Project Lead the Way is a series of five honor courses that are offered nationwide. These courses are designed

to prepare students for college and/or a career in engineering, connecting math and science courses to

technology (STEM). These series of classes are designed to develop high-tech skills for solving problems.

1st Course -

2nd

Course -

3rd

Course -

4th

Course -

5th

Course -

If you are interested in PLTW, then the first course is Introduction to Engineering Design (IED). It is

recommended that students begin their freshmen year, so they will have an opportunity to take as many PLTW

courses as they wish throughout their high school career.

Please visit our Project Lead the Way’s web site at https://sites.google.com/site/lancerpltw

Honors Pre-Engineering Academy – Weighted Courses

3D Modeling Software,

3D Printer & 3D Scanner

3D Architecture Software

Introduction to Engineering Design - IED

Principles of Engineering - POE

Civil Engineering and Architecture - CEA

Digital Electronics - DE

Engineer Design & Development Engineering - EDD

ENROLLMENT REQUIREMENTS CHECKLIST

In addition to the other forms in this packet, copies of ALL the following documentation must be provided before the enrollment appointment can be scheduled (no exceptions):

Student’s birth certificate or passport

Student’s Social Security Number

Custody documentation

If the student does not live with both parents, this must be a legal document such as a divorce decree, which states that the person registering the student is the legal guardian or custodial parent.

Proof of Residency (Electric bill preferred by State of Maryland)

Any one (1) of the following:

Rental/Lease Agreement or Housing Contract

Property Tax Bill

Electric Utility Bill (Within past 2 months)

ACP

If parent/legal guardian is not able to provide proof of residency in his/her name, then the enclosed Parent Residency Affidavit must be completed and notarized, and submitted with proof of residency from the owner of the home.

Health/Immunization records

Refer to enclosed list of immunization requirements. If any vaccination is missing, the parent must provide proof of an appointment for vaccination, otherwise the student cannot be enrolled.

Transferring within Frederick County—it is recommended that the student has a physical, prior to 9th grade.

Transferring from Out of State—student must receive physical within first 6 months of enrollment.

Student’s current grades or most recent grade report (Report Card or Interim)

Students transferring from another Maryland public school must provide a Maryland Student Withdrawal/Transfer Record (SR-7).

Student Transcript and attendance information

May be official or unofficial, but must include all credits attempted and earned.

HSA/MSA/PARCC Test Scores (In-State transfers only)

Required if transferring from a school outside of Frederick County Public Schools.

Special Education Documentation (IEP/504 Plan if applicable)

English Placement Test Results (Exchange Students Only)

All exchange students must be pre-approved by Linganore High School. English Placement Test Results are to be provided by supervising exchange program agency.

YOUR SON/DAUGHTER WILL BE ENROLLED ON THE BASIS OF AVAILABLE INFORMATION. UPON RECEIPT OF ALL RECORDS AND INFORMATION, FORMAL

ENROLLMENT WILL BE COMPLETED. ANY PERSON WHO WILLFULLY MAKES A MATERIAL MISREPRESENTATION SHALL BE SUBJECT TO A PENALTY PAYABLE TO THE

COUNTY FOR THREE TIMES THE PRO RATA SHARE OF TUITION FOR THE TIME THE CHILD FRAUDULENTLY ATTENDS A FREDERICK COUNTY PUBLIC SCHOOL.

NEW STUDENT SURVEY

This form is REQUIRED to be completed and returned before the enrollment appointment can be scheduled.

1. My student lives with both biological parents.

Yes No

If you answered no, legal documentation, such as a divorce decree, must be provided which states that the person registering the student is the legal guardian or custodial parent.

2. My student’s primary language is English.

Yes No

If you answered no, please contact the ESL program at 240.236.8761 (English) or 240.236.8762 (Spanish.)

3. At the previous school, my student is currently suspended, has been expelled, or was in an alternative program. This information is required to be made available to Linganore High School.

Yes No

4. My student has/had an IEP(Individual Education Plan). My student currently has an IEP. My student previously had an IEP, but does not currently have one. My student has never had an IEP.

5. My student has a Section 504 Plan.

Yes No

6. My student has an ILP (Individual Learning Plan).

Yes No

7. My student is being enrolled after being homeschooled, and I would like FCPS to

review my student’s coursework to determine if my student may earn credit for coursework completed prior to enrollment.

