MCH213G: Commonwealth of Virginia School Entrance Health Form

Enter the Name of School, the Current Grade and the Student's Name (Last First Middle).

Enter the Student's Date of Birth, Sex, State or Country of Birth and Main Language Spoken.

Enter the Student's Address, City, State and Zip Code.

Enter the Name of Parent or Legal Guardian 1 with Phone and Work or Cell, the Name of Parent or Legal Guardian 2 with Phone and Work or Cell, and the Emergency Contact with Phone and Work or Cell. Enter the Hospital Preference.

Under Child's Health Insurance, mark None, FAMIS Plus (Medicaid), FAMIS or Private/Commercial/ Employer Sponsored.

Under Box 1. Pre-Existing Conditions, mark Yes and add Comments for each Condition. Please list Life Threatening Allergies.

Describe any other important health-related information about your child (Feeding tube, Trach, Oxygen support, Hearing aids, Dental appliance, Wheelchair, Hospitalizations, etc.).

Under Box 2. Medications, List all prescription, emergency, over-the-counter, and herbal medications your child takes regularly (Home/ School): Medication Name, Dosage, Time Administered (Home/School) and Notes.

Check here if you want to discuss confidential information with the school nurse or other school authority. Mark Yes or No.

Provide the Name, Phone and Date of Last Appointment of the Pediatrician/primary care provider, the Specialist, the Dentist and the Case Worker (if applicable).

I ___ (do) (do not) authorize my child's health care provider and designated provider of health care in the school setting to discuss my child's health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child's school. When information is released from your child's record, documentation of the disclosure is maintained in your child's health or scholastic record. Sign on the Signature of Parent or Legal Guardian line and enter the Date.

A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form.

Check if the student's Immunization Records are attached using a separate form signed by HCP

Please contact your local health department for assistance with foreign vaccine records.

The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the student's parent/guardian submits an affidavit to the school's admitting official stating that the administration of immunizing agents conflicts with the student's religious tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local health department, school division superintendent's office or local department of social services.

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date. This section must be attached to Part I Health Information (to be filled out and signed by parent).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days.

The physical examination must be completed by a qualified licensed physician, nurse practitioner, or physician assistant, and must be completed within 12 months prior to the date such child first enters public kindergarten or elementary school.⁠^[2]

The Medical Provider or Health Department Official signs on the Signature of Medical Provider or Health Department Official line: "I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child care or preschool prescribed by the State Board of Health's Regulations for the Immunization of School Children (Reference Section III)."