InsightSchoolofWashingtonQuillayuteValleySchoolDistrict#402

2601South35thStreet,Ste100Tacoma,WA98409Ph866‐992‐5505Fax855‐278‐8928

insightwafax@k12.com www.wa.insightschools.net 

2013‐2014SchoolYear

FaxCoverSheetFAXALLDOCUMENTS CALLYOURPAL1‐855‐278‐8928 1‐866‐992‐5505

EMAIL:insightwafax@k12.comDate: Student First Name: Student Last Name: Student’s Primary Phone Number: # of pages faxed (including cover sheet):

*****CHECK CORRESPONDING DOCUMENTS****

NEW STUDENT DOCUMENTS    Must be completed, submitted, and approved by the local office prior to approval   REQUIRED 

      ****** IF STUDENT IS 18 OR WILL TURN 18 ON OR BEFORE THE FIRST DAY OF SCHOOL STUDENT MUST SIGN ALL DOCUMENTS***** 

New Student Enrollment and Statement of Understanding 

Registration Choice Form and Computer Option 

Birth Certificate    (This document is used to verify legal guardianship when last names do not match) 

Proof of Residency  (Utility Bill/Lease Agreement /WA State ID DSHS/Social Security Statement).  (DO ̀NOT SEND IN PESRONAL HAND WRITTEN MAIL STATEMENTS  

OR BANK/PERSONAL/FINANCIAL INFOMATION) 

Immunizations    (Immunization forms are acceptable if issued by the doctor or state agency.  Submit with the new Department of Health standardized form sign    

in the top right hand corner) 

Transcript  9th‐12th Grade    ACADEMIC HISTORY  OR WITH DRAW GRADES ARE NOT ACCEPTABLE 

Report Card             ENTERING 9TH GRADE ONLY   

Proof of Guardianship    (The birth certificate, DSHS/Social Security w/parent/student name, Guardianship papers)   

Learning Coach Waiver Form   (This form is required when an adult student (18 & over) wants another to have access to educational information, OR if a legal guardian 

wants to give access to student’s information and/or if legal guardian want’s a non‐guardian as a  learning coach) 

Additional documents MAY need to be submitted if requested: Parenting plan/Custody Order/Restraining Order 

  

RETURNING STUDENT DOCUMENTS    REQUIRED  

YOU ARE A RETURNING STUDENT IF YOU DID NOT WITHDRAW FROM THE PROGRAM 

Registration Choice Form and Computer Options 

Income Eligibility 

Proof of Residency  (if you have a new address) 

Student Name__________________________________________________________ Date of Birth_______________ Please Print

*INSIGHT SCHOOL OF WASHINGTON IS A FULL-TIME HIGH SCHOOL ONLY*

Student Name First Legal Last Name Birthdate Grade Entering Phone Number

DISCIPLINE INFORMATION: NOTE: DISCIPLINE WILL BE ASSESSED AND REVIEWED PRIOR TO ENROLLMENT

Current/Pending Suspension or Expulsion: �YES �NO Previous Suspension/Expulsion: �YES �NO LAST 12 MONTHS

Reason___________________________________ Date __________ Reason_______________________________ Date______________

Becca Bill/Truancy Petition? �YES �NO Name of School_________________________________________________

CUSTODY INFORMATION: NOTE: JOINT CUSTODY, PARENTING PLANS, & RESTRAINING ORDERS MUST BE SUBMITTED PRIOR TO APPROVAL

Joint Custody or Parenting Plan in effect �YES �NO Primary Custodial Parent: Mother � Father � Both □ 

Is there a restraining order in effect? �YES �NO Against: �Mother �Father �Other: ____ Date:_____ Exp Date:______

SPECIAL PROGRAMS: NOTE: Students enrolling in SE services will participate in a review process prior to approval

Statement of Understanding: In accordance with the Alternative Learning Experience Implementation Standards, reference WAC 392-121-182 (3)(e), prior to enrollment parent(s) or guardians shall be provided with, and sign, documentation attesting to the understanding of the difference between home-based instruction and enrollment in an alternative learning experience (ALE).