Yes No N/A

Please note that only Math and World Language courses may be evaluated for high school credit if completed prior to your student beginning the 9th grade. If you select yes, your student’s School Counselor will discuss the process for consideration with you.

I understand that my student is being enrolled based on the information provided, and as such, I understand if any of the above statements are found to be incorrect, it could delay or invalidate my student’s enrollment at Linganore High School.

PARENT/GUARDIAN SIGNATURE DATE

PLEASE

READ

If you can provide current proof of residency, (an electric utility bill, contract/lease on your home, or current property tax bill,) in your name, then you may skip the form on the next page. If you cannot provide current proof of residency in your name, then you and the owner of your home must complete the form on the next page, have it notarized, and submit it along with one of the items listed above from the owner. If you do not live in the LHS district, then you must also submit a copy of your Out-of-District approval letter in addition to your proof of residency as listed above. Thanks!

Proof of

Residency

Instructions

FREDERICK COUNTY PUBLIC SCHOOLS

PARENT RESIDENCY AFFIDAVIT

Multi-Family Disclosure

I, ____________________________________________________, certify that I am the custodial parent/legal guardian of (Print Parent Name)

_____________________________________________________, and that I have established permanent residence at: (Print Student Name)

______________________________________________________________________________________________________ (Complete Home Address)

With Phone:

(Name of Person the family resides with) (Phone of Person the family resides with)

in Frederick County, Maryland. I further certify that the above-mentioned student resides with me at this address.

I understand that I may not have my child or ward enrolled in Frederick County Public Schools at any time unless I, as custodial

parent, am maintaining a bona fide residence within Frederick County. I agree to notify Frederick County Public Schools if my child

or ward and I move from the aforementioned address.

Any effort on my part to illegally have my child or ward enrolled in Frederick County Public Schools in violation of the residency

requirements can result in a penalty as stipulated under Maryland law 7-101 of the Education Article. The penalty can be equivalent

to a pro-rata share of tuition for the time the child fraudulently attends Frederick County Public Schools. Annual tuition rates for

students in grades K-12 are:

Out-of-State (transported) $12,189 Out-of-County (transported) $5,757

Out-of-State (non-transported) $11,475 Out-of-County (non-transported) $5,457

I hereby waive my rights to confidentiality of information relative to my residence and understand that Frederick County Public

Schools will use whatever legal means it has as its disposal to verify my residency.

_______________________________________ ___________________________

Parent’s Signature* Date

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Must be completed in the presence of a Notary Public

I affirm and attest that the persons identified above are living with me at this

Address: ________________________________________________ AFFIX SEAL

_______________________________________________________

and accept all terms of this document.

Affirmed by: ____________________________________

(Person’s signature that family is living with)

Notary Public

Sworn to before me and subscribed in my presence this _____ day of ______________, 20 ___ ______________________________

Notary Signature

*Your signature attests to the truthfulness of the information provided. Penalties for misrepresenting

information may subject the signee to damages equivalent to the tuition amount deemed due to Frederick

County Public Schools.

STS_Parentresidencyaffidavit/cz Revised 8/2014

Rev. 9/27/2016 acw

Enrollment Date Student ID# School Name Bus #

Enrollment Code Teacher Name School # Walker

FREDERICK COUNTY PUBLIC SCHOOLS ENROLLMENT FORM THE FOLLOWING ITEMS ARE REQUIRED BY MARYLAND LAW BEFORE A STUDENT CAN ATTEND/ENROLL IN SCHOOL If you are missing any of the following information please see the secretary.

Proof of Date of Birth Birth Certificate, Physicians Certificate, Church Certificate, Passport/Visa/Hospital Certificate, Parent Affidavit

Proof of Residency Signed Lease Agreement, Utility Bill (electric/water/gas). NOT ACCEPTED: Phone bills, cable bills

Proof of Immunizations Legal Name of Student: ________________________________________________________________ _______ __________________ First Name FULL Middle Name Last Name Gender Date of Birth

Student’s Social Security #: _________-______-_________ Home Phone Number: _____________________________ Grade: ____________ Student’s Preferred Name or Nickname (optional): __________________________________________ EVIDENCE OF DATE OF BIRTH (Check one. School will retain a copy.)

