1 Rev. 12/2019 Community Action Council Howard County Head Start Enrollment Information 9820 Patuxent Woods Drive, Columbia, Maryland 21046 410-313-6443 410-313-6479 (fax) First MI Last Date of Birth: / / Child Name: Age: Does the child speak English? very well well not well not at all Has your child ever been enrolled in Head Start or any other child development program? Yes No If yes, please list the program name and dates of attendance: Does your child have any special needs or do you have concerns about your child’s development behavior, speech or health? Yes No If yes, please list any concerns: Is your child receiving services to address any special needs? Yes No If yes, what type of services? ____________________________________________ Who provides these services? (please list name of agency and contact information) ________________________________________________________________ ________________________________________________________________________________ I certify that the information provided to support this application is accurate and truthful to the best of my knowledge. I understand that program staff may verify this information and that deliberate misrepresentation may subject me to withdrawal from thi s agency’s programs. Parent Signature: _______________________________________ Date: _____________________ Parent Signature: _______________________________________ Date: _____________________ Assurance of Confidentiality: The information on this form is being requested on a voluntary basis. The information you provide will help us to deliver or direct services most appropriate for your family’s needs. Some of the information may be used to help plan program initiatives. If you prefer not to provide some of the information, it will not affect the services we will try to deliver. However, some information is required for eligibility determination. All information will be held in strict confidence. AGENCY USE ONLY Preferred Center: _____________________________ Does the child need transportation: Yes No Proof of Age: Birth Certificate Passport Baptismal Record Medical records Eligibility: Qualifies by meeting Income Guidelines for Head Start Qualifies by meeting Income Guidelines for MSDE Pre-K Over-Income for Head Start-funded classrooms, 100-130% FPL 130% - 200% FPL Income documentation: (circle all that apply) 1040 Tax Form, W2 Statement, Pay Stubs Letter from Employer, Child Support, Declaration of Income Form, Other: _______________________ Qualifies with TCA Notice Qualifies with Foster Care Letter Qualifies with SSI Letter Qualifies with Homeless verification I certify that all of the information provided is complete and accurate to the best of my ability: FSW Staff Signature/Date: ______________________________ Certifier’s Signature/Date: _______________________________
Howard County Head Start Frequently Asked Questions
1. Can I submit an application without the medical paperwork?
We require all medical paperwork be completed before we process your application.
We urge parents to send in all of the paperwork as soon as possible.
2. What happens after I submit my application?
Once all of the paperwork has been submitted, your application will be reviewed by staff. If any paperwork is missing,
staff will contact you. Completed applications are submitted for a final review and if space is available, your child will be
enrolled in our program. If space is not available, you will receive a letter stating your child’s wait list status. Once space is
available, staff will contact you.
3. What if my family income is higher than the income guidelines?
Your application will be processed; however, children whose family income is higher than the Federal Poverty guidelines
will only be considered for enrollment once all income-eligible children have been considered to fill our open slots.
4. Will my child get transportation?
Transportation is very limited and is based on residency center assignment and bus stop location. Transportation is not
guaranteed. Daily transportation to Old Cedar Lane is provided by parents only.
5. Can I request a center assignment?
Children are enrolled at centers primarily based on what center zone they reside in. If a parent requests a center outside of
their zoned area or accept enrollment at a center outside of their zoned area, then the parent must provide transportation to
that Center.
6. Do I need to send food with my child?
No, ALL meals (breakfast, lunch and a snack) are provided at Head Start. Children who have allergies and/or special
dietary restrictions must have documentation from a physician stating the need for a substitute and the name of the desired
substitute. The Head Start Allergy and Nutrition form has appropriate space to share this information.
7. Does my child need to be toilet-trained to attend school?
No, children do not need to be toilet- trained to attend Head Start. The Head Start staff will assist your child in becoming
toilet trained. You should send a complete set of labeled clothing for your child along with a supply of pull–ups or diapers
for use at school.
8. Can I visit the school?
Yes! We have an open-door policy and parents are encouraged to visit or volunteer at the school. However, if you need
to speak with the teacher, please plan to do so before or after class time.
9. How many days will my child attend school?
Children attend school 5 days a week. We also observe all federal holidays. We also include a week off for winter and
spring breaks. Your child is expected to attend each day that school is open unless he/she is ill or family emergency.
Head Start requires an attendance rate of 85% or higher.
