margaret teltow, president sandra fortuna, trustee ... · 68399 forest * richmond, michigan 48062 *...

Richmond Community Schools 35276 Division * Richmond, Michigan 48062 * (586) 727-3565 * www.richmond.k12.mi.us

Margaret Teltow, President Jessica Sexton, Vice President

Kristine Furtaw, Secretary Kyle Simmons, Treasurer Sandra Fortuna, Trustee Angela Pacitto, Trustee

Sherri Zube, Trustee

Brian J. Walmsley, Ed.S. Superintendent

Richmond Early Childhood Learning Center & Will L. Lee Elementary School

68399 Forest Richmond, Michigan 48062

David Kochan, Principal

Richmond Middle School

35250 Division Richmond, Michigan 48062

Keith Bartels, Principal

Richmond High School

35320 Division Richmond, Michigan 48062

Andrew Kastl, Principal

Dear Parent/Guardian,

We are pleased to invite you to apply for a free preschool program available to those that qualify. The program is available to eligible students who are or will be FOUR YEARS OLD on or before the date of SEPTEMBER 1, 2020. (Consideration will be given to students who turn four between September 1 and December 1, 2020.)

The Great Start Readiness Program is a preschool program funded by the Michigan Department of Education. There are specific eligibility requirements for this program. Program enrollment is NOT first come, first serve. Priority enrollment is based on income eligibility. Other eligibility factors are also taken into consideration for placement. This completed application will help to determine qualification for the program. An interview with a GSRP teacher is part of the application process and will be scheduled in June or August. Placement will be determined at the end of AUGUST and families will be notified at that time.

Currently, we offer a school day and a two half day classes with 16 openings in each class. They meet Monday through Thursday. There are no classes on Friday. This program is scheduled to run from the middle of September 2020 through the end of May 2021.

Busing is provided for families in Richmond School District. Breakfast, Lunch and Snack provided at no cost to families. We have highly qualified teachers and teaching assistants who attend regular training and will visit your home two times and provide you two conferences per year. The program uses Creative Curriculum and also offers 2 field trips per year provided at no cost to families.

Thank you for your interest in our preschool program. We are looking forward to the privilege of educating your child.

Guaranteed Learning for All Students!

In compliance with Title VI of the Civil Rights Act of 1964, Title IX of the Education amendments of 1972, Section 504 of Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disability Act of 1990, and Elliott-Larsen Civil Rights Act of 1977, it is the policy of the Richmond Community School District that no person shall, on the basis of race, color, religion ,military status, national origin or ancestry, sex (including sexual orientation), disability, age (except as authorized by law,) height, weight, or marital status be excluded from participation in, be denied the benefits of, or be subjected to, discrimination during any program, activity, service or employment. Inquiries related to any nondiscrimination policies should be directed to the Superintendent, 35276 Division Road, Richmond, MI 48062, (586) 727-3565.

http://www.richmond.k12.mi.us/

RICHMOND EARLY CHILDHOOD LEARNING CENTER – GREAT START READINESS PROGRAM

Richmond Community Schools 68399 Forest * Richmond, Michigan 48062 * (586) 727-2509 * Fax (586) 727-9223

Great Start Readiness Program (GSRP) Enrollment - Parent Checklist

Child’s Name:

Please Complete Required Documents GSRP Application and Enrollment Birth Certificate

(Before child can start Preschool) Child Information Record Form Proof of Income

Last Year’s W-2’s or two consecutive pay stubs Parent Notice of Program Measurement

Form Proof of Residency

(bill with your name and current address on it) Learning Center Policy Agreement Health Appraisal (within 30 days of Preschool

start date or ASAP; form included in packet Learning Center Preschool Discipline Policy Immunization Record

(Before child can start Preschool; must be official) Statement of Varicella Disease

- if applicable Consent to Disclose Immunization Information

Concussion Awareness Form

Optional: Pesticide Notification Advisory to Parents

Optional: Do Not Photo/Video Form

ITEMS TO KEEP FOR YOUR RECORDS:

Concussion Fact Sheet for Parents

Macomb County Health Department Clinic Information

Required Childhood Immunizations for Michigan School Settings

GSRP Eligibility Form

Child’s Name: DOB:

STATE GUIDELINE FACTORS YES NO DOCUMENTATION (please specify) 1 Low Family Income

Head Start Referral needed Yes No

Mother Employed Father Employed

2 Diagnosed Disability or Identified Delay

a. Special Education/IEP

b.Developmental delay

c. Chronic health issue

3 Severe or Challenging Behavior

a. Child has been expelled from preschool

b. Social Services or professional letter

4 Primary Home Language

(Other than English)

a. Is a language other than English spoken in the home?

b. Is English the child’s first language?