Birth Certificate Physician’s Certificate Church Certificate Passport/Visa Hospital Certificate Parent’s Affidavit Other (specify) _______________________________________________________________________________

RACE: (check all that apply): American Indian/Alaskan Native Asian Black or African American White Native Hawaiian or other Pacific Islander ETHNICITY: Is the student Hispanic or Latino? Yes No Language spoken at home: _____________________________________ Country of Birth: __________________________________________ STUDENT ADDRESS: Please include a street address with PO Boxes _____________________________________________________________________________________________________________________ House Number / Street Name / Apartment Number / PO Box City / State / Zip Code

DWELLING TYPE: Apartment/Condo Townhouse/Duplex Single Family / Detached Is this address out-of-district? Yes No If yes, school will refer to PPW LEGAL PARENT/GUARDIAN INFORMATION Enter one guardian in each area. Enter PRIMARY CONTACT FIRST. Legal Parent/Guardian Name: ___________________________________________________ Relationship to Student: _____________________ Address (if different from student):___________________________________________________________________________________________ House Number / Street Name / Apartment Number / PO Box City / State / Zip Code

Phone Numbers: Cell: _____________________________ Home: ________________________________ Work: _________________________ Email: ________________________________________________________________________________________________________________ Legal Parent/Guardian Name: ___________________________________________________ Relationship to Student: _____________________ Address (if different from student):___________________________________________________________________________________________ House Number / Street Name / Apartment Number / PO Box City / State / Zip Code

Phone Numbers: Cell: _____________________________ Home: ________________________________ Work: _________________________ Email: ________________________________________________________________________________________________________________ Is there a court order concerning custody? Yes** No Not applicable Type of proof of custody and/or guardianship, e.g., court / legal documents: ____________________________________________________ Is there a “NO CONTACT” order? Yes** No **FCPS must have a copy of any court orders relating to CUSTODY or NO CONTACT in order to honor the request. ADDITIONAL STUDENT INFORMATION Will you allow your child’s name to be published? (e.g., newspaper, FCPS television broadcasts, Honor Roll) Yes No Is the current address a temporary living arrangement? Yes No If yes, is this current living arrangement due to lack of housing or economic hardship? Yes No Is your child eligible for Free / Reduced Meals? Yes No

Rev. 9/27/2016 acw

PRIOR SCHOOL INFORMATION School Last Attended: _______________________________________________________________ Date(s) Last Attended: ________________ Address: ______________________________________________________________________________________________________________ Contact: __________________________________________________________________________ Phone: ______________________________ Is your child currently attending, or has your child ever attended a Maryland Public School? Yes No If YES, please provide school district name: ___________________________________________________________________________________ Is the student currently expelled or suspended from another school? Yes No If yes, school will refer to PPW Is the student transferring from an alternative school? Yes No If yes, school will refer to PPW SPECIAL SERVICES Was your child enrolled in a special program? Yes No If yes, please specify: Special Education: Hours of service: _______ 504 Plan Student Support Teacher Services

Court Placement: _____Residential _____Other English Language Learner Specify one: _____Beginner _____Intermediate _____Advanced

EMERGENCY CONTACTS (OTHER THAN LEGAL PARENT/GUARDIAN) Name: _________________________________________________________________ Relationship to Student: __________________________ Address (if different from student):__________________________________________________________________________________________ House Number / Street Name / Apartment Number City / State / Zip Code

Phone Numbers: Cell: _____________________________ Home: ________________________________ Work: _________________________ Email: ________________________________________________________________________________________________________________ Name: _________________________________________________________________ Relationship to Student: __________________________ Address (if different from student):__________________________________________________________________________________________ House Number / Street Name / Apartment Number City / State / Zip Code

Phone Numbers: Cell: _____________________________ Home: ________________________________ Work: _________________________ Email: ________________________________________________________________________________________________________________ DAY CARE PROVIDER: _____________________________________________________________________________________________________________________ Name House Number / Street Name City / State / Zip Code

Phone Numbers: _____________________________________ (home) ____________________________________ (cell) OTHER HOUSEHOLD MEMBERS ______________________________________________________________________________________________________________________ Name Date of Birth Relationship to student

______________________________________________________________________________________________________________________ Name Date of Birth Relationship to student