Home-Based Instruction (Home School not using Insight Program) Is provided by the parent or guardian as authorized under RCW 28A.200 and

28A.225.010. Students are not enrolled in Public Education. Students are not subject to the rules and regulations governing public schools, including

course, graduation, and assessment requirements. The public school is under no obligation to provide instruction or instructional materials,

or otherwise supervise the student’s education.

Alternative Learning Experience-Insight School of Washington Is authorized under WAC 392-121-182. Students are enrolled in public education either full time or part time. Students are subject to the rules and regulations governing public school students

including course, graduation, and assessment requirements for all portions of the ALE. Learning experiences are:

Supervised, monitored, assessed, and evaluated by certified staff. Provided via a written student learning plan. Provided in whole, or part outside the regular classroom.

I have read the descriptions of home-based instruction and alternative learning experiences provided and understand the difference between home-based instruction and the alternative learning experience program in which my child is enrolling

Parent/Guardian/Student Signature: ____________________________________________________ Date_____________________

Ethnicity and Race Data Collection:

Question 1: Is your child of Hispanic or Latino origin (Check all that apply)

Question 2: What race(s) do you consider your child (Check all that apply)

**All Students 18 Years and Older Must Sign ALL Enrollment Paperwork**

African American/Black Chinese Hmong Klallam Makah Nisqually Quileute Snoqualmie TaiwaneseAlaska Native Colville HOH Korean Malaysian Nooksack Quinalut Sohal Water ThaiAlaska Native Cowlitz Indonesian Laotian Mariana Islander Other Asian Samish Spokane TonganAsian Indian Fijian Jamestown Lower Elwha Melanesian Pakistani Samoan Squaxin Island TulalipChamorro Filipino Japanese Lummi Muckleshoot Port Gamble Sauk-Suiattle Stillaguamish VietnameseChehalis Guamanian Kalispel Makah Native Hawaiian Puyallup Singaporean Suquamish Yakama

Student currently has an active IEP YES NO School _________________________________

Student previously had an IEP YES NO School _______________________Date_______________ Did student ask for a revocation of services YES NO School ____________________Explain:___________________________ Student has a 504 YES NO School_____________________________________________

Student currently enrolled in Running Start Skill Center Other public or private program

Student travels outside WA State/US YES NO Frequently____________________________

Not Hispanic/Latino Spaniard South American Cuban Puerto Rican Dominican Central American Other Hispanic/Latino Mexican/Mexican American/Chicano (30)

InsightSchoolofWashingtonQuillayuteValleySchoolDistrict#402

2601South35thStreet,Ste100Tacoma,WA98409Ph866‐992‐5505Fax855‐278‐8928

insightwafax@k12.com www.wa.insightschools.net 

 2013‐2014SchoolYear

 ChoiceForm(RequestforRelease)One form per student-If the student is 18 years or older they must sign this form.Quillayute Valley School District No. 402

NEW STUDENT RETURNING STUDENT ADDRESS CHANGE

 

 Student Name: ____________________________________________________________________     Grade 2013‐14:__________Date of Birth: ___________    Parent/Guardian Name: ___________________________________________  Parent/Guardian Name:____________________________________________                  List all guardians   Not Required if student is 18 years or older      List all guardians   

 

Address: ____________________________________________________________City:________________________________Zip Code: _________________   

  

Learning Coach _______________________________________LC Phone #_____________________   Is Learning Coach Students Legal Guardian?   Y  N    

Resident School District _____________________________________________________________________________ Currently Enrolled.  Y    N   (School District where your house is currently located)       

 

Please check all that apply  Special Ed      504      Discipline Issues     Regular Ed  

BASIS FOR REQUEST OF RELEASE  

A financial, educational, safety or health condition affecting the student would be reasonably improved as a result of the transfer. 

Attendance at the school requested is more accessible to the parent’s place of work or childcare. 