5 Parent/Guardian with Low Educational

Attainment: (Did not graduate High School)

6 Abuse/Neglect of Child or Parent

a. Domestic, sexual, or physical abuse

b. Substance abuse(drugs, alcohol, etc) by a family member or in the home.

7 Environmental Risk

a. Parental loss/absence

b. Sibling issues(chronic illness, behavior, disability, death)

c. Teen parent (not yet age 20 at birth of first child)

d. Housing stability(homeless, foreclosure, frequent moves)

e. Residence in high-risk neighborhood(poverty, crime, crowded housing)

f. Prenatal/postnatal exposure to toxic substances.

Please explain any other factors that may cause learning or school adjustment problems for this child:

I certify that all the above information is true and correct and that all income is reported. I understand that this information is being collected to determine eligibility for the state-funded Great Start Readiness Program.

Parent/Guardian Signature: _

Interviewer Signature: _ Date:



IDENTIFICATION FORM

Student’s Full Legal Name (as shown on Birth Certificate) Parent/Guardian Name

Last Name First Name Middle Name Primary Phone

Birth Date Birth City & State (if born in US) Gender M F

Secondary Phone:

Street Address City State Zip Code County

Email Address:

What name would you like on your child’s name tag:

Annual Income: (Jan 1-Dec 31 of the previous year) $

Proof of income must be obtained to be considered for eligibility (pay stubs, tax form)

Ethnicity Is the student Hispanic/Latino?

No, not Hispanic or Latino

Yes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Race The question to the left is about ethnicity, not race. No matter what you selected, please answer the following by marking one or more boxes to indicate what you consider your student’s race to be:

American Indian/Alaskan Native Asian American Black or African American Native Hawaiian/Other Pacific Islander White

Born in US? Yes No Date First Attended School in US (month & year)

Does your child receive Special Services? Yes No If yes, check all that apply below and provide copy ofplan.

Special Education 504 Plan Speech/Language Title 1 Math Reading Social Work Other Services

Please describe other services:

Primary Household Information Student lives with:

Both Parents Father/Stepmother Mother/Stepfather Father Only Mother Only Guardian Relative Foster Court Placed Divorced, Joint Custody Other:

Parent/Guardian Name Relationship to Child Email Address

Home Phone Unlisted

Cell Phone Employer Work Phone

Parent/Guardian Name Relationship to Child Email Address

Home Phone Unlisted

Cell Phone Employer Work Phone

Name of Parent Living Elsewhere Relationship to Child Email Address

Address Home Phone Cell Phone

Have custody papers been provided to the office? Yes No Custody Restrictions

PARENTAL STATUS NUMBER OF PERSONS NUMBER OF CHILDREN

( ) One Parent ( _) Two Parent In the House In the Family In the Family

LIST ALL PERSONS WHO LIVE IN THE HOME

NAME

BIRTHDATE

RELATIONSHIP

SEX

MARITAL STATUS GRADE COMPLETED

OCCUPATION

INCOME (PLEASE LIST ALL SOURCES) NAME EMPLOYER WAGES (SSI, WIC, Child Support)

Health Information

Asthma Allergy Diabetes Heart Condition Seizure Hearing Problem Vision Problem

List all non-food allergies Epi-Pen

List all food allergies Epi-Pen

Other Medical Alerts/Health Conditions

Physical Limitations

Medications Taken (include inhaler) Is your child required to take medication or inhaler during the school day? Yes No

Medical Plan: Complete a medical plan if your child has allergies/asthma/diabetes/seizures or other conditions which requires treatment during the school day.

