MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE CHILD'S NAME LAST FIRST MI SEX: MALE FEMALE BIRTHDATE /_/ COUNTY _ SCHOOL GRADE PARENT NAME PHONE NO. _ OR GUARDIAN ADDRESS CITY ZIP RECORD OF IMMUNIZATIONS (See Notes On Other Side) Dose # DTP-DTaP-DT Polio Hib Hep B PCV Vaccines Type Rotavirus MCV HPV 1 1 Dose # Hep A MMR Varicella History of Varicella Disease Mo/Yr 2 2 3 4 5 Td Tdap FLU Other To the best of my knowledge, the vaccines listed above were administered as indicated. 1. _ Signature Title Date (Medical provider, local health department official, school official, or child care provider only) 2. _ Signature Title Date 3. _ Signature Title Date Clinic / Office Name Office Address/ Phone Number Lines 2 and 3 are for certification of vaccines given after the initial signature. LOST OR DESTROYED RECORDS: (Must be reviewed and approved by a medical provider or the local health department. See notes) I hereby certify that the immunization records of this child have been lost, destroyed or are unobtainable. Signed: _ Date: Parent or Guardian --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM IMMUNIZATION ON MEDICAL OR RELIGIOUS GROUNDS. ANY IMMUNIZATIONS THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE. MEDICAL CONTRAINDICATION: The above child has a valid medical contraindication to being immunized at this time. This is a permanent condition temporary condition until // Check appropriate box, indicate vaccine(s) and reasons: Signed: _ Date Medical Provider / LHD Official RELIGIOUS OBJECTION: I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any immunizations being given to my child. This exemption does not apply during an emergency or epidemic of disease. Signed: _ Date: DHMH Form 896 Rev. 2/11 Center for Immunization www.edcp.org (Immunization)
How To Use This Form The medical provider that gave the vaccinations may record the dates directly on this form (check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be listed individually, per each component of the vaccine. A different medical provider, local health department official, school official, or child care provider may transcribe onto this form and certify vaccination dates from any other record which has the authentication of a medical provider, health department, school, or child care service. Only a medical provider, local health department official, school official, or child care provider may sign Record of Immunization section of this form. This form may not be altered, changed, or modified in any way. Notes: 1. When immunization records have been lost or destroyed, vaccination dates may be reconstructed for all vaccines except varicella, measles, mumps, or rubella. 2. Reconstructed dates for all vaccines must be reviewed and approved by a medical provider or local health department no later than 20 calendar days following the date the student was temporarily admitted or retained. 3. Blood test results are NOT acceptable evidence of immunity against diphtheria, tetanus, or pertussis (DTP/DTaP/Tdap/DT/Td). 4. Blood test verification of immunity is acceptable in lieu of polio, measles, mumps, rubella, hepatitis B, or varicella vaccination dates, but revaccination may be more expedient. 5. History of disease is NOT acceptable in lieu of any of the required immunizations, except varicella. Immunization Requirements The following excerpt from the DHMH Code of Maryland Regulations (COMAR) 10.06.04.03 applies to schools: A preschool or school principal or other person in charge of a preschool or school, public or private, may not knowingly admit a student to or retain a student in a: (1) Preschool program unless the student's parent or guardian has furnished evidence of age appropriate immunity against Haemophilus influenzae, type b, and pneumococcal disease; (2) Preschool program or kindergarten through the second grade of school unless the student's parent or guardian has furnished evidence of age-appropriate immunity against pertussis; and (3) Preschool program or kindergarten through the 12th grade unless the student's parent or guardian has furnished evidence of age-appropriate immunity against: (a) Tetanus; (b) Diphtheria; (c) Poliomyelitis; (d) Measles (rubeola); (e) Mumps; (f) Rubella; (g) Hepatitis B; and (h) Varicella. Please refer to the Minimum Vaccine Requirements for Children Enrolled in Pre-school Programs and in Schools to determine age-appropriate immunity for preschool through grade 12 enrollees. The minimum vaccine requirements and DHMH COMAR 10.06.04.03 are available at www.edcp.org (Immunization). Age-appropriate immunization requirements for licensed childcare centers and family day care homes are based on the Department of Human Resources COMAR 13A.15.03.02 and COMAR 13A.16.03.04 G & H and the Age-Appropriate Immunizations Requirements for Children Enrolled in Child Care Programs guideline chart are available at www.edcp.org (Immunization). DHMH Form 896 Rev. 2/11 Center for Immunization www.edcp.org (Immunization)
CONSENT TO TREATMENT FORM 2016-2017 Phone: 301-365-0955 Fax: 301-365-0981 www.holychild.org FOR EMERGENCIES WHEN PARENTS/GUARDIAN CANNOT BE REACHED. Student s name: _ First Middle Last Preferred name Home Address: Street City State Zip code Date of Birth: _ Mother s/guardian s Name: Home Phone: Work Phone: Cell Phone: _ Emergency Contact: (other than parents/guardians) Name: _ Relation to Student: Work Phone: Cell Phone: _ Physician: Dentist: Father s/guardian s Name: Home Phone: _ Work Phone: _ Cell Phone: Emergency Contact: (other than parents/guardians) Name: Relation to Student: Work Phone: _ Cell Phone: Physician s Phone: _ Dentist s Phone: Hospital Preference: Insurance: Policy Holder: ID/Policy #: Phone Number: In the event of any illness or accident involving my daughter, I hereby give to Connelly School of the Holy Child and its faculty representatives, including the athletic coaches, the authority to determine what is an emergency situation. I further give said persons the authority to select a hospital and/or physician to render medical treatment to her, and I do hereby consent to such medical treatment, including surgery, as the hospital and/or physician may deem necessary or advisable. This consent shall continue during the period of the current school year 2016-2017 in which my daughter attends Connelly School of the Holy Child unless I revoke this in writing. I understand that Connelly School of the Holy Child will make all reasonable efforts to inform me if my daughter is admitted to a hospital and prior to the recommended surgery. In no event will Connelly School of the Holy Child, its faculty representatives, including the athletic coaches, be liable in any manner for any claims arising out of or in connection with the selection of the hospital and/or physician, or the consent to the recommended treatment. _ Signature of Parent/Guardian Date