There is some other special hardship or detrimental condition affecting the student or the student’s immediate family that would be alleviated because of the transfer. Please explain.  Use back of  page if necessary  

  Parent/Guardian Signature: ____________________________________________________________Date:______________   School Year 2013‐2014  

        (Student signature if over 18 years or emancipated) 

 

For School/District use only

Approved Denied Authorized Signature ___________________________________ Title _________________________ Date ____________ Releasing School District Authorized Signature

Approved Denied CERTIFICATION OF NON-RESIDENT SCHOOL ACCEPTANCE FROM: Quillayute Valley School District #402

Signature __________________________________________ Signature _________________________________ Date __________________ Insight School of Washington Official Quillayute Valley School Superintendent

Computer Options

Student Name____________________________________________________________ is interested in Insight’s Computer loaner program.

Did you complete the Family Income Form? Online Paper If you qualify for Insight’s Computer Loaner Program, which would you prefer? Computer Printer

Responsible Party ________________________________________________________________________ Date ______________________ Legal Guardian

Once student turns 18 the above student will submit a new form to the administration office.

Computer Eligibility: 2013–2014 YEARLY APPLICATION List all students living with you that are attending school. If the student is a foster child, indicate this by placing an “x” in the appropriate box. Include any personal income received by the student and make an “x” in the correct box for how often it is received. If you have written a case number for any of your children, skip to Section 4.However, if you have written a case number only for the foster child and want to apply for all students in the household, you must proceed to Section 2. If any child you are applying for is homeless (McKinney-Vento), or migrant, check the appropriate box. Homeless Migrant

List the names of all other household members - Enter income and CHECK how often it is received. If you write a case number for another household member, skip to Section 4. However, if the case number is only for the foster child(ren), you must proceed to Section 3

INSTRUCTIONS FOR APPLYING

If your household receives benefits from the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program, follow these instructions:

Part 1: List all child(ren)’s attending this district by name, school, grade. Part 2: Complete the name of the household member receiving SNAP benefits and the SNAP case number. Part 3: Skip this part. Part 4: Sign the form. A Social Security Number is not necessary. Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic. Part 6: If the household does not want the student’s eligibility information shared with Medicaid If NO ONE in your household receives SNAP benefits AND if all child(ren) in your household is/are foster child(ren): Part 1: List all the child(ren) in the household attending school at this district by name, school, and grade. Check the box for each child(ren) that is the legal responsibility of welfare agency or court. Part 3: Skip this part. Part 4: Sign the form. A Social Security Number is not necessary. Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic. Part 6: If the household does not want the student’s eligibility information shared with Medicaid then check this box.

ALL OTHER HOUSEHOLDS, including households with both foster and non-foster children in the same household and WIC households, follow these instructions:

Part 1: List each child’s name, school, and grade. Check the box for each child(ren) that is the legal responsibility of welfare agency or court.

Part 2: If the household does not have a SNAP case number skip this part. If a SNAP case number is listed skip to Part 4 of this form.

Part 3: Follow these instructions to report total household income from last month. Column 1: Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children who live with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them. Column 2: Gross income last month and how often it was received. Next to each person’s name list each type of income received for the month, and how often the money is received. For example, Earnings from work: List the gross income (not take home pay) each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person receives the income (for example: weekly, every other week, twice a month, or monthly). Column 3: List the amount each person got last month from welfare, child support, alimony, Column 4: List the amount each person got last month from pensions, retirement, Social Security Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), Column 5: List the amount each person got last month from ALL OTHER INCOME SOURCES. Do not include the Department of Defense’s Family and Subsistence Supplemental Allowance (FSSA) as income. Include disability benefits, Worker’s Compensation, unemployment, strike benefits and regular contributions from people who do not live in your household, and ANY OTHER INCOME. Report net income for self-owned business, farm, or rental income. Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance. Column 6–Check if no income: If the person does not have any income, check the box. Part 4: An adult household member must sign the form and list the last four digits of his or her Social Security

Number, or mark the box if he or she doesn’t have a Social Security Number. Part 5: Answer this question if you choose to. Mark one box for racial identity and one box for ethnic. Part 6: If the household does not want the student’s eligibility information shared with Medicaid or then check this box.