Preferred Hospital: Physician Name: Dentist Name:

Physician Phone: Dentist Phone:

Concussion Awareness Educational Material Acknowledgment Form By my name and signature below, I acknowledge in accordance with Public Act 342 and 343 of 2012 that I received and reviewed the Concussion Fact Sheet for Parents provided by Richmond Community Schools. The form shall be kept on file with the student CA-60 for the duration of attendance in Richmond Community Schools or age 18. Students and Parents should keep the educational materials for future reference. Parent/Legal Guardian Signature Date

Verification of Information-the undersigned acknowledges that the information provided on this form is true and accurate Parent/Legal Guardian Signature Date


___ ___

___ __

___ ___

No _

Richmond Community Schools 35276 Division*Richmond, Michigan 48062*(586)727-3565*www.richmond.k12.mi.us

Macomb Intermediate School District Home Language Survey

The Richmond Community School District is required by Federal and state law to collect information regarding the language background of each student. This information will be used by the district to determine the number of children who should be provided bilingual instruction according to Sections 380.1152-380.1157 of the Michigan School Code of 1995, Michigan’s Bilingual Education law.

Name of Student: Grade: Age:

Name of School Building:

1. What language did your child first learn to speak?

2. Is your child’s native tongue a language other than English? Yes No If yes, what is that language?

3. Is the “primary language” (the dominant language used by a person for communication) used in your child’s home a language other than English? Yes If yes, what is that language?

4. Has your student been identified or have they received Bilingual/ESL services in another district? Yes No If yes, what district?

5. *Was your student born in the US? Yes No

6. *Month and Year First School Attended?

*Optional

Parent/Guardian Signature:

Date Completed:

Rev 2/21/20


Parent/Legal Guardian Initials:

Date Signed Signature of Parent or Guardian

I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form.

CHILD INFORMATION RECORD State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing

Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.

For Provider Date of Admission Use Only:

Date of Discharge

Name of Child (Last, First, Middle Initial) Child’s Date of Birth

Address (Number and Street, Building/Apartment Number) City State Zip Code

Parent/Legal Guardian’s Name Home Phone ( )

Parent/Legal Guardian’s Name (Optional) Home Phone ( )

Home Address (if not child’s address) Cell Phone ( )

Home Address (if not child’s address) Cell Phone ( )

City State Zip Code City State Zip Code

Email Address (optional) Email Address

Employer Name Work Phone ( )

Employer Name Work Phone ( )

Name of Child’s Physician or Health Clinic Physician’s or Health Clinic’s Phone Number ( )

Hospital Preferred for Emergency Treatment (optional)

Allergies, Special Needs and Special Instructions (Attach additional sheets, if necessary.)

BCAL-3731 (Rev. 7-18) Previous edition 6-17 may be used. See Reverse Side

Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank. (If more individuals, attach additional sheets.)

1. ( )

(

)

2. ( )

(

)

3. ( )

(

)

Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)

1. ( ) 2. ( )

3. ( ) 4. ( )

Date Card Reviewed

Parent or Legal Guardian Initials

Date Card Reviewed


Date Card Reviewed


Date Card Reviewed


LARA is an equal opportunity employer/program.

AUTHORITY: 1973 PA 116

COMPLETION: Required

PENALTY: Rule Violation Citation.

BCAL-3731 (Rev. 7-18) Previous edition 6-17may be used.

I give permission to , licensed by the Department of Licensing and Regulatory Affairs to secure emergency medical treatment for the above named minor child while in care.

Macomb Intermediate School District

Macomb Intermediate School District

Parent Notice of Program Measurement*

Richmond Community Schools is required to work with the Michigan Department of Education (MDE) to measure the effect of the state-wide Great Start Readiness Program (GSRP). Information is sometimes collected about GSRP staff, enrolled children, and their families. Program staff or a representative from MDE might:

• Ask parents questions about their child and family. • Observe children in the classroom. • Measure what children know about letters, words, and numbers. • Ask teachers how children are learning and growing.

Information from you and about your child will not be shared with others in any way that you or your child could be identified. It is protected by law.

Questions? Contact: [email protected] or 517-373-8483 Or MDE, Office of Early Childhood Education and Family Services, 608 W. Allegan, P.O. Box 30008, Lansing, MI 48909

*Provided to parents upon enrollment.