______________________________________________________________________________________________________________________ Name Date of Birth Relationship to student

HEALTH CONCERNS (e.g., takes daily medications, wears glasses, hearing problem, allergies, diabetic, etc.) Describe: _____________________________________________________________________________________________________________ Immunization records on file? Yes No Has the child received a physical examination in the past 9 months? Yes No Is DHMH on file? Yes No If no, give reason: Insufficient financial resources Lack of access to care Community Services (optional): If your family has been in contact and/or has received services from outside agencies, please indicate (e.g., Mental Health, Social Services, Community Agency School Services (CASS): _______________________________________________________ DISCLAIMER: Your son/daughter ___________________________________________ has been enrolled on the basis of available information. Upon receipt of all records and information, formal enrollment will be completed. Any person who willfully makes a material misrepresentation shall be subject to a penalty payable to the County for three times the pro rata share of tuition for the time the child fraudulently attends a Frederick County Public School. Signature: ___________________________________________________________________________ Date: ____________________________

PLEASE

READ

In order to properly enroll your student, LHS needs unofficial copies of your stu-dent’s current grades, last report card, and high school transcript. Please bring these documents along with your exit documents from previous school when you enroll. Please complete the next page, which is the Records Request form so that LHS can request the official records from the previous school. Once your student has been enrolled, we will send this request for official student records to the previous school. Thanks!

Providing

Student

Records

Student Services Linganore High School

Paula Larson, Department Chair 12013 Old Annapolis Rd.

Katherine Becker, Counselor Frederick, MD 21701

Ilana Blum, Counselor (240) 566-9730

Renata Emery, Counselor (240) 566-9729 (fax)

Kathryn Rich, Registrar

Previous School Name:________________________________________________________

To: ______________________________ From: _________________________________

Fax: _____________________________ Pages: _________________________________

Phone: ___________________________ Date: __________________________________

Please forward a copy of records as requested below for:

Student Name Date of Birth Grade

________________________________ ____________________ ________

who is attempting to enroll at Linganore High School. All Maryland Schools are required to

send original records not photocopies. Thank you for your promptness.

____ Transcript Grades ____ Health records, including immunizations

____ Standardized test results ____ IEP/504, if applicable

____ Attendance record ____ Discipline record

____ Birth certificate ____ Most recent report card

____ MD Student Record (SR) Cards

I hereby give permission to LHS to secure from other schools the above specified information.

_______________________________________ ________________________

Parent Signature Date

________________ _________________ ________________

1st request date 2

nd request date 3

rd request date

LINGANORE HIGH SCHOOL STUDENT SERVICE LEARNING Student Service Learning Transfer/New Enrollee Documentation

Basic Information Student Name: FCPS Student ID #:

Guardian Name: Graduation Year:

School Information Current Grade Level: 9

th 10

th 11

th 12

th

Previous School:

another FCPS middle/high school

another middle/high school in MD

another private school in MD

Other:

Rationale/History: Maryland is the only state that requires Service Learning as a graduation requirement for its students. Maryland requires seventy-

five (75) hours of documented service learning for high school graduation. Many local school systems have developed local

alternatives to meet the requirement. Frederick County Public Schools follows a local system plan that has the hours infused in

classroom curriculum. Service Learning objectives and activities are included in 24 curricular areas spanning grades 1-12.

Transfer students who are unable to satisfy the service learning requirement through curricular infusion may have to supplement

hours through additional volunteering. As a transfer from another school you will need to document hours you may have

completed. If you need to complete additional hours our Service Learning Coordinator will work with you to develop a plan that

may include the Student Service Learning class or individual service learning activities such as volunteering after school and/or on

weekends.