Letter to Household

2012-13

FREE AND REDUCED PRICE SCHOOL MEALS HOUSEHOLD APPLICATION Part 1. Children in School at this District

Names of all children in school at this district (First, Middle Initial, Last)

School Name Grade Check if a foster child (legal responsibility of welfare agency or court). If all children listed below are foster

children, skip to part 4 of this form.

�

�

�

�

�

�

�

Part 2. SNAP Benefits: If any member of your household receives Supplemental Nutrition Assistance Program (SNAP) benefits, provide the name and case number for any household member that receives benefits and skip to Part 4. If no one receives SNAP benefits, skip to Part 3.

Name: ______________________________________________ Case Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Part 3. Total Household Gross Income — You must tell us how much and how often

A. Name (List everyone in

household)

B. Gross income and how often it was received Example: $100/monthly $100/twice a month $100/every other week $100/weekly C. Check

if NO income

Earnings from work before deductions

Income / How often

Welfare, child support, alimony

Income / How often

Pensions, Retirement, Social Security, SSI, VA

benefits Income / How often

All Other Income Income / How often

$______/________ $______/________ $______/________ $______/________ �

$______/________ $______/________ $______/________ $______/________ �

$______/________ $______/________ $______/________ $______/_______ �

$______/________ $______/________ $______/________ $______/_______ �

$______/________ $______/________ $______/________ $______/_______ �

$______/________ $______/________ $______/________ $______/_______ �

$______/________ $______/________ $______/________ $______/_______ �

$______/________ $______/________ $______/________ $______/_______ �

$______/________ $______/________ $______/________ $______/_______ �

Part 4. Signature and Last Four Digits of Social Security Number (Adult Must Sign)

An adult household member must sign the application. If Part 3 is completed, the adult signing the form also must list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this form.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.

Sign here: X ________________________________________ Social Security Number: xxx-xx- ___ ___ ___ ___ (last 4 digits only)

Print Name: ________________________________________ � I do not have a Social Security Number

Phone Number: _____________________________________ Address: _______________________________________________

Date: _____________________________________________ City, State, Zip: ___________________________________________

Part 5. Children’s racial and ethnic identities. Mark one box in each category (optional).

Choose one or more (regardless of ethnicity):

Choose one ethnicity:

� Asian � American Indian or Alaska Native � White � Native Hawaiian or Other Pacific Islander � Black or African American

� Hispanic or Latino � Not Hispanic or Latin

Part 6. Disclosure (Optional) � I do not want school officials to share information from my free and reduced price meal application with Medicaid or the State Children’s Health Insurance Program

Don’t fill out this part. This is for school use only. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24, Monthly x 12

Total Income: ______________ Per: _____ Week, _____ Every 2 Weeks, _____Twice a Month, _____Month, _____Year

Household size: __________ SNAP* (food stamps): _________ Categorically Eligible: ________ Date Withdrawn: __________

Eligibility: Free _______ Reduced ________ Denied ________ Reason: ___________________________________________

Determining Official’s Signature: ________________________________________________ Determination Date: ______________________

Application 2012-13

InsightSchoolofWashingtonQuillayuteValleySchoolDistrict#402

2601South35thStreet,Ste100Tacoma,WA98409Ph866‐992-5505 Fax855‐278‐8928

insightwafax@k12.com www.wa.insightschools.net 

 2013‐2014 SchoolYear

Page 5 RELEASEOFSTUDENTRECORDS

Please accept this document as formal approval for the release of all official school records (including the record of transcripts, testing information, special education, health and 

immunization records).  Please do not send any records unless this form has been sent to you directly by a Insight School of Washington. 

Student Information 

Student’s Full Name: _____________________________________________________________________________________________________________________                    First                                                                 Middle                                                        Legal Last                                                              Also known as: 

 Student’s Date of Birth: ________________________________                                                                                              Home Phone: ____________________________  Student’s Legal Address: __________________________________________________________________________________________________________________ 

                          Street                                                                                                                                                                         Apt #  _______________________________________________________________________________________________________________________________________ City                                                                                 County                                                                           State                                                                    Zip Code  

 

□ Student was always previously homeschooled   □ Student is currently attending, or has previously  attended a public or private school 

 