Parent Signature Date

GSRP Staff Signature Position/Title Date

mailto:[email protected]

Policy Agreement

Child (ren’s) Name(s) Program

1. I agree to clock in/out my child each time I drop off and/or pick up my child. 2. I agree to call the program to inform staff whenever my child will be absent. If my child

is ill, I will not send my child to his/her program/class and will make alternative arrangements.

3. I will complete all enrollment forms and supply other necessary documents. I will keep all information current and up-to-date.

4. I will read all communications: newsletters, e-mails, posters, and bulletin boards. 5. I agree and assume full responsibility for any damage to person or property caused by

my child. 6. I agree that if the behavior or health of my child should necessitate sending him/her

home, I (or someone listed on the Child Information Record) will IMMEDIATELY pick up my child from his/her program.

7. I understand if my child has persistent pattern of negative behavior and interventions have not been successful, I may be asked to remove my child from the program.

8. I understand that there may be field trips or special activities, which I can sign up for and pay for in advance.

9. I have read and received a copy of the Richmond Early Childhood Learning Center Parent Handbook which includes program policies, disciplinary procedures, and payment information, etc. I will discuss the rules, regulations, and expectations of the program with my child.

10. In the event of an emergency, I give permission to Richmond Early Childhood Learning Center to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care. The staff member in charge shall make reasonable attempts to contact me prior to any emergency medical treatment.

11. My child has permission to use the Richmond Community Schools playground equipment while participating in the Child Care and Preschool Programs.

12. I have been informed that the center maintains a Child Care Licensing Notebook which is available to view during business hours.

13. I have read, understood, and agree to all of the above. If I have any questions or concerns I will contact the Director, at (586)727-2509 ext. 1051.

Parent Signature: Date



RICHMOND EARLY CHILDHOOD LEARNING CENTER - PRESCHOOL


RICHMOND EARLY CHILDHOOD LEARNING CENTER - PRESCHOOL

Preschool Discipline Policy

Staff will use positive methods of child management, which encourage self-control, self- direction, self-esteem, and cooperation.

Group Management Technique- Limiting the number of children in each area of the room avoids overcrowding and allows for sufficient materials and the opportunity for constructive interactions, which reduces opportunities for negative behaviors. Positive Redirection - If a behavior is inappropriate; we will use positive redirection- Redirecting the child to another area of the room.

Your child’s teachers will do every step necessary to positively guide your child in the right direction. You will be notified if a problem has occurred and will be responsible for following up on it. It is the student’s responsibility to:

1. BE SAFE: walk in halls, keep hands and feet to self, be cooperative and follow the instructions of caregivers.

2. BE KIND: Use appropriate language, take turns with materials, and respect other students or adults.

3. BE RESPONSIBLE: Clean-up materials and centers, treat materials and equipment properly, play co-operatively with others, play in designated areas, and be responsible for their actions.

Our goal is to nurture self-control and positive behavior in our students. The staff will promote good behavior by being a part of the Positive Behavior Support System. Redirection and discussion will be used when appropriate choices are made. Inappropriate behavior will be brought to the attention of the parent who drops off or picks up the child. In some situations, the parents will be contacted by phone either at home or work. Repeated misbehavior will result in a meeting between the caregivers, parents, and administrator. A written warning will be given. Possible suspension or removal from the program may result.

I have read and discussed the above rules with my child.

Parent’s Signature Date

Guaranteed Learning for All Students! In compliance with Title VI of the Civil Rights Act of 1964, Title IX of the Education amendments of 1972, Section 504 of Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Title II of the Americans with Disability Act of 1990, and Elliott-Larsen Civil Rights Act of 1977, it is the policy of the Richmond Community School District that no person shall, on the basis of race, color, religion ,military status, national origin or ancestry, sex (including sexual orientation), disability, age (except as authorized by law,) height, weight, or marital status be excluded from participation in, be denied the benefits of, or be subjected to, discrimination during any program, activity, service or employment. Inquiries related to any nondiscrimination policies should be directed to the Superintendent, 35276 Division Road, Richmond, MI 48062, (586) 727-3565.

