Registration Requirements for CYS Services

PARENT CENTRAL SERVICES

 Official shot record with a Negative TB test result (12 months and older) or TB Document F:

State of Hawaii TB Clearance Form, signed & stamped by a Licensed Practitioner.

 Flu shot is required for children enrolled in FULL DAY CARE. The deadline for the Flu Shot will

be December 31

of each year. Children who are 6 months or older, or have never had the flu

shot will receive the first half of the shot and then the second half 30 days later

(For more information regarding the flu shot please call (808)655-0073)

 CYS Services Health Assessment (due within 30 days of registration)

o If your child has special needs (i.e. asthma, diet restrictions/intolerances, seizures,

ADHD, Diabetes, Autism, Eczema, Behavioral concerns, etc.) additional forms will need

to be submitted. Contact one of our offices for details.

 Two local emergency contacts (adults other than parents or legal guardian)

 Proof of Total Family Income (most recent end of month LES and/or pay stubs)

 Family Care Plan for Single/Dual Military families (due within 30 days of registration)

***Parent or Guardian must attend an orientation at the program (CDC, SAC, or Youth Center)

prior to utilizing child care services***

Aliamanu Parent Central Services (AMR)

154 Kauhini Road, BLDG 1782

Phone (808) 833-5393

Hours 0800-1700

Walk-in 0800-1100

Appointments 1300-1600

Schofield Parent Central Services

241 Hewitt Street, BLDG 1283

Phone (808) 655-5314/ (808)655-8380

Hours 0730-1700

Walk-in 0730-1100

Appointment 1200-1500

PROGRAM REGISTRATION FORM

Child & Youth School Services

SPONSOR: _______________________________________________________ Cell Phone #:_____________________________________

Grade Last First

Home Address:

___________________________________________________________________________________________________________

Include Zip Code

Dual Military: Y/N On Post/Off Post

(circle one) (circle one)

Unit/Employer Name: _____________________________________________________________________________________________________

Duty/Work Address: ______________________________________________________________________________________________________

Include Zip Code

AKO or E-Mail Address:____________________________________________ Work/Staff Duty Phone:____________________________________

Total Family Size:____________ Status: Active/Retired/DA Civilian/Civilian (circle one)

************************************************************************************************************************

SPOUSE: ____________________________________________

Cell Phone #:_____________________________________________

Grade Last First

Unit/Employer Name: _____________________________________________________________________________________________________

Duty/Work or College Address: _____________________________________________________________________________________________

Include Zipcode

AKO or E-Mail Address:____________________________________________ Work/Staff Duty Phone: ___________________________________

Status: Active/Retired/DA Civilian/Civilian (circle one)

************************************************************************************************************************

Child: _______________________________________________________________________________

Last First M.I.

D.O.B.: __________________________ Gender:

Male / Female (Circle One) School:___________________________

Medical Concerns: ____________________________________________________________________________________________

Allergies: ____________________________________________________________________________________________________

************************************************************************************************************************

Child: _______________________________________________________________________________

Last First M.I.

D.O.B.: __________________________ Gender: Male / Female (Circle One) School:___________________________

Medical Concerns: ____________________________________________________________________________________________

Allergies: ____________________________________________________________________________________________________

************************************************************************************************************************

Child: _______________________________________________________________________________

Last First M.I.

D.O.B.: __________________________ Gender: Male / Female (Circle One) School:___________________________

Medical Concerns: ____________________________________________________________________________________________

Allergies: ____________________________________________________________________________________________________

************************************************************************************************************************

Child: _______________________________________________________________________________

Last First M.I.

Child Release Designee: Yes/ No (circle one)

Name (2): ___________________________________________________________

Child Release Designee: Yes/ No (circle one)

Duty/Work Phone: _______________________________

Home Phone:____________________________________

Duty/Work Phone: _______________________________

Relationship: ________________________________________________________

D.O.B.: __________________________ Gender: Male / Female (Circle One) School:___________________________

Medical Concerns:

____________________________________________________________________________________________

llergies: ____________________________________________________________________________________________________

************************************************************************************************************************

EMERGENCY NOTIFICATION DESIGNEES (other than parents or legal guardians):

Name (1): ___________________________________________________________

Home Phone:____________________________________

HEALTH ASSESSMENT/SPORTS PHYSICAL STATEMENT (HASPS)

for CYS SERVICES

ENROLLMENT, Renewal & SPORTS PHYSICAL Requirements

Revised 08Jan 09

DATA REQUIRED BY THE PRIVACY ACT OF 1994

PRINCIPA

L PURPOSE: Information is used by DA personnel to: (1) verify child health status of immunization per admission requirements; (2) not

special program

considerations or restriction on child participation; (3) execute emergency medical procedure for chronic illnesses/conditions; (4) refer

child for enrollment in Exceptional Family Member Program; (5) certify physically fit to participate in sports. ROUTINE USES: No information is disclosed

outside DOD. DISCLOSURE: Information is voluntary; however, if information is not provided, individuals may not be able to participate in community

activities.

