We need an additional non-parent emergency contact. We will alway contact both Parents/Guardians first.
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Information and Instructions for Parents/Guardians
The following information is required prior to a child attending a Maryland State Department of Education licensed, registered or approved child care or nursery school:
￼• A physical examination by a physician or certified nurse practitioner completed no more than twelve months prior to attending child care. 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 (See COMAR 13A.15.03.02, 13A.16.03.02 and 13A.17.03.02).
•Evidence of immunizations. A Maryland Immunization Certification form for newly enrolling children 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. This form can be found at: http://ideha.dhmh.maryland.gov/IMMUN/pdf/896_form.pdf
•Evidence of Blood-Lead Testing for children living in designated at risk areas. 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:
Exemptions from a physical examination, immunizations and Blood-Lead testing are permitted if the family has an objection based on their religious beliefs and practices. The Blood-Lead certificate must be signed by a Health Care Practitioner stating a questionnaire was done.
Children may also be exempted from immunization requirements if a physician, nurse practitioner or health department official certifies that there is a medical reason for the child not to receive a vaccine.
The health information on this form will be available only to those health and child care provider or child care personnel who have a legitimate care responsibility for 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 during child care hours, you must have the physician complete a Medication Authorization Form (OCC 1216) for each medication. The Medication Authorization Form can be obtained at
If you do not have access to a physician or nurse practitioner or if your child requires an individualized health care plan, contact your local Health Department.
Assessment of Child's Health
To the best of your knowledge has your child had any problem with the following? Check Yes or No. If you check Yes please explain at the bottom.
If you answered yes to any of the above questions please explain in the space below.
The following Information is required for program participants:
All Participants must be current on all immunizations, see www.EDCP.org