Richmond Community Schools 35276 Division * Richmond, Michigan 48062 * (586) 727-3565 * (586) 727-2098 (FAX) * www.richmond.k12.mi.us


Page 1 | 1 2020-2021 School Year

STATEMENT OF VARICELLA DISEASE


Richmond Community Schools 35276 Division * Richmond, Michigan 48062 * (586) 727-3565 * (586) 727-2098 (FAX) * www.richmond.k12.mi.us

Consent for Disclosure of Immunization Information to Local and State Health Departments

Immunizations are an important part of keeping our children healthy. Schools and State and Local health departments must monitor immunization levels to ensure that all communities are protected from potentially life-threatening diseases and, if necessary, respond promptly to an emerging public health threat. It is important that disease threats be minimized through the monitoring of students being immunized.

Sharing immunization and personally identifiable information including the student’s name, Date of Birth, gender, and address with local and state health departments will help to keep your child safe from vaccine preventable diseases. The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g, requires written parental consent before personally identifiable information from your child’s education records is disclosed to the health department. If your child is 18 or over, he or she is an “eligible student” and must provide consent for disclosures of information from his or her education records.

You may withdraw your consent to share this information in writing at any time.

I authorize Richmond Community Schools to release my child’s immunization record to the Michigan Department of Health and Human Services and Local Health Department. I understand this information will be used to improve the quality and timeliness of immunization services and to help schools comply with Michigan Law. This includes any immunization information and limited personally identifiable information from the school.

Student’s Name: Date of Birth: / /

Signature of Parent/Guardian or Eligible Student: Date: / /

Printed Parent/Guardian Name:

District Contact Person: Brian J. Walmsley, Ed.S., Superintendent [email protected] * (586) 727-3565

Page 1 of 1 Rev 1-30-20


mailto:[email protected]

WHAT IS A CONCUSSION?

A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move quickly back and forth. This fast movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging the brain cells.

HOW CAN I SPOT A POSSIBLE CONCUSSION?

Children and teens who show or report one or more of the signs and symptoms listed below—or simply say they just “don’t feel right” after a bump, blow, or jolt to the head or body—may have a concussion or other serious brain injury.

SIGNS OBSERVED BY PARENTS OR COACHES

• Appears dazed or stunned. • Forgets an instruction, is confused about an

assignment or position, or is unsure of the game, score, or opponent.

• Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows mood, behavior, or personality changes. • Can’t recall events prior to or after a hit or fall.

SYMPTOMS REPORTED BY CHILDREN AND TEENS

• Headache or “pressure” in head. • Nausea or vomiting. • Balance problems or dizziness, or double or blurry

vision. • Bothered by light or noise. • Feeling sluggish, hazy, foggy, or groggy. • Confusion, or concentration or memory problems. • Just not “feeling right,” or “feeling down.”

This sheet has information to help protect your children or teens from concussion or other serious brain injury. Use this information at your children’s or teens’ games and practices to learn how to spot a concussion and what to do if a concussion occurs.

CONCUSSION INFORMATION SHEET

Richmond Community Schools

WHAT ARE SOME MORE SERIOUS DANGER SIGNS TO LOOK OUT FOR?

In rare cases, a dangerous collection of blood (hematoma) may form on the brain after a bump, blow, or jolt to the head or body and can squeeze the brain against the skull. Call 9-1-1 or take your child or teen to the emergency department right away if, after a bump, blow, or jolt to the head or body, he or she has one or more of these danger signs:

• One pupil larger than the other. • Drowsiness or inability to wake up. • A headache that gets worse and does not go away. • Slurred speech, weakness, numbness, or decreased

coordination. • Repeated vomiting or nausea, convulsions or seizures

(shaking or twitching). • Unusual behavior, increased confusion, restlessness, or

agitation. • Loss of consciousness (passed out/knocked out). Even a

brief loss of consciousness should be taken seriously.

WHAT SHOULD I DO IF MY CHILD OR TEEN HAS A POSSIBLE CONCUSSION?