Prior School Information  

Current School of Attendance: ____________________________________________________________________________________________________  School Address: _________________________________________________________________________________________________________________________                               Street _______________________________________________________________________________________________________________________________________ City                                                                                                   County                                                                                         State                                               Zip Code  Attended from: _____________________________            School Phone: ____________________________             School Fax: __________________________  

Previous School of Attendance (if differs from above):_________________________________________________________________________________ 

 School Address: _________________________________________________________________________________________________________________________                               Street _______________________________________________________________________________________________________________________________________ City                                                                                                   County                                                                                         State                                               Zip Code   Attended from: _____________________________            School Phone: ____________________________             School Fax: __________________________ 

 

 Recognizing this legal requirement, I hereby verify that the student named above physically resides within Washington State and all of the above provided information is correct.  Print name of Parent/Guardian: _________________________________Parent/Guardian’s Signature: ______________________________Date:_______________                             

SCHOOL OFFICIALS ONLY:                                                                                                                                                          Send Records to:   InsightSchoolofWashingtonOfficialStudentRecords2601South35thStreet,Ste100Tacoma,WA98409 

 

Vaccine

Dose Date

Month Day Year

+ Hepatitis B (Hep B) 1 2 3

or Hep B - 2 dose alternate schedule for teens

1 2 Rotavirus (RV1, RV5)

1 2 3 + Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)

1 2 3 4 5 + Tetanus, Diphtheria, Pertussis (Tdap, Td)

1 2 • Haemophilus influenzae type b (Hib)

1 2 3 4 • Pneumococcal (PCV, PPSV)

1 2 3 4

Vaccine Dose Date Month Day Year

+ Polio (IPV, OPV) 1

2

3

4

Influenza (flu, most recent)

+ Measles, Mumps, Rubella (MMR) 1

2

+ Varicella (chickenpox) or verify disease 1-4

1

2

Hepatitis A (Hep A) 1

2

Meningococcal (MCV, MPSV) 1

Human Papillomavirus (HPV) 1

2

3

Office Use Only: Immunization information updated and verified with parent/guardian permission:

Printed Staff Name Date

Printed Staff Name Date

If the child can show immunity by blood test (titer) and hasn’t had the vaccine, ask your HCP to fill in this box.

Documentation of Disease Immunity I certify that the child named on this CIS has laboratory evidence of immunity (titer) to the diseases marked. Signed lab report(s) MUST also be attached. 0 Diphtheria 0 Hepatitis A 0 Hepatitis B 0 Hib 0 Measles

0 Mumps 0 Polio 0 Rubella 0 Tetanus 0 Varicella

0 Other:

Licensed health care provider (HCP) Signature Date (MD, DO, ND, PA, ARNP)

HCP Printed Name:

PAGE 6

Certificate of Immunization Status (CIS) DOH 348-013 January 2010

Please print. See back for instructions on how to fill out this form or get it printed from the Immunization Registry.

Office Use Only: Reviewed by: Date: Signed Cert. of Exemption on file? 0 Yes 0 No

Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: I certify that the information provided on this form is correct and verifiable.

Parent/Guardian Signature Required Date

Symbols below: + Required for School and Child Care/Preschool • Required for Child Care/Preschool Only

Parent/Guardian Name (please print):

If the child named on this CIS had chickenpox disease (and not the vaccine), disease history must be verified. Mark option 1, 2, 3, OR 4 below – see, back #5.

1) 0 Chickenpox disease verified by printout from CHILD Profile Immunization Registry

Must be marked by printout (not by hand) to be valid.

2) 0 Chickenpox disease verified by Health Care Provider (HCP)

If you choose this box, mark 2A OR 2B below. 2A) 0 Signed note from HCP attached OR 2B) 0 HCP signed here and print name below:

Licensed health care provider (HCP) Signature Date

(MD, DO, ND, PA, ARNP)

HCP Printed Name:

3) 0 Chickenpox disease verified by school staff from CHILD Profile Immunization Registry

If you choose this box, staff must initial that parent or guardian approves: (initial) (date)

4) 0 Chickenpox disease verified by parent* If you choose this box, fill in the date or child’s age when he or she had the disease:

Age/Date of disease: *Can ONLY verify for some grades, see back #5 (4).