10. My child has an Individualized Education Plan (IEP) from the public school system.
Should I give it to Head Start?
Yes, please bring us any IEP or individual plan that you and another agency may have developed to meet your child’s
special needs. Head Start will work closely with the agency that wrote your child’s IEP or individual plan to make sure
that we provide the services that your child needs. Rev. 12/2019
Community Action Council
Howard County Head Start
Checklist
We can only accept COMPLETED applications. Before you turn in your
application, you must have all the following items:
Universal Application
Enrollment Form
Income Verification (1040 Form, Pay Stubs, SSI Benefits Letter, Letter from Employer,
your most recent tax return, W-2, TANF, Declaration of Income Form). You will need to
provide proof of your gross income for the last 12 months for the student’s parent(s) or
guardian(s) only.
Birth Certificate, Birth Notification, Passport OR Baptismal Record
Proof of Residency (Lease, Utility Bill, Deed, or Multiple Family Disclosure Form)
Health Inventory Part I
Health Inventory Part II
Lead Test Date/Results
Immunizations
Dental Form
Insurance Card
Emergency Card
Child and Adult Care Food Program (CACFP) Enrollment Form
Transportation Form
Parent Consent Form
Allergy and Nutrition Form
Asthma/Allergy Action Plan (if applicable, please request)
Medication Order Form (if applicable, please request)
Copy of IEP (if applicable)
MSDE Consent for Before/After Care (if applicable)
Rev. 01/2020-2
EMERGENCY FORM INSTRUCTIONS TO PARENTS: (1) Complete all items on this side of the form. Sign and date where indicated. (2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child’s
health practitioner review that information. NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.
Child’s Name ___________________________________________________________________________ Birth Date ___________________________ Last First Enrollment Date ______________________________ Hours & Days of Expected Attendance ____________________________________ Child’s Home Address __________________________________________________________________________________________________________ Street/Apt. # City State Zip Code
Name of Person Authorized to Pick up Child (daily) ___________________________________________________________________________________ Last First Relationship to Child Address _____________________________________________________________________________________________________________________ Street/Apt. # City State Zip Code Any Changes/Additional Information_____________________________________________________________________________________________ __________________________________________________________________________________________________________________________ ANNUAL UPDATES _____________________ ______________________ ______________________ ______________________ (Initials/Date) (Initials/Date) (Initials/Date) (Initials/Date)
When parents/guardians cannot be reached, list at least one person who may be contacted to pick up the child in an emergency: 1. Name _____________________________________________________________ Telephone (H) _________________ (W) __________________
Last First Address _________________________________________________________________________________________________________________ Street/Apt. # City State Zip Code 2. Name ______________________________________________________________ Telephone (H) _________________ (W) __________________ Last First Address _________________________________________________________________________________________________________________ Street/Apt. # City State Zip Code 3. Name ______________________________________________________________ Telephone (H) _________________ (W) __________________ Last First Address _________________________________________________________________________________________________________________ Street/Apt. # City State Zip Code Child’s Physician or Source of Health Care ___________________________________________________ Telephone ____________________________ Address _____________________________________________________________________________________________________________________ Street/Apt. # City State Zip Code In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital. Signature of Parent/Guardian _________________________________________________________ ___Date ___________________________________ OCC 1214 (Revised 9/12) - Side 1 of 2 - All previous editions are obsolete.
INSTRUCTIONS TO PARENT/GUARDIAN: (1) Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical
care. (2) If necessary, have your child’s health practitioner review the information you provide below and sign and date where
indicated. Child’s Name: ___________________________________________________ Date of Birth: _______________________
Medical Condition(s): _________________________________________________________________________________ ____________________________________________________________________________________________________________________________
Medications currently being taken by your child: ____________________________________________________________ ____________________________________________________________________________________________________________________________
Date of your child’s last tetanus shot: _____________________________________________________________________
EMERGENCY MEDICAL INSTRUCTIONS: (1) Signs/symptoms to look for: _________________________________________________________________________ ____________________________________________________________________________________________________________________________
(2) If signs/symptoms appear, do this: _____________________________________________________________________
(3) To prevent incidents: _______________________________________________________________________________ ____________________________________________________________________________________________________________________________
Note to Health Practitioner: If you have reviewed the above information, please complete the following: ________________________________________________ ____________________________________ Name of Health Practitioner Date
_________________________________________________ (_____)______________________________ Signature of Health Practitioner Telephone Number
OCC 1214 (Revised 9/12) - Side 2 of 2 - All previous editions are obsolete.