Previous Service Hours Documentation: (attach additional sheets if necessary)

Experience #1-Description of Service Experience:

Total number of hours: Date(s) Completed:

Supervisor name: Title:

Supervisor Signature: Date:

Experience #2-Description of Service Experience:

Total number of hours: Date(s) Completed:

Supervisor name: Title:

Supervisor Signature: Date:

Experience #3-Description of Service Experience:

Total number of hours: Date(s) Completed:

Supervisor name: Title:

Supervisor Signature: Date:

Enrollment Transfer Hours Awarded: (Will be completed by Registrar)

ATH_Supplemental Enrollment-Athletic Eligibility 2016-17 wisner 031115

Supplemental Enrollment Information for 2016-2017 Athletic Eligibility

_________________ High School Counselor: ____________________ Enrollment Date: _____________

Parents/Guardians of newly enrolled high school students in Frederick County Public Schools (FCPS) are asked to attach a

current copy of a Report card with term grades and complete this form at the time of enrollment. The information

provided in this document will verify eligibility to participate in FCPS high school sports. Specific questions regarding this

form should be directed to Mr. Kevin Kendro, FCPS Supervisor of Athletics and Extracurricular Activities, by email

kevin.kendro@fcps.org or phone 301.696.6845. This completed form will be forwarded by the high school counselor to the

high school athletic director.

STUDENT NAME: __________________________________ STUDENT BIRTH DATE: _____________

HOME ADDRESS: _________________________________________________________________________

ENROLLING PARENT/GUARDIAN NAME: ___________________________________________________

Check one of the following: □ STUDENT WILL ATTEND HOME SCHOOL OR

□ STUDENT IS APPROVED TO ATTEND SCHOOL OUTSIDE HIS/HER HOME DISTRICT

HAS STUDENT EVER PARTICIPATED IN HIGH SCHOOL SPORTS? Yes No (circle one) *

* If previous answer is ‘No’ please skip to the bottom of this form, sign and date

2015-2016 GRADE LEVEL: ________ 2016-2017 GRADE LEVEL: ________

PREVIOUS HIGH SCHOOL: _____________________________________________________________

DATES ATTENDED: __________ LAST TERM G.P.A. _______ (provide current copy of Report Card with term grades)

List all high school sports and seasons that student participated at the previous school:

Sport: ___________________________________________ Seasons of Participation: ____________________

Sport: ___________________________________________ Seasons of Participation: ____________________

Sport: ___________________________________________ Seasons of Participation: ____________________

We verify that all information provided herein is complete, accurate and truthful. __________________________________________________ _________________________________________________ Parent/Guardian Signature Date Student Signature Date

Linganore High School Health Services

12013 Old Annapolis Road Frederick, Maryland 21701

Phone: 240 566 9745 Fax: 240 566 9747 Visit us at lhs.fcps.org

A Nationally Recognized Blue Ribbon School of Excellence

Principal David A. Kehne

Assistant Principals

Gregory M. Keller Andrew S. McWilliams

Jan L. Witt

Dear Parent/Guardian(s): In 1990 a bill was passed by the Maryland State Legislature requiring a physical examination for all students who are entering the Maryland Public School system for the first time. The examinations must take place during the period of nine (9) months prior to the student’s first day, or six (6) months following his/her first day. If your student has never attended a Maryland Public School before, please have your physician or nurse practitioner complete the appropriate section of the Health Inventory Form, which is provided in your enrollment packet. Parent/guardian(s) should also complete sections as indicated. Also, when new students enroll in school, they must be fully immunized. A student who is not in compliance may be temporarily admitted if the parent or guardian presents evidence of an appointment with a health care provider or the health department to receive the required immunizations, reconstruct lost records, or obtain evidence of immunity. The date of the appointment may not be later than 20 calendar days following the student’s first day of school if the evidence of immunizations is not provided. Proof of an appointment date should be in writing from the health care provider or health department on the physician’s prescription pad or letterhead. This written statement is to be placed in the student’s school health record until the required proof of immunization is received. For your convenience, immunization requirements and a blank immunization certificate (DHMH 896) are provided in this packet. Completed forms should be returned to the Registrar as soon as possible. It is essential that this process be followed in order to comply with Maryland State Law (COMAR 10.06.04) and to help keep our students healthy, in school, and ready to learn. Thank you in advance for your prompt attention to this matter.

PLEASE

READ

IF YOU ARE COMING FROM… ANOTHER PUBLIC SCHOOL IN MARYLAND… You do not need to complete any forms beyond this point, unless you do not have a current copy of your student’s immunization record. If you do not have a copy, a blank Immunization Record (DHMH 896) is provided for you.

A MARYLAND PRIVATE SCHOOL, OR ANY SCHOOL OUTSIDE THE STATE OF MARYLAND… You must have the Maryland Schools Record of Physical Examination completed in its entirety, and provide a copy of your student’s immunization record. If you do not have a copy, a blank Immunization Record (DHMH 896) is provided for you.

