Deadline: May 1, 2020

RE-ENROLLMENT PACKET The following steps are required to complete re-enrollment:

Complete IP Re-Enrollment Forms (Online only — See page 2)

Submit updated health documents (Online only — See pages 3-11)

Complete D.C. Residency Verification Email only this year due to COVID-19 (Email only — See page 12)

Your student is officially enrolled for the 2020-2021 school year at Ingenuity Prep!

1: Go to ingenuityprep.schoolmint.com and sign in with the username provided and your password from last year. If you forgot your

password, click “Forgot Password?”

3: Complete forms You may “Save Progress