Rev. 8/19
Maryland State Department of Education Office of School and Community Nutrition Programs
CHILD AND ADULT CARE FOOD PROGRAM (CACFP) ENROLLMENT FORM
Instructions for Completion:
All parent/guardians are to complete this form for each child enrolled at the child care center/home participating in CACFP.
List the child’s name, age, birth date, the days and hours normally in care and the meals received while in care.
CACFP Federal regulations require that an enrollment form be completed annually and signed by the child’s parent or guardian.
Name of Child Care Center/Home
1. Child’s Name Child’s Date of Birth (MM/DD/YYYY)
Times Child Normally in Care Hours from: (For example 7:30 AM – 5 PM)
______ to ______
Check () the days your child normally attends:
Monday Thursday
Tuesday Friday
Wednesday Saturday
Sunday
Check () the meals that your child will receive while in care:
Breakfast AM Snack
Lunch PM Snack
Supper Evening
Snack
2. Child’s Name Child’s Date of Birth (MM/DD/YYYY)
Times Child Normally in Care Hours from: (For example 7:30 AM – 5 PM)
______ to ______
Check () the days your child normally attends:
Monday Thursday
Tuesday Friday
Wednesday Saturday
Sunday
Check () the meals that your child will receive while in care:
Breakfast AM Snack
Lunch PM Snack
Supper Evening
Snack
3. Child’s Name Child’s Date of Birth (MM/DD/YYYY)
Times Child Normally in Care Hours from: (For example 7:30 AM – 5 PM)
______ to ______
Check () the days your child normally attends:
Monday Thursday
Tuesday Friday
Wednesday Saturday
Sunday
Check () the meals that your child will receive while in care:
Breakfast AM Snack
Lunch PM Snack
Supper Evening
Snack
Parent/Guardian Signature ______________________________________________ Date Signed _____________________________
Howard County Head Start provides some services and activities that require specific parental consent. Please
read the statements below and initial if you agree/consent.
______ Head Start may exchange information with my child’s health care provider, dentist, Howard County Health
Department to facilitate his/her enrollment or attendance, obtain paperwork, or develop a care plan.
______ Head Start may exchange information with the Howard County Board of Education, Child Find, or other
educational institutions to facilitate the delivery of services and/or the development of educational plans.
______ Occasionally, Head Start has media events with photographers present; my child may be included in events
where pictures may be taken for media or display purposes. Rev. 1/2020
Community Action Council
Howard County Head Start Enrichment Activities Consent Form
Dear Parent/Guardian,
We are fortunate to be in a county where we have access to a number of resources and partnerships
which benefit our children. Howard County Public Schools, Howard County Community
College, Howard County Arts Council, Howard County Health Department, National Council of
Jewish Women, Sunrise Rotary Club, Glenelg Country School, and our weekly story teller Miss
Mary Koch, are among the many organizations and individuals who provide enrichment to our
classrooms on an ongoing basis.
We also have groups and individuals who come to share special occasions or holidays with our
children and staff and we notify families of these events in our menus, newsletters or special
notifications.
Each of the groups and/or individuals is supervised by program staff at all times while they
are in the centers.
We request that parents/guardians sign a consent form yearly acknowledging that there will be
times when groups and/or individuals will be invited into our centers to interact with children.
Please complete this form and return it to your child’s center. The form will be kept on file and
will be effective as long as the child is enrolled in the program.
I understand that my child _______________________________________ may be interacting Child’s Name with different groups and/or individuals during the program year. I understand that these groups
and/or individuals will be supervised by program staff at all times and by signing this form I am
allowing my child to participate in these enrichment activities.
____________________________________________ ___________________ Parent Signature Date
Rev. 1/2020
DHMH Form 896 Center for Immunization
Rev. 2/14 www.dhmh.maryland.gov
How To Use This Form
The medical provider that gave the vaccinations may record the dates (using month/day/year) directly on this form
(check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be
listed individually, by each component of the vaccine. A different medical provider, local health department official,
school official, or child care provider may transcribe onto this form and certify vaccination dates from any other record
which has the authentication 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 vaccines
except varicella, measles, mumps, or rubella.