Vaccine Dose DateMonth Day Year

+ Diphtheria, Tetanus, Pertussis (DTaP, DTP, DT)

DTaP 1 01 12 2011 DTaP 2 03 20 2011DTaP 3 06 01 2011

Vaccine Trade Names in alphabetical order (For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)

Trade Name

Vaccine Trade Name

Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Engerix-B Hep B Ipol IPV Pentavalente DTaP + Hep B + Hib TriHIBit DTaP + HibAdacel Tdap Fluarix Flu (TIV) Infanrix DTaP Pneumovax PPSV or PPV23 Tripedia DTaPAfluria Flu (TIV) FluLaval Flu (TIV) Kinrix (Knrx) DTaP + IPV Prevnar PCV or PCV7 or PCV13 Twinrix (Twnrx) Hep A + Hep B Boostrix Tdap FluMist Flu (LAIV) Menactra MCV or MCV4 ProQuad (PrQd) MMR + Varicella Vaqta Hep ACervarix HPV2 Fluvirin Flu (TIV) Menomune MPSV or MPSV4 Quadracel (Qdrcl) DTaP + IPV Varivax VaricellaComvax (Cmvx) Hep B + Hib Fluzone Flu (TIV) Pediarix (Pdrx) DTaP + Hep B + IPV Recombivax HB Hep BDaptacel DTaP Gardasil HPV4 PedvaxHIB Hib Rotarix Rotavirus (RV1)Decavac Td Havrix Hep A Pentacel (Pntcl) DTaP + Hib + IPV RotaTeq Rotavirus (RV5)

Vaccine Abbreviations in alphabetical order (For updated lists, visit http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines-508.pdf)Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name Abbreviations Full Vaccine Name

DT Diphtheria, Tetanus Hep A (HAV) Hep B (HBV)

Hepatitis A Hepatitis B

MPSV or MPSV4 Meningococcal Polysaccharide Vaccine

Rota (RV1 or RV5)

Rotavirus

DTaP Diphtheria, Tetanus, acellular Pertussis Hib Haemophilus influenzae

type bMMR / MMRV Measles, Mumps, Rubella /

with VaricellaTd Tetanus, Diphtheria

DTP Diphtheria, Tetanus, Pertussis HPV Human Papillomavirus OPV Oral Poliovirus Vccine Tdap Tetanus, Diphtheria, acellular

PertussisFlu (TIV or LAIV) Influenza IPV Inactivated Poliovirus

VaccinePCV or PCV7 or PCV13

Pneumococcal Conjugate Vaccine TIG Tetanus immune globulin

HBIG Hepatitis B Immune Globulin MCV or MCV4 Meningococcal

Conjugate VaccinePPSV or PPV23 Pneumococcal Polysaccharide

Vaccine VAR or VZV Varicella

PAGE 8 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Registry or filling it in by hand.

#1 To print with info filled in: First, ask if your health care provider’s office puts vaccination history into the CHILD Profile Immunization Registry (Washington’s statewide database). If they do, ask them to print the CIS from CHILD Profile and your child’s information will fill in automatically. Be sure to review all the information, sign and date the CIS in the upper right hand box, and return it to school or child care. If your provider’s office does

not use CHILD Profile, ask for a copy of your child’s vaccine record so you can fill it in by hand using steps #2-7 (below):

#2 To fill in by hand: Print your child’s name, birthdate, sex, and your own name in the top box. #3 Write each vaccine your child received under the correct disease. Write the vaccine type under the “Vaccine”

column and the date each dose was received in the “Month,” “Day,” and “Year” columns (as mm/dd/yyyy). For example, if DTaP was received Jan 12, March 20, June 1, ’11, fill in as shown here

#4 If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV.

#5 If your child has had chickenpox (varicella) disease and not the vaccine, use only one of these four options to record this on the CIS:

EXAMPLE

1) 0 If your child’s CIS is printed directly from the CHILD Profile Immunization Registry (by your health care provider or school system), and disease verification is found, box 1 is automatically marked. To be valid, this box must be marked by the Immunization Registry printout (not by hand).

