1. Medications should be taken at home whenever possible. Any medication taken in a YMCA Child Care Program must have a parent or guardian-signed authorization: some medications also require physicians orders. Medication must be turned in at your YMCA Summer Camp/Child Care Program desk prior to the start of the day. The parent or guardian must transport medication to and from site.


2. No medication will be accepted by YMCA Summer Camp/Child Care personnel without receipt of completed and appropriate medication forms. Form must be updated yearly. The YMCA Summer Camp/Child Care Center calendar runs from 9/1 to 8/30.


3. A physician may use office stationary or a prescription pad in lieu of completing Part II. Include the following information written in lay language with no abbreviations:


• Name of student


• Date of birth


• Reason for medication or diagnosis


• Name of medication


• Exact dosage to be taken, (e.g. milligrams per tablet, milligrams per ml/cc) as applicable


• Time to take medication a to be administered and frequency or exact time interval dosage


• Sequence in which the medications should be taken in cases where more than one medication is prescribed


• If medication in given on an as needed basis, specify the exact conditions or symptoms when medication is to be taken and the time at which it may be given again. (“repeat as necessary” is unacceptable.)


• Duration of medication order or effective dates


• Physician’s signature


• Date


4. All prescription medications, including physician’s prescription drug samples, must be in their original containers and labeled by a physician or pharmacist. An over-the-counter medication must be in the original container with the name of the medication visible. The parent or guardian must label the original container with the following:


• Name of student


• Exact dosage to be taken in school (e.g. milligram tablet, milligrams per ml/cc)


• Frequency or time interval dosage is to b administered


5. The first dose of any medication must be given at home.


6. The parent or guardian is responsible for submitting a new form to the YMCA Summer Camp/Child Care Center at the time of registration or the start of the program.


7. Medication will be stored in a locked area accessible only to authorized personnel.


8. Within one week after expiration of the effective date on the physician order, or on the last day of the program, the parent or guardian must personally collect any unused portion of the medication. Medications not claimed within that period will be destroyed.


9. Medication can be given no more than one half hour before or after the prescribed time.


10. YMCA of Metropolitan Washington Summer camp/Child Care programs do not assume responsibility for authorized medication taken independently by the student.


11. In no case may any YMCA Summer Camp/Child Care Center staff or member administer any medication outside the framework of the procedures outlined here.

1. Epinephrine may be given in school, during school-sponsored activities, or at a YMCA Summer Camp/Child Care Program only with both physician and parent or guardian-signed authorization.


2. This form must be on file in the clinic or in another approved location. The parent or guardian is responsible for obtaining the physician's statement in part II. For a student who attends a YMCA Summer Camp/Child Care Program, a copy of the medication form must be on file with the YMCA Program.


3. A new form must be submitted to the Program/school each school year and whenever there is a change in the dosage or a change in the conditions under which epinephrine is to be injected.


4. A physician may use office stationery or a prescription pad in lieu of completing part II. Information necessary includes:


• Name of student


• Specific allergen for which epinephrine is being prescribed


• Route of exposure (e.g., ingestion, skin contact, inhalation, or insect sting or bite)


• Brand name of medication


• Amount of premeasured epinephrine


• Time for repeated dose if deemed necessary


• Duration of medication order and effective dates


• Physician signature


• Date


5. Only premeasured doses of epinephrine may be given by FCPS, FCHD, and YMCA Program staff members.


6. Medication must be properly labeled by a pharmacist. If a physician orders include a repeat of EpiPen or Twinject injection

for a student who carries his or her own, then the parent or guardian must supply the school with two EpiPens or Twinjects. Expiration date
must be clearly indicated and cannot expire during the period that the child is in camp.

7. Epinephrine must be hand-delivered to the school clinic by the parent or guardian unless approved for the student to carry during school and Summer Camp/SACC/Early Learning hours.


8. Unless the student has been authorized to carry epinephrine, the parent or guardian is to collect any unused epinephrine within one week after the end of expiration of the order or on the last day of school/Camp. Epinephrine not claimed within that period shall be destroyed.


9. Form must be updated yearly. The YMCA Child Care calendar runs from 9/1 to 8/30.

1. Nonessential medication will not be permitted in the YMCA Summer Camp/Child Care program(s). Any medication taken in YMCA Child Care Center must have the parent or guardian –signed authorization and physician order if required by regulation.


2. The parent or guardian is responsible for obtaining the physician’s statement in Part II.


3. A physician may use office stationary or a prescription pad in lieu of completing Part II. Include the following information written in lay language with no abbreviations:


• Name of student


• Date of birth


• Reason for medication or diagnosis


• Name of medication


• Exact dosage to be taken


• Time to take medication and frequency or exact time interval dosage is to be administered


• If medication in given on an as needed basis, specify the exact conditions or symptoms when medication is to be taken and the time at which it may be given again. (“Repeat as necessary” is unacceptable.)


• Symptoms, other medications the student is taking


• Statement that the student may self-administer


• Physician’s signature


• Date


4. Physician samples must be appropriately labeled by the physician to include information requested in item 3 above.


5. The parent or guardian is responsible for submitting a new form to the YMCA Summer Camp/Child Care Center at the time of registration or the start of the program and each time there is a change in the dosage or in the time at which the medication is taken. The first dose of any new medication shall be given at home.


6. Inhaler must be hand delivered to the Program Director or Staff by the parent or guardian unless approved for the student to carry during the YMCA Child Care program hours.