As a parent, if you think your child or teen may have a concussion, you should:

1. Remove your child or teen from play. 2. Keep your child or teen out of play the day of the

injury. Your child or teen should be seen by a health care provider and only return to play with permission from a health care provider who is experienced in evaluating for concussion.

3. Ask your child’s or teen’s health care provider for written instructions on helping your child or teen return to school. You can give the instructions to your child’s or teen’s school nurse and teacher(s) and return-to-play instructions to the coach and/or athletic trainer.

Do not try to judge the severity of the injury yourself. Only a health care provider should assess a child or teen for a possible concussion. Concussion signs and symptoms often show up soon after the injury. But you may not know how serious the concussion is at first, and some symptoms may not show up for hours or days. The brain needs time to heal after a concussion. A child’s or teen’s return to school and sports should be a gradual process that is carefully managed and monitored by a health care provider.

HOW CAN I HELP KEEP MY CHILDREN OR TEENS SAFE?

Sports are a great way for children and teens to stay healthy and can help them do well in school. To help lower your children’s or teens’ chances of getting a concussion or other serious brain injury, you should:

• Help create a culture of safety for the team. ›› Work with their coach to teach ways to lower

the chances of getting a concussion. ›› Talk with your children or teens about

concussion and ask if they have concerns about reporting a concussion. Talk with them about their concerns; emphasize the importance of reporting concussions and taking time to recover from one.

›› Ensure that they follow their coach’s rules for safety and the rules of the sport.

›› Tell your children or teens that you expect them to practice good sportsmanship at all times.

• When appropriate for the sport or activity, teach your children or teens that they must wear a helmet to lower the chances of the most serious types of brain or head injury. However, there is no “concussion- proof” helmet. So, even with a helmet, it is important for children and teens to avoid hits to the head.

JOIN THE CONVERSATION AT www.facebook.com/CDCHEADSUP

Content Source: CDC’s HEADS UP campaign. Customizable HEADS UP fact sheets were made possible through a grant to the CDC Foundation from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

TO LEARN MORE GO TO >> cdc.gov/HEADSUP

http://www.facebook.com/CDCHEADSUP




Page 1 | 1 2020-2021 School Year

CHILD’S NAME (Last, First, Middle) DATE OF BIRTH (mm/dd/yy)

/ / ADDRESS (Number & Street) (City) (ZIP Code) TODAY’S DATE (mm/dd/yy)

MI / / PARENT/GUARDIAN (Last, First, Middle) HOME TELEPHONE NUMBER

( )

ADDRESS (Number & Street) (City) (ZIP Code) WORK TELEPHONE NUMBER

MI ( )

SECTION I - HEALTH HISTORY

h h h 12 Dental Problems: Date of Last Exam h h h Other (please describe):

/ /

h h Does your child take any medication(s) regularly? Reason for Medication

If yes, list medications: [

/ / Was the health history reviewed by a health professional? Parent/Guardian Signature Date h Yes h No Examiner’s Initials:

HEALTH APPRAISAL Dear Parent or Guardian: The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD’S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL

Yes

No

Reso

# Is your child having any of the problems listed below? Birth History: h h h 1 Allergies or Reactions (for example, food, medication or other)

h h h 2 Hay Fever, Asthma, or Wheezing

h h h 3 Eczema or Frequent Skin Rashes

h h h 4 Convulsions/Seizures

h h h 5 Heart Trouble

h h h 6 Diabetes

h h h 7 Frequent Colds, Sore Throats, Earaches (4 or more per year) Are there any current or past diagnosis(es) h Yes h No h h h 8 Trouble with Passing Urine or Bowel Movements If yes, please describe: h h h 9 Shortness of Breath

h h h 10 Speech Problems

h h h 11 Menstrual Problems

SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS

Required for Child Care and Head Start / Early Head Start Tests and Measurements

No

Yes

Was child tested for:

Test results: Norm

al

Refe

rred

Unde

r Car

e

No

Yes

Was child tested for:

Test results: Norm

al

Refe

rred

Unde

r Car

e

h

h

VISION Date: / /

Visual Acuity h

h

h

h

HEIGHT & WEIGHT Other:

Height

Muscle Imbalance Weight

Other: Other

h

h

HEARING Date: / /

Audiometer h h HEMOGLOBIN / HEMATOCRIT ]

Other: h

h

BLOOD PRESSURE

Reading:

h

h

URINALYSIS Date: / /

Sugar

h

h

TUBERCULIN Date: / /

Type:

Neg.: h Pos.: h mm

Albumin

Microscopic

h

h

BLOOD LEAD LEVEL Date: / /

Level ug/dl [ NOTE: Blood lead level required for all children enrolled in Medicaid must be tested at one and two years of age, or once between three and six years of age if not previously tested. All children under age six living in high-risk areas should be tested at the same intervals as listed above.