2) 0 If your health care provider (HCP) can verify that your child has had chickenpox, mark box 2. Then mark either 2A to attach a signed note from your HCP, or 2B if your HCP signs and dates in the space provided. Be sure your HCP’s full name is also printed.

3) 0 If school staff access the CHILD Profile Immunization Registry and see verification that your child has had chickenpox, they will mark box 3. Then, they must initial and date that they got parent or guardian approval to mark this box (i.e. make this change) to the CIS.

4) 0 If your child started kindergarten in the 2008-2009 school year or later, you CANNOT use this box. If your child started kindergarten before the 08-09 school year, mark this box if you know he or she has had chickenpox. If you mark box 4, you must also write the approximate age or date your child had chickenpox. To find out which grades require chickenpox vaccine (or history), visit: http://www.doh.wa.gov/cfh/immunize/schools/vaccine.htm

#6 Documentation of Disease Immunity: If your child can show immunity by blood test (titer) and has not had the vaccine, have your health care provider (HCP) fill in this box. Ask your HCP to mark the disease(s), sign, date, print his or her name in the space provided, and attach signed lab reports.

#7 Be sure to sign and date the CIS in the upper right hand box, and return to school or child care. #8 If a school or child care makes a change to your CIS, staff will print their name in the middle bottom box and date to show that you gave approval.

If you have a disability and need this document in another format, please call 1-800-525-0127 (TDD/TTY 1-800-833-6388). DOH 348-013 January 2010

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DOH 348-106 June 2011

CertificateofExemptionFor School, Child Care and Preschool Immunization

Requirements1

DIRECTIONS: All exemptions must have a licensed health care provider sign & date Box 1 (‘Provider Statement’).2 Exception: Box 1 is not required for religious exemptions when Box 2 (‘Demonstration of Religious Membership’) is completed. All exemptions must also have a parent/guardian sign & date Box 3 (‘Parent/Guardian Statement’). Child’s Last Name: First Name: Middle Initial: Birthdate (mm/dd/yyyy): Sex: Parent/Guardian Name (please print):

Parent/Guardian, please choose the exemption(s) that apply to your child below. 0 Temporary Medical Exemption 0 Permanent Medical Exemption

Until Vaccine(s) Date (or Permanent)

Print Name of Licensed Health Care Provider (MD, DO, ND, PA, ARNP)

X X

Signature of Licensed Health Care Provider Date

0 Personal/Philosophical Exemption (see Box 1) 0 Religious Exemption (see Box 1) 0 Religious Membership Exemption (see Box 2) I do not want my child to get the following vaccine(s): 0 Diphtheria 0 Hepatitis B 0 Hib 0 Measles 0 Mumps 0 Pertussis (whooping cough) 0 Pneumococcal 0 Polio 0 Rubella 0 Tetanus 0 Varicella (chickenpox)

0 Other (indicate):

Box 1 Box 2 Provider Statement2: “I, , am a qualified provider (MD, DO, ND, PA, ARNP) licensed under Title 18 RCW. I confirm that the parent or guardian signing in Box 3 (Parent/Guardian Statement) has received information on the benefits and risks of immunization to their child as a condition for exempting their child for medical, religious, personal, or philosophical reasons.” X Signature of Licensed Health Care Provider (MD, DO, ND, PA, ARNP) X Date

Parent/Guardian Demonstration of Religious Membership: “I am a member of a church or religious body whose beliefs or teachings do not allow for medical treatment from a health care practitioner. By supplying the information requested below, no further proof or signed provider statement in Box 1 is required for this religious exemption.” X Name of Church or Religious Body X X Signature of Parent or Guardian Date

Box 3

Parent/Guardian Statement: “I certify that all the information provided on this certificate is correct and verifiable. I understand that if there is an outbreak of a vaccine-preventable disease my child has not been fully immunized against (as indicated above, for medical, personal/philosophical or religious reasons), my child may be at risk for disease and can be excluded from school, child care, or preschool until the outbreak is over.” X X Signature of Parent or Guardian Date

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