INSTRUCTIONS: All sections A, B, C. must be completed

PART: A Medical History (Filled out by parent / guardian)

Name of Sponsor Home Telephone

Cell Telephone

Duty

/Work Telephone

Sponsor Unit / Work Address Spouse’s Work Telephone

CHILD HEALTH INFORMATION

Name of Child Birth Date Sex

Male Female

Does your child have ongoing medical concerns?

(If Yes, explain circumstances and current status)

Yes No

Is your child enrolled in Exceptional Family Member Program?

(If Yes, explain)

Yes No

MEDICAL HISTORY

YES NO YES NO

1. Any hospitalization or operations 14. Heat stroke or exhaustion

2. Allergies to medicine, insect bites or food 15. Broken bones or sprains

3. Speech or development delays 16. Joint injuries (Ankle/Knee/Wrist)

4. Vision Problems (Glasses / Contacts) 17. Required restricted physical activity

5. Ear or hearing problems 18. Diabetes

6. Seizures or Convulsions 19. Cancer

7. Dizziness or fainting with exercise 20. Dental or orthodontic braces

8. Headaches 21. Learning problems

9. Head injury or loss of consciousness 22. Sleep problems

10. Neck or back injury 23. Behavioral problems

11. Asthma or difficulty breathing 24. ADD / ADHD

12. Heart or blood pressure problems 25. Autism Spectrum Disorder

13. Chest pain with exercise 26. Other (please list below)

If you answer yes to any of the above, please explain:

Ongoing Medications

Name Dosage Frequency

Allergies – All Types (Foods, Medicines and Insect Bites)

Type Reaction

Child and Youth Services Health Assessment / Sports Physical Statement Page 1 of 2

PART B: Physical Exam

Medical Staff Assessment (Completed by licensed independent practitioner: Doctor-Dr., Nurse Practitioner-NP, Physician’s Assistant-PA)

Age

YRS MOS

Height

__________ cm. ( _____ %ile)

Weight

__________ kgs. (_____ %ile)

BP: /

Visual Acuity

Right / Left / Tested with / without glasses

NORMAL ABNORMAL N / A COMMENTS

1. Eyes

2. Ears, Nose & Throat

3. Hearing

4. Mouth & Teeth

5. Neck (Soft tissues)

6. Cardiovascular

7. Chest & Lungs

8. Abdomen

9. Genitalia – Hernia

10. Skin & Lymphatics

11. Spine – Scoliosis

12. Extremities

13. Neurological

14. Wears braces / plates

Based on this HX and PX exam, the following abnormalities were found and may need treatment:

Immunizations are current and up to date: Yes No

PARTI

CIPATION RECOMMENDATIONS

All sports _____Yes _____ No Normal physical activity to including PE

Additional comments:

Restrictions:

Sports Physical is valid for 1 year from date indicated below

PART C

Special Medical Considerations: Describe any special program needs, considerations or restrictions which the child requires in order to participate in

CYS programs (to include Sports).

Child / Youth is able to participate in normal CYS programs? Yes No

Date Licensed Health Care Professional Stamp Licensed Health Care Professional; Dr., NP or PA Signature

Initial Date Type or print name of Parent or Guardian Signature of Parent or Guardian

HASPS Renewal (Not Part of the Sports Physical)

Year 2 Date Health Status Changed Signature of Parent or Guardian

Yes No

Year 3 Date Health Status Changed Signature of Parent or Guardian

Yes No

Child and Youth Services Health Assessment / Sports Physical Statement Page 2 of 2

APD LC v1.00ES

EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP)

CYS SERVICES PROGRAMS HEALTH/DEVELOPMENTAL SCREENING

For use of this form, see AR 608-75; the proponent agency is ACSIM.

Installation:

SNAP Case Number:

PROOF

PRIVACY ACT STATEMENT

AUTHORITY:

10 U.S.C. 3013, Secretary of the Army; 29 U.S.C. 794, Nondiscrimination Under Federal Grants and Programs; DoDI 1342.17 Family Policy;

AR 608-75, Exceptional Family Member Program; DoDI 6060.02, Child Development Programs; AR 608-10, Child Development Services.

PRINCIPAL PURPOSE: Information will be used to assist Army activities in their responsibilities in the overall execution of the Army's Exceptional Family

Member Program and Child, Youth and School Services Programs.