Examinations and/or Inspections Essential Findings Deviating from Normal:

Exam Date: / / MDHHS/BCAL-3305 (formerly OCAL 3305/BRS-3305) Page 1 of 2 Rev. July 2015

lved

No

Yes

SECTION III - IMMUNIZATIONS Statements such as “UP-TO-DATE” or “COMPLETE” will not be accepted. Admission to school may be denied on the basis of this information.*

VACCINES (Circle Type) DATE ADMINISTERED

MM/DD/YYYY

VACCINES (Circle Type) DATE ADMINISTERED

MM/DD/YYYY

Hepatitis B

(HepB)

1 3 Hepatitis A (HepA) 1 2

2 Influenza (IIV/LAIV)

1 3

DTaP/DTP/DT/Td

1 4 2 4

2 5 Meningococcal (MCV4 / MPSV4) 1 2

3 6 Human Papillomavirus

(HPV9/HPV4/HPV2) 1 3

Tdap 1 2

Haemophilus Influenzae

type b (HIB)

1 3 OTHER Vaccines

Specify Date & Type

Type of Vaccine(s) Date of Vaccine(s)

2 4 1

Polio

(IPV/OPV)

1 3 2

2 4 3

Pneumococcal Conjugate

(PCV7/PCV13)

1 3 Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable

2 4 *NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for the first time must be adequately immunized, vision tested and hearing tested. Exemptions to these requirements are granted for medical, religious and other objections, provided that the waiver forms are properly prepared, signed and delivered to school administrators. Forms for these exemptions are available at your provider office for medical waiver forms and through your local health department for nonmedical waiver forms.

Rotavirus (RV1/RV5) 1 3

2

Measles,Mumps, Rubella (MMR) 1 2

Varicella (Chickenpox) 1 2 History of Chickenpox Disease? h Yes h No If yes, date: Parent/Guardian refused immunizations: h

I certify that the immunization dates are true to the best of my knowledge / /

Health Professional’s Signature Title Date

SECTION IV - RECOMMENDATIONS (Required for Child Care and Head Start/Early Head Start)

h h Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:

h h Should the child’s activity be restricted because of any physical defect or illness? If yes, check and explain degree of restriction(s): h Classroom h Playground h Gymnasium h Swimming Pool h Competitive Sports h Other

Other Recommendations

SECTION V - DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL)

I have examined ’s teeth. As a result of this examination, my recommendation for treatment is: child’s name

Dentist’s Signature

/

Date

/

PHYSICIAN’S SIGNATURE

/ /

Examiner’s Signature Date Examiner’s Name (Print or Type) Degree or License

MI ( )

Number & Street City ZIP Code Telephone

Information required for:

Early On - Hearing and Vision Status; Diagnosis; Health Status Child Care Licensing - Physical Exam, Restrictions, Immunizations Head Start/Early Head Start - Determination that child is up-to-date on a schedule of age-appropriate preventive and primary health care, including medical, dental, and mental health. The schedule must incorporate the well-child care visit required by EPSDT and the latest immunizations schedule recommended by the Centers for Disease Control and Prevention, State, tribal, and local authorities. An EPSDT well-child exam includes height, weight, and blood tests for anemia at regular intervals based on age. ************** Developed in Cooperation with the Department of Health and Human Services, Education, Michigan American Association of Pediatrics, Early Childhood Investment Corporation, Child Care Licensing, Head Start, Michigan State Medical Society, Michigan Association of Osteopathic Physicians and Surgeons.

MDHHS/BCAL 3305 (formerly OCAL 3305/BRS-3305) Page 2 of 2 Rev. July 2015