTDOOR ADVENTURE CAMP: AGES (Weekend Stayover Yes) SESSION DATE 6/7 6/21 7/5 FEE (M/NM) $635/$660 $670/$695 $670/$695 TEEN LEADERS: AGES (Weekend Stayover Yes) SESSION DATE 1/2: Sunday, June 7- Saturday, June 20 5/6: Sunday, July 5- Saturday, July 18 FEE (M/NM) $1,105/$1,155 $1,205/$1,255 COUNSELOR IN TRAINING: AGES (Weekend Stayover Yes) SESSION DATE 3/4: Sunday, June 21- Saturday July 4 7/8: Sunday, July 19- Saturday, August 1 FEE (M/NM) $655/$705 $655/$705 YMCA Financial Assistance participants must be authorized BEFORE REGISTERING. For more information call x2730 or elizabeth.baker@ ymcabv.org BEFORE registering. CAMP FEES: Camp fees must be paid in full prior to camp start date. Participant must be the active member to receive member rates (M) or non-member (NM) rates will apply. Special session fees for June weeks (6/-6) are noted on form. CANCELLATIONS: Refunds or credits, less $100 per week per participant will be authorized when a cancellation form is submitted at least 2 weeks in advance of camp start date. credits or refunds without a 2 week written notice. refunds will be given if there is a balance owed for any Y program. CHANGE FEES: A $25 change fee will be assessed per week when camp week changes are submitted on an add/change/cancellation form at least 1 week in advance of program start date. ADDS: Additional camp weeks can be added after initial registration by submitting an add/change/cancellation form or registering online 1 week prior to camp start date. PAYMENT OPTIONS: Camp fees may be paid in full upon registration or remaining balance will be automatically drafted per fee schedule below. For drafted balances YOU MUST: 1.) Register at least 2 weeks prior to the draft date; 2.) Pay a $100 per week non-refundable deposit; 3.) Provide an approved debit or credit card for scheduled balance payments. $ Total Camp Fees $ Total Fees Paid At This Time $ Balance Due Payment Method I have enclosed a check for $ Check# OR Credit/Debit (check one) VISA MC AMEX DISC Name on Card: Card# Exp. VCODE Signature Date Fee Schedule: By providing my signature below, I authorize the YMCA of Boulder Valley to charge my credit card on the following dates: $ on May 1, 2014 for registered s 1-4 (6/7-6/28) $ on June 1, 2014 for registered s 5-9 (7/5-8/2) $ on July 1, 2014 for Mini-Camp (8/9-8/12) Y COMMUNITY SUPPORT CAMPAIGN One in three of our participants attend camp on some form of scholarship. If your family would like to help another child attend camp, please add a donation amount. $ I/We understand and agree to the above payment terms. I/We understand that completion of all required summer camp forms is a required condition of participation in summer camp programs. 1ST PARENT/LEGAL GUARDIAN Print Name: Signature: Date: 2ND PARENT/LEGAL GUARDIAN Print Name: Signature: Date:

7 2015 YMCA OF BOULDER VALLEY/CAMP SANTA MARIA REGISTRATION FORM: PAGE 7 Letter To Counselor & Cabinmate Request Child s Name: (s) Attending: Photo: Please attach a current photo of your camper or provide a photo upon check-in of session date. Cabinmate Request: (Request cannot be guaranteed, age must be within one year of your camper and be a mutual request. Please include first and last name(s): 1)_ 2)_ PARENT/GUARDIAN QUESTIONNAIRE 1) Has your child been away from or at an overnight camp before? / Yes, please explain 2) What would you like your child to gain from their camp experience this summer? 3) Please list any special behaviors or circumstances that the camp staff should be aware of: 4) Please list all household members and relationship to the child: CAMPER QUESTIONNAIRE 1) Nickname or name you go by: 2) If you have been to camp before, what did youlike about it? What didn t you like about it? 3) What are you looking forward to at camp this summer? 4) What actvities are you interested in doing at camp? 5) Is there anything that you are nervous about at camp? 6) Additional comments:

8 COLORADO LAW REQUIRES THIS FORM BE COMPLETED AND PROVIDED TO THE SCHOOL Name Date of Birth Parent/Guardian COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT CERTIFICATE OF IMMUNIZATION VACCINE Enter date each immunization was given DTaP Td/DT OPV/IPV Hib Diphtheria-Tetanus-Pertussis (see footnote c below) Tetanus-Diphtheria Polio Haemophilus influenzae type b Required for children < 5 yrs. of age. (see footnote j below) Measles Measles Varicella and the first MMR cannot be given more than four days before the first birthday to be considered valid for school Mumps Mumps requirements. Written evidence of laboratory tests showing immunity to measles, Rubella Rubella mumps, rubella, polio, and hepatitis B is acceptable. Attach written proof to this Certificate or record test results and dates in the boxes at left. HB Hepatitis B Varicella Chickenpox History of disease. Yes year (optional) (see footnote e below) Other To the best of my knowledge, the person named above has received the above immunizations. DO NOT SIGN UNLESS MINIMUM IMMUNIZATION REQUIREMENTS ARE MET Signed Title Date (Physician, nurse, or school health authority) Table 1. MINIMUM NUMBER OF DOSES REQUIRED FOR CERTIFICATE OF IMMUNIZATION Level of School/Age of Student Vaccine Child Care 2 3 mos See Table 2 (on back of certificate) for the year of implementation of Measles, Mumps, and Rubella (MMR-second dose) and Varicella (VAR). Footnotes: * The requirements for the 4 th and 5 th doses of diphtheria, tetanus, and pertussis vaccines will be reinstated September 15, Vaccine doses administered 4 days before the minimum interval or age are be counted as valid. a This requirement is indefinitely suspended. b Five doses of pertussis, tetanus, and diphtheria vaccines are required at school entry in Colorado unless the 4 th dose was given at 48 months (i.e., on or after the 4 th birthday) in which case only 4 doses are required. Vaccine doses administered 4 days before the minimum interval or age are to be counted as valid. c For students 7 years who have not had the required number of pertussis doses, no new or additional doses are required. d Any student 7 years 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 3 rd dose if it is given > 6 months after the 2 nd dose. e For polio, measles, mumps, rubella, or hepatitis B, in lieu of immunization, written evidence of a laboratory test showing Child Care 4 5 mos Child Care 6 14 mos Child Care mos Pre-school mos immunity is acceptable for the specific disease tested. For varicella, a laboratory test showing immunity or a disease history from a health care provider, parent, or guardian is acceptable. f Four doses of polio vaccine are required at school entry in Colorado unless the 3 rd dose was given 48 months (i.e., on or after the 4 th birthday) in which case only 3 doses are required. Vaccine doses administered 4 days before the minimum interval or age are to be counted as valid. g The 1 st dose of measles, mumps, and rubella vaccine and varicella vaccine must have been administered at 12 months of age (i.e., on or after the 1 st birthday) to be acceptable. Vaccine doses administered 4 days before the minimum interval or age are to be counted as valid. h If the student received a 2 nd measles dose prior to July 1, 1992, the 2 nd rubella and mumps doses are not required. The 2 nd dose of measles vaccine or measles, mumps, and rubella vaccine must have been administered at least 28 calendar days after the 1 st dose. Vaccine doses administered 4 days before the minimum interval or age are to be counted as valid. i Measles, mumps, and rubella vaccine is not required for college students born before January 1, Pre-school mos Pre-school 3 4 yrs Grades K yrs Pertussis * 4* 4* 5 b,+,c,* Tetanus/Diphtheria * 4* 4* 5 b,+,d,* Polio e f,+ Measles/Mumps/Rubella e,g, h 2 h,i Haemophilus influenzae type B /2/1 j 3/2/1 j 3/2/1 j 3/2/1 j Pneumococcal Conjugate a, /2 k 4/3/2 k 4/3/2 k Hepatitis B Varicella + 1 g 1 g 1 g 1 g College j The number of Haemophilus influenzae type be (Hib) vaccine doses required depends on the student s current age and the age when the Hib vaccine was administered. If any dose is given 15 months, the Hib vaccine requirement is met. For students who begin the series < 12 months, 3 doses are required of which at least 1 dose must be administered at 12 months (i.e., on or after the 1 st birthday). If the 1 st dose is given at months, 2 doses are required. If the current age is 5 years, no new or additional doses are required. Vaccine doses administered 4 days before the minimum interval or age are to be counted as valid. k The number of pneumococcal conjugate vaccine doses depends on the student s current age and the age when the 1 st dose was administered. If the 1 st dose was administered at: (i) 6 months of age, 3 doses are required at 6 14 months and 4 doses are required at months of age with 1 dose administered on or after the 1 st birthday; (ii) 7 11 months of age, 2 doses are required at 6 14 months and 3 doses are required at months of age with 1 dose on or after the 1 st birthday; (iii) months of age, 2 doses are required. If the current age is 2 years, no new or additional doses are required. Vaccine doses administered 4 days before the minimum interval or age are to be counted as valid.

9 Name Date of Birth 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) 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) 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 CDPHE-DCEED-IMM CI RC14#10 Rev. 5/05 (Padre, tutor, estudiante emancipado o consentimiento del menor) Table 2. TIMETABLE FOR IMPLEMENTATION OF REQUIREMENTS FOR SELECTED IMMUNIZATIONS FOR GRADES K 12 Below is a partial chart of specific immunization requirements. By , the measles, mumps and rubella (MMR) vaccine (second dose) will be required for K 12. By , the varicella (VAR) vaccine will be required for grades K 12. The school year is July 1 through June 30. In Table 2, after a vaccine is required for grades K 12, it is no longer shown, but the requirements listed in Table 1 continue to apply. School Year Grade Level K MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 VAR VAR VAR VAR VAR VAR MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR#2 MMR required VAR VAR VAR VAR VAR VAR VAR for K VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR VAR required for K 12