Health &

Immunization

Records

Maryland Schools

Record of Physical Examination

To Parents or Guardians: In order for your child to enter a Maryland Public school for the first time, the following are required:

A physical examination by a physician or certified nurse practitioner must be completed within nine months prior to entering the public school system or within six months after entering the system. A Physical Examination form designated by the Maryland State Department of Education and the Department of Health and Mental Hygiene shall be used to meet this requirement. (http://www.dsd.state.md.us/comar/13a/13a.05.05.07.htm)

Evidence of complete primary immunizations against certain childhood

communicable diseases is required for all students in preschool through the twelfth grade. A Maryland Immunization Certification form for newly enrolling students may be obtained from the local health department or from school personnel. The immunization certification form (DHMH 896) or a printed or a computer generated immunization record form and the required immunizations must be completed before a child may attend school. This form can be found at: http://www.edcp.org/pdf/DHMH896new.pdf.

Evidence of blood testing is required for all students who reside in a designated at

risk area when first entering Pre-kindergarten, Kindergarten, and 1st grade. The blood-lead testing certificate (DHMH 4620) (or another written document signed by a Health Care Practitioner) shall be used to meet this requirement. This form can be found at: http://www.fha.state.md.us/och/pdf/MarylandDHMHBloodLeadTestingCertificateDHMH4620.pdf.

Exemptions from a physical examination and immunizations are permitted if they are contrary to a students’ or family’s religious beliefs. Students may also be exempted from immunization requirements if a physician/nurse practitioner or health department official certifies that there is a medical reason not to receive a vaccine. Exemptions from Blood-Lead testing is permitted if it is contrary to a families religious beliefs and practices. The Blood- lead certificate must be signed by a Health Care Practitioner stating a questionnaire was done.

The health information on this form will be available only to those health and education personnel who have a legitimate educational interest in your child.

Please complete Part I of this Physical Examination form. Part II must be completed by a physician or nurse practitioner, or a copy of your child's physical examination must be attached to this form. If your child requires medication to be administered in school, you must have the physician complete a medication administration form for each medication. This form can be obtained at http://www.marylandpublicschools.org/NR/rdonlyres/8D9E900E-13A9-4700-9AA8-5529C5F4C749/3341/medicationform404.pdf. If you do not have access to a physician or nurse practitioner or if your child requires a special individualized health procedure, please contact the principal and/or school nurse in your child's school. Maryland State Department of Health and Mental Hygiene Maryland State Department of Education Records Retention - This form must be retained in the school record until the student is age 21.

Maryland Schools -Record of Physical Examination Revised 12/04

PART I - HEALTH ASSESSMENT To be completed by parent or guardian

Student’s Name (Last, First, Middle)

Birthdate (Mo. Day Yr.)

Sex (M/F)

Name of School

Grade

Address (Number, Street, City, State, Zip) Phone No. Parent/Guardian Names Where do you usually take your child for routine medical care? Phone No. Name: Address: When was the last time your child had a physical exam? Month Year Where do you usually take your child for dental care? Phone No. Name: Address:

ASSESSMENT OF STUDENT HEALTH To the best of your knowledge has your child any problem with the following? Please check

Yes No Comments Allergies (Food, Insects, Drugs, Latex) Allergies (Seasonal) Asthma or Breathing Problems Behavior or Emotional Problems Birth Defects Bleeding Problems Cerebral Palsy Dental Diabetes Ear Problems or Deafness Eye or Vision Problems Head Injury Heart Problems Hospitalization (When, Where) Lead Poisoning/Exposure Learning problems/disabilities Limits on Physical Activity Meningitis Prematurity Problem with Bladder Problem with Bowels Problem with Coughing Seizures Serious Allergic Reactions Sickle Cell Disease Speech Problems Surgery Other Does your child take any medication? No Yes Name(s) of Medications: ___________________________________________________ Is your child on any special treatments? (nebulizer, epi-pen, etc.) No Yes Treatment ______________________________________________________________ Does your child require any special procedures? (catheterization, etc.) No Yes Parent/Guardian Signature ___________________________________________ Date:_____________________

Maryland Schools -Record of Physical Examination Revised 12/04

PART II - SCHOOL HEALTH ASSESSMENT To be completed ONLY by Physician/Nurse Practitioner

Student’s Name (Last, First, Middle)

Birthdate (Mo. Day Yr.)