7. Medication kept at the YMCA will be stored in a locked area only accessible to authorized personnel unless approved for the student to carry during the program hours. If a student carries his or her own inhaler, a backup may be kept in the clinic.


8. Within in one week after expiration of the effective date on the physician order, or on the last day of the program, the parent or guardian must personally collect any unused portion of the medication(s) unless the student has been authorized to carry them. Medications not claimed within that period will be destroyed.


9. In no case may any YMCA Child Care staff member administer any medication outside the framework of the procedures outlined here and /or in YMCA Child Care Program regulations.


10. Form must be updated yearly. The YMCA Child Care Center calendar runs from 9/1 to 8/30.

1. Medications should be taken at home whenever possible. Any medication taken in a YMCA Child Care Program must have a parent or guardian-signed authorization: some medications also require physicians orders. Medication must be turned in at your YMCA Child Care Program’s desk prior to the start of the day. The parent or guardian must transport medication to and from site.


2. No medication will be accepted by YMCA Child Care personnel without receipt of completed and appropriate medication forms. Form must be updated yearly. The YMCA Child Care Center calendar runs from 9/1 to 8/30.


3. The first dose of any medication must be given at home.


4. The parent or guardian is responsible for submitting a new form to the YMCA Child Care Center at the time of registration or the start of the program.


5. Medication will be stored in a locked area accessible only to authorized personnel.


6. YMCA of Metropolitan Washington Child Care/Summer Camp programs do not assume responsibility for authorized medication taken independently by the student.


7. In no case may any YMCA Child Care Center staff or member administer any medication outside the framework of the procedures outlined here.


8. All medications should be in original containers, with directions, expiration date, and child’s name clearly marked.

Instructions For Completion of Oral Health Assessment Form : District of Columbia Child Health Certificate

This Form replaces the Dental Appraisal Form used for entry into DC Schools, all Head Start programs, Childcare providers, camps, after school programs, sports or athletic participation, or any other District of Columbia activity requiring a physical examination. The form was developed by the DC Department of Health and follows the American Academy of Pediatric Dentistry (AAPD) Guidelines on Mandatory School-Entrance Oral Health Examinations. AAPD recommends that a child be given an oral health exam within 6 months of eruption of the child’s first tooth and no later than his or her first birthday. The DC Department of Health recommends that all children 3 years of age and older have an oral health examination performed by a licensed dentist and have the DC Oral Health Assessment Form completed. This form is a confidential document. Confidentiality is adherent to the Health Insurance Portability and Accountability Act of 1996 (HIPPA) for the health providers, and the Family Education Rights and Privacy Act (FERPA) for the DC schools and other providers.

General Instructions: Please use black ball point pen when completing this form.
Part 1: Child’s Personal Information

Please complete all sections including child’s race or ethnicity. Please indicate the ward of your home address. List primary care provider, dental provider, and type of dental insurance coverage. If child has no dental provider and is uninsured, then please write “None” in each box. This form will not be complete without Parent or Guardian signature in Part 5.

Part 2: Child’s Clinical Examination: Dental Provider: Form must be fully completed. The Universal Tooth Numbering System is used.

Please use key to document all findings for each tooth. An ‘X’ signifies a missing tooth (teeth) with no replacement; | | non-restorable/extraction; UE: unerupted tooth; S: Sealants; • Restoration; 1D: one surface decay; 2D: two surface decay; 3D: three surface decay; 4D: more then three surface decay

- The Key should be used to designate status for each tooth at time of examination on the Oral Health Assessment Form.
- If a portion of an existing restoration is defective or has recurrent decay, but part of the restoration is intact, the tooth should be classified as a decayed tooth. If one surface has decay, then mark as 1D; if two surface has decay then mark as 2D.
- Key UE: unerupted, does not apply to a missing primary tooth when a permanent tooth is in a normal eruption pattern.
Part 3: Clinical Findings and Recommendations
- Circle Yes or No in Findings Column
- For Yes, please explain in the Comments Section.
1- Advance periodontal conditions (pockets etc., will be noted under gingival inflammation).
1- Gingival inflammation adjacent to an erupting tooth is NOT noted.
1- Inflammation adjacent to orthodontically banded teeth or a dental appliance – whether fixed or removable is noted.
2- Indicate if there is sub and/or supra gingival plaque and or calculus and areas where present.
3- All gingival tissues must be free of inflammation e.g. gingiva is pale pink in color and firm in texture for a finding of 'NO' to be recorded.
3- Frenum attachments labial, sublingual, etc., will be noted under the Abnormal Gingival Attachment Indicator Code if they are the cause of a specific problem- e.g., spacing of central incisors, speech impediment, etc.
4- Status of orthodontic condition should be noted under Malocclusion. Classification of occlusion is: Class I, Class II, Class III, an overbite, over jet, cross-bite or end to end.
5- Other is to be used, together with comments, for conditions such as cleft lip/palate.
- Indicate whether oral health preventive services such as prophylaxis, sealant and or fluoride treatment have been administered.
Part 4. Final Evaluation/Required Dental Provider Signature; Indicate whether the child has been appropriately examined and if treatment is complete. If treatment is incomplete refer patient for follow up care. Dentist must sign, date, and provide required information.

Part 5 Required Signatures. This Form Will Not Be Complete Without Parent or Guardian Signature and Date

The parent or guardian must print, sign, and date this part. By signing this section the parent or guardian gives permission to the dentist or facility to share the oral health information on this form with the child’s school, childcare, camp, Department of Health, or the entity requesting this document. All information will be kept confidential.