Connelly School of the Holy Child Health Room Requirements for Students 2016-2017 All students are required to have an annual physical examination with their primary care provider prior to returning to school in September. Evidence of immunization against common childhood diseases is also required for all students entering Middle School or Upper School. Please use the student s full legal name on all forms. All of the forms must be completed, signed and returned to the school nurse by July 15, 2016, or your daughter will not receive her schedule and she will not be allowed to attend school. Authorization for Release of Confidential Medical Information (HIPAA Guidelines) Connelly School of the Holy Child Health Office complies with the national requirements regarding confidentiality of medical information. This federal regulation is known as HIPAA or Health Insurance Portability and Accountability Act. This Act has many purposes and components, but there is one aspect that relates specifically to the student in a school situation. This component is the privacy rule that ensures privacy and confidentiality of all personal medical information. Information provided on this form is applicable until the end of the 2016-2017 school year. Connelly School of the Holy Child Health Office requests your permission to share, release and exchange health information with physicians or other health care providers (which can include psychiatrists, psychologists and therapists) as may pertain to the health and safety of the student. I have read and understand the above information regarding HIPAA regulations and agree to allow the Health Office to share health information for my daughter as deemed necessary. Name of Student (Print): _ Date: Signature of Student: Name of Parent or Guardian (Print): Signature of Parent or Guardian: _
Connelly School of the Holy Child Health Assessment/share with the physician To be completed by parent/guardian Please check Yes or No for each of the following questions. Explain all yes answers in the Comments column. Include dates where appropriate. Student Name: Grade: Do you know of any reason why this individual should not participate in all sports? Has the individual been advised by a physician during the past year to restrict activity? Has the student ever had surgery? Has the student ever: been hospitalized? (When? Where?) been unconscious / or fainted? sustained a concussion? had frequent headaches? had convulsions? had numbness or tingling of face, arms, hands, legs or feet? had chest pain / shortness of breath? had enlarged liver or spleen? become weak or ill when exposed to high temperatures? Has the student ever had: head or neck injury? back pain? shoulder separation or dislocation? ankle sprain? knee trouble (including torn cartilage or cap dislocation)? broken bone or fracture? pulled ligament or ruptured tendon? swollen, dislocated, or painful joint? serious muscle injury or rupture? Does the student have loss or seriously impaired function of any paired organ (eye, ear, lungs, kidney, ovary, etc )? If yes, specify the organ and problem. Does the student wear: glasses or contact lenses? dental braces? Other: Yes No Comments Parent/Guardian Signature _/_/_ Date
Connelly School of the Holy Child Annual Physical Exam Form 2016-2017 To be completed and signed by a Physician / Nurse Practitioner Please print all information Student Name: Grade: Date: Height: Weight: Pulse Rate: Blood Pressure: Date of Most Recent Tetanus Shot: Date of Most Recent PPD and Results: _ Allergies (Medications) If yes, list here: Allergies (Food, Insects) If yes, list here: Epi-pen needed YES NO Rx Given YES NO Medications (include Dosage and Diagnosis): Review of Systems/Physical Exam WNL Treatments/Dates Asthma: Inhaler Needed? YES NO Exercise Induced? YES NO Attention Deficit / Hyperactivity Birth Defects Development Diabetes Gastrointestinal / Urinary Heart / Lungs Hematological / Immunologic Mental / Emotional Health ( In Therapy?) Migraines Hx. of Mononucleosis Nutrition Seizure / Neurological Disorder Speech / Language Thyroid Vision Screening Scoliosis Screening Hearing Screening Other The above named student has had a complete physical examination and is cleared for participation in athletics. ( ) Physicians / Nurse Practitioner Name Phone Number Original Signature
MEDICATION ADMINISTRATION AUTHORIZATION To be completed by Physician/Nurse Practitioner By having your daughter s physician sign this form, the parent or guardian agrees to release, indemnify and hold harmless Connelly School of the Holy Child, any of the officers, staff members, or agents from lawsuit, claim demand, or action, etc. against them, for administering the medications (prescription and nonprescription) as listed and requested below to this student. Student Name: _ Grade: Allergies: List all medications taken at home: CSHC SCHOOL NURSE OR HER DESIGNATED SUBSTITUTE MAY ADMINISTER THE FOLLOWING AS NEEDED: (check those requested) Acetaminophen (generic for Tylenol) 325 mg 1-2 tablets Ibuprofen (generic for Advil/Motrin) 200 mg 1-2 tablets Benadryl 25 mg 1-2 tablets, or Claritin 10 mg (allergic symptoms) Tums (antacid) 1-2 tablets Robitussin Syrup / Cough drops Lozenge Bacitracin ointment Calamine lotion, or Benadryl gel (ant-itch relief for skin) Anbesol gel (oral anesthetic) Clear Eyes Redness Relief Eye Drops (Regular or for Contact Lenses) Prescription Medication to be given during school hours: Name of medication: Dosage: Time(s) to be given: Route: If PRN, specify when indicated/ frequency: Side Effects: Authorization by physician (Required by MD State School Health Services Guidelines) _/_/_ PHYSICIAN NAME (Print) SIGNATURE DATE