Sex (M/F)

Name of School

Grade

1. Does the child have a diagnosed medical condition? No Yes _____________________________________________________________________________________ __________________________________________________________________________________________________ ________________________________________________________________________________________________ 2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is at school? (e.g., seizure, insect sting allergy, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE. Additionally, please “work with your school nurse to develop an emergency plan”. No Yes______________________________________________________________________________________ _____________________________________________________________________________________________________ 3. Are there any abnormal findings on evaluation for concern?

Evaluation Findings/CONCERNS

Physical Exam

WNL

ABNL

Area of

Concern

Health Area of Concern

YES

NO Head Attention Deficit/Hyperactivity Eyes Behavior/Adjustment ENT Development Dental Hearing

Respiratory Immunodeficiency Cardiac Lead Exposure/Elevated Lead GI Learning Disabilities/Problems GU Mobility Musculoskeletal/orthopedic Nutrition Neurological Physical Illness/Impairment Skin Psychosocial Endocrine Speech/Language

Psychosocial Vision Other R EMARKS: (Please explain any abnormal findings.)

4. RECORD OF IMMUNIZATIONS – DHMH 896 is required to be completed by a health care provider or a computer generated

immunization record must be provided. 5. Is the child on medication? If yes, indicate medication and diagnosis. No Yes (A medication administration form must be completed for medication administration in school). 6. Should there be any restriction of physical activity in school? If yes, specify nature and duration of restriction. No Yes 7. Screenings

Results

Date Taken

Tuberculin Test Blood Pressure

Height

Weight

BMI %tile

Lead Test Optional

Maryland Schools -Record of Physical Examination Revised 12/04

PART II - SCHOOL HEALTH ASSESSMENT - continued To be completed ONLY by Physician/Nurse Practitioner

(Child’s Name) _________________________________________________ has had a complete physical examination and has 9 no evident problem that may affect learning or full school participation problems noted above _______________________________________________________________________________________ Additional Comments:

Physician/Nurse Practitioner (Type or Print)

Phone No. Physician/Nurse Practitioner Signature Date

Maryland Schools -Record of Physical Examination Revised 12/04

DHMH Form 896 Center for ImmunizationRev. 6/10 www.EDCP.org (Immunization)

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________

To the best of my knowledge, the vaccines listed above were administered as indicated. Clinic / Office NameOffice Address/ Phone Number

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

Lines 2 and 3 are for certification of vaccines given after the initial signature.

RECORD OF IMMUNIZATIONS (See Notes On Other Side)

Vaccines TypeDose # DTP-DTaP-DT

Mo/Day/Yr

Polio

Mo/Day/Yr

Hib

Mo/Day/Yr

Hep B

Mo/Day/Yr

PCV

Mo/Day/Yr

Rotavirus

Mo/Day/Yr

MCV

Mo/Day/Yr

HPV

Mo/Day/Yr

Dose

#

Hep A

Mo/Day/Yr

MMR

Mo/Day/Yr

Varicella

Mo/Day/Yr

History of

VaricellaDisease

1 1

2 2

Mo/Yr

3 Td_______

Tdap_______

Other________

Other_______

4

5

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 MEDICALOR 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 anyimmunizations being given to my child. This exemption does not apply during an emergency or epidemic of disease.

Signed: _____________________________________________________________________ Date: _______________________

DHMH Form 896 Center for ImmunizationRev. 6/10 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 notacceptable) and certify them by signing the signature section. Combination vaccines should be listed individually, pereach component of the vaccine. A different medical provider, local health department official, school official, or childcare provider may transcribe onto this form and certify vaccination dates from any other record which has theauthentication 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 vaccinesexcept varicella, measles, mumps, or rubella.

2. Reconstructed dates for all vaccines must be reviewed and approved by a medical provider or local healthdepartment 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, orvaricella 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 notknowingly 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 inSchools” to determine age-appropriate immunity for preschool through grade 12 enrollees. The minimum vaccinerequirements 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 onthe 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” guidelinechart are available at www.EDCP.org (Immunization).