ROUTINE USES: The DoD "Blanket Routine Uses" that appear at the beginning of the Army's compilation of systems of records apply to this system.

DISCLOSURE: Disclosure of requested information is voluntary; however, if information is not provided individual may not be able to utilize Army

Child, Youth and School Services.

FOR POS COMPLETION ONLY

Initial Registration Re-registration/already in program

On waiting list? Yes No

Current Program

Date care needed?

Change in Condition

Date in from Patron:

Date out to APHN:

PART A- GENERAL INFORMATION (Parent completes)

Child/Youth's Name

Child/Youth School Grade (example: 3rd Grade)

Date of Birth (YYYYMMMDD)

Age

Type of Program Requested (check all that apply):

Hourly Care Full Day Care Middle School/Teen Program Summer Camp Other:

Part Day Care Before/After School Care SKIES/Instructional Classes Sports

Sponsor Name

Sponsor Email (AKO)

Sponsor SSN (Last 4 digits)

Spouse Name

Spouse Email

Sponsor DOB

Home Phone

Cell Phone

Sponsor Unit

Home Address

Sponsor Duty Phone

PART B - CHILD / YOUTH MEDICAL / DEVELOPMENTAL CONDITIONS (check yes or no)

Does your child/youth have:

1. Asthma/Reactive Airway Disease/Breathing Problems?

Yes

a. Does it require a rescue medication?

Yes

8. Emotional problems/difficulties?

Yes

9. Autism Spectrum Disorder?

Yes

2. Allergies?

Yes

a. Does it require a rescue medication?

Yes

10. Developmental Disability?

Yes

11. Visual problems/difficulties not corrected by glasses/

contacts?

Yes

3. Dietary Restrictions?

Yes

a. Medically-based b. Religiously-based

12. Hearing problems/difficulties?

Yes

13. Speech/language delays?

Yes

14. Other developmental delays?

Yes

4. Diabetes?

Yes

15. Physical disability?

Yes

5. Epilepsy/Seizures?

Yes

16. Other medical condition or concerns?

Yes

If yes, please explain:

6. Attention Deficit/Hyperactivity Disorder (ADD/ADHD)?

Yes

a. Is your child/youth prescribed medication?

Yes

7. Diagnosed Behavior/Conduct concerns?

Yes

a. Is your child/youth prescribed medication?

Yes

PART C - MEDICATIONS

List any medications that are prescribed for your child/youth:

Will your child require medication administration during child care/youth supervision hours?

Yes

DA FORM 7725, XXX 2015

(Last revised: 03-09-2015)

Page 1 of 3

DA FORM 7725, XXX 2015

Page 2 of 3

APD LC v1.00ES

Child/Youth's Name:

PART D - EARLY INTERVENTION AND SPECIAL EDUCATION

Does your child/youth receive special services/therapies?

Yes

If yes, please specify:

Does your child/youth have an:

a. Individualized Education Plan (IEP)

Yes

b. Individualized Family Service Plan (IFSP)

Yes

c. 504 Plan

Yes

PART E - EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP) ENROLLMENT

Is your child enrolled in the EFMP?

Yes

If yes, specify for what condition:

If you have answered NO to all the questions above or YES to ONLY Part B, 3b., sign and date below, indicating

that the information above is accurate and complete to the best of your knowledge.

Printed Name of Parent/Personal Representative of Child/Youth

Signature of Parent/Personal Representative of Child/Youth

Date (YYYYMMMDD)

If you answered YES to any of the questions above (OTHER THAN PART B, 3b.), complete Part F below.

Child, Youth and School Services strives to provide the safest and healthiest environment for your child/youth and relies on your accurate and honest

information to support this goal. Please understand that placement and/or care for your child/youth could be delayed/suspended if information is falsified

or intentionally omitted on registration documentation. If there are any changes to your child/youth's health status please notify CYS Services immediately.

PART F - RELEASE OF INFORMATION

Is this child/youth currently covered by TRICARE or other military health care?

Yes

I authorize to release any medical information regarding my child

(name of Medical Treatment Facility or physician's practice)

to the

(name of child) (name of installation)

Child, Youth & School (CYS) services and Multidisciplinary Inclusion Action Team (MIAT) personnel, are necessary to

conduct a MIAT review. This authorization will remain in effect for one year. I understand I may revoke this consent in

writing at any time before expiration, but any action taken by the MIAT team on this authorization prior to revocation is

valid and will remain in effect.