2. Reconstructed dates for all vaccines must be reviewed and approved by a medical provider or local health
department 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, or
varicella 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 not
knowingly 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
Lines 2 and 3 are for certification of vaccines given after the initial signature.
RECORD OF IMMUNIZATIONS (See Notes On Other Side)
Vaccines Type Dose # 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
Varicella
Disease
1 1 Mo/Yr
2 2
3 Td Mo/Day/Yr
____
____
____
Tdap Mo/Day/Yr
____
____
FLU Mo/Day/Yr
____
____
Other Mo/Day/Yr
_____
_____ 4
5
COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM VACCINATION ON MEDICAL
OR RELIGIOUS GROUNDS. ANY VACCINATION(S) THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE.
MEDICAL CONTRAINDICATION:
Please check the appropriate box to describe the medical contraindication.
This is a: □ Permanent condition □ Temporary condition until _______/________/________
The above child has a valid medical contraindication to being vaccinated at this time. Please indicate which vaccine(s) and the reason for the
contraindication,
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 any vaccine(s)
being given to my child. This exemption does not apply during an emergency or epidemic of disease.
MARYLAND STATE DEPARTMENT OF EDUCATION Office of Child Care
HEALTH INVENTORY Information and Instructions for Parents/Guardians
REQUIRED INFORMATION
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://earlychildhood.marylandpublicschools.org/system/files/filedepot/3/maryland_immunization_certification_form_dhmh_896_-_february_2014.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: http://earlychildhood.marylandpublicschools.org/system/files/filedepot/3/dhmh_4620_bloodleadtestingcertificate_2016.pdf
•
•
EXEMPTIONS
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.
INSTRUCTIONS
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.
OCC 1215 - Revised June 2016 - All previous editions are obsolete Page 1 of 5
Your Child’s Routine Medical Care Provider Name: Address: Phone #
Your Child’s Routine Dental Care Provider Name: Address: Phone
Last Time Child Seen for Physical Exam: Dental Care: Any Specialist :
ASSESSMENT OF CHILD’S HEALTH - To the best of your knowledge has your child had any problem with the following? Check Yes or No and
provide a comment for any YES answer.
Yes No Comments (required for any Yes answer) Allergies (Food, Insects, Drugs, Latex, etc.) Allergies (Seasonal) Asthma or Breathing Behavioral or Emotional Birth Defect(s) Bladder Bleeding Bowels Cerebral Palsy Coughing Communication Developmental Delay Diabetes Ears or Deafness Eyes or Vision Feeding Head Injury Heart Hospitalization (When, Where)
Lead Poison/Exposure complete DHMH4620 Life Threatening Allergic Reactions Limits on Physical Activity Meningitis Mobility-Assistive Devices if any Prematurity Seizures Sickle Cell Disease Speech/Language Surgery Other Does your child take medication (prescription or non-prescription) at any time? and/or for ongoing health condition?
No Yes, name(s) of medication(s):
Does your child receive any special treatments? (Nebulizer, EPI Pen, Insulin, Counseling etc.)
No Yes, type of treatment:
Does your child require any special procedures? (Urinary Catheterization, G-Tube feeding, Transfer, etc.)
No Yes, what procedure(s):
I GIVE MY PERMISSION FOR THE HEALTH PRACTITIONER TO COMPLETE PART II OF THIS FORM. I UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING MY CHILD’S HEALTH NEEDS IN CHILD CARE.
I ATTEST THAT INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Signature of Parent/Guardian Date
PART II - CHILD HEALTH ASSESSMENT To be completed ONLY by Physician/Nurse Practitioner
ere be any restriction of physical activity in child care?
has had a complete physical examination and any concerns have been noted above. (Child’s Name)
Additional Comments:
OCC 1215 - Revised June 2016 - All previous editions are obsolete. Page 3 of 5
Physician/Nurse Practitioner (Type or Print):
Phone Number:
Physician/Nurse Practitioner Signature:
Date:
Child’s Name:
Birth Date:
Sex
Last First Middle Month / Day / Year M F 1. Does the child named above have a diagnosed medical condition?
No Yes, describe:
2. Does the child have a health condition which may require EMERGENCY ACTION while he/she is in child care? (e.g., seizure, allergy, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE and describe emergency action(s) on the emergency card.
No Yes, describe:
3. PE Findings Not
Health Area WNL ABNL Evaluated
Not Health Area WNL ABNL Evaluated
Attention Deficit/Hyperactivity Lead Exposure/Elevated Lead Behavior/Adjustment Mobility Bowel/Bladder Musculoskeletal/orthopedic Cardiac/murmur Neurological Dental Nutrition Development Physical Illness/Impairment Endocrine Psychosocial ENT Respiratory GI Skin GU Speech/Language Hearing Vision Immunodeficiency Other: REMARKS: (Please explain any abnormal findings.)
4. RECORD OF IMMUNIZATIONS – DHMH 896/or other official immunization document (e.g. military immunization record of immunizations) is required
to be completed by a health care provider or a computer generated immunization record must be provided. (This form may be obtained from: http://earlychildhood.marylandpublicschools.org/system/files/filedepot/3/maryland_immunization_certification_form_dhmh_896_-_february_2014.pdf
RELIGIOUS OBJECTION:
I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any immunizations being given to my child. This exemption does not apply during an emergency or epidemic of disease.
Parent/Guardian Signature: Date:
5. Is the child on medication?
No Yes, indicate medication and diagnosis: (OCC 1216 Medication Authorization Form must be completed to administer medication in child care).
6. Should th
No
Yes, specify nature and duration of restriction:
7. Test/Measurement
Results
Date Taken
Tuberculin Test Blood Pressure Height Weight BMI %tile
LeadTest Indicated:DHMH 4620 Yes No Test #1 Test#2 Test # 1 Test #2
/ / / STREET ADDRESS (with Apartment Number) CITY STATE ZIP
Page 4 of 5 OCC 1215 -June 2106
MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE BLOOD LEAD TESTING CERTIFICATE
Instructions: Use this form when enrolling a child in child care, pre-kindergarten, kindergarten or first grade. BOX A is to be completed by the parent or guardian. BOX B, also completed by parent/guardian, is for a child born before January 1, 2015 who does not need a lead test (children must meet all conditions in Box B). BOX C should be completed by the health care provider for any child born on or after January 1, 2015, and any child born before January 1, 2015 who does not meet all the conditions in Box B. BOX D is for children who are not tested due to religious objection (must be completed by health care provider).
BOX A-Parent/Guardian Completes for Child Enrolling in Child Care, Pre-Kindergarten, Kindergarten, or First Grade
CHILD'S NAME / / LAST FIRST MIDDLE
CHILD’S ADDRESS / / / STREET ADDRESS (with Apartment Number) CITY STATE ZIP
SEX: Male Female BIRTHDATE / / PHONE
PARENT OR / / GUARDIAN LAST FIRST MIDDLE
BOX B – For a Child Who Does Not Need a Lead Test (Complete and sign if child is NOT enrolled in Medicaid AND the answer to EVERY question below is NO):
Was this child born on or after January 1, 2015? YES NO Has this child ever lived in one of the areas listed on the back of this form? YES NO Does this child have any known risks for lead exposure (see questions on reverse of form, and
talk with your child’s health care provider if you are unsure)? YES NO
If all answers are NO, sign below and return this form to the child care provider or school.
Parent or Guardian Name (Print): Signature: Date:
If the answer to ANY of these questions is YES, OR if the child is enrolled in Medicaid, do not sign Box B. Instead, have health care provider complete Box C or Box D.
BOX C – Documentation and Certification of Lead Test Results by Health Care Provider Test Date Type (V=venous, C=capillary) Result (mcg/dL) Comments Comments:
Person completing form: Health Care Provider/Designee OR School Health Professional/Designee
Provider Name: Signature:
Date: Phone:
Office Address:
BOX D – Bona Fide Religious Beliefs
I am the parent/guardian of the child identified in Box A, above. Because of my bona fide religious beliefs and practices, I object to any blood lead testing of my child. Parent or Guardian Name (Print): Signature: Date: ******************************************************************************************************************** This part of BOX D must be completed by child’s health care provider: Lead risk poisoning risk assessment questionnaire done: YES NO
Provider Name: Signature:
Date: Phone:
Office Address:
DHMH FORM 4620 REVISED 5/2016 REPLACES ALL PREVIOUS VERSIONS
Community Action Council
Howard County Head Start
Allergy and Nutrition Screening Form
Child’s Name _________________________________ Date of Birth __________________
Does your child have any Food Allergies or restrictions*?(see form below) ____Yes ____ No