I understand that information disclosed pursuant to this authorization is For Official Use Only (FOUO) and may be subject

to redisclosure. I understand that information redisclosed is no longer protected by DoD 6025, 18-R; however,

confidentiality of this information will remain protected by the Privacy Act of 1974, 5 U.S.C. section 552a.

The Military Health System (which includes the TRICARE Health Plan) may not condition treatment in MTFs/DTFs,

payment by the TRICARE Health Plan, enrollment in the TRICARE Health Plan or eligibility for TRICARE Health Plan

benefits on failure to obtain this authorization.

Printed Name of Parent/Personal Representative of Child/Youth

Signature of Parent/Personal Representative of Child/Youth

Date (YYYYMMMDD)

DA FORM 7725, XXX 2015

Page 3 of 3

APD LC v1.00ES

Child/Youth's Name:

PART G - ARMY PUBLIC HEALTH NURSE (APHN) CASE REVIEW

Medical Records Reviewed?

Yes No

Not Available

Special Needs/Diagnosis:

Medical History (Applicable to Special Needs/Diagnosis):

Training Required for CYS Staff/FCC Provider (detail type of training, who will provide the training and projected timeline):

Recommendation Summary (if additional space is needed please add a continuation page):

REVIEWED (check all that apply):

Allergy MAP Diabetes MAP Epilepsy/Seizure MAP Respiratory MAP Special Diet Statement

MULTIDISCIPLINARY INCLUSION ACTION TEAM REQUIRED:

Administrative Modified

Full

Annual Review

APHN Printed Name or Stamp

APHN Signature

Date (YYYYMMDD)

Date Received by APHN (YYYYMMMDD)

Date Returned to Parent Central Services/EFMP (YYYYMMMDD)

DOH TB Control Program DOH TB Clearance Manual 7/18/2017

- 12 -

TB Document F: State of Hawaii TB Clearance Form

Hawaii State Department of Health

Tuberculosis Control Program

Patient Name DOB TB Screening Date

I have evaluated the individual named above using the process set out in the DOH TB Clearance Manual

dated 2/10/17 and determined that the individual does not have TB disease as defined in section 11-164.2-

2, Hawaii Administrative Rules.

Screening for schools, child care facilities or food handlers

(TB Document A or E)

Negative TB risk assessment

Negative test for TB infection

Positive test for TB infection, and negative chest X-ray

Initial Screening for health care facilities or residential care settings

(TB Document B or C)

Negative test for TB infection (2-step)

New positive test for TB infection, and negative chest X-ray

Previous positive test for TB infection, negative CXR within previous 12 months,

and negative symptom screen

Previous positive test for TB infection, and negative CXR

Annual Screening for Health care facilities or residential care settings (

TB Document D)

Negative test for TB infection

New positive test for TB infection, and negative chest X-ray

Previous positive test for TB infection, and negative symptoms screen

Previous positive test for TB infection, and negative CXR

Signature or Unique Stamp of Practitioner: _____________________________________

Printed Name of Practitioner: _____________________________________

Healthcare Facility: _____________________________________

This TB clearance provides a reasonable assurance that the individual listed on this form was free from

tuberculosis disease at the time of the exam. This form does not imply any guarantee or protection from

future tuberculosis risk for the individual listed.

DOH TB Control Program DOH TB Clearance Manual 7/18/2017

- 13 -

TB Document G: State of Hawaii TB Risk Assessment for Adults and Children

Hawaii State Department of Health

Tuberculosis Control Program

1. Check for TB symptoms

If there are significant TB symptoms, then further testing (including a chest x-ray) is required

for TB clearance.

If significant symptoms are absent, proceed to TB Risk Factor questions.

Yes

Does this person have significant TB symptoms?

Significant symptoms include

cough for 3 weeks or more, plus at least one of the following:

Coughing up blood

ever

Night sweats

Unexplained weight loss

Unusual weakness Fatigue

2. Check for TB Risk Factors

If all boxes below are

Yes

Was this person born in a country with an elevated TB rate?

Includes countries other than the United States, Canada, Australia, New Zealand, or

Western and North European countries.

Yes

Has this person traveled to (or lived in) a country with an elevated TB rate for four weeks

or longer?

Yes

At any time has this person been in contact with someone with infectious TB disease?

if exposed only to someone with latent TB)

Yes

Does the individual have a health problem that affects the immune system, or is medical

treatment planned that may affect the immune system?

(Includes HIV/AIDS, organ transplant recipient, treatment with TNF-alpha antagonist, or

steroid medication for a month or longer)

Yes

For persons under age 16 only:

an elevated TB rate?

Provider Name with Licensure/Degree:

Assessment Date:

Person's Name and DOB:

Name and Relationship of Person Providing

Information (if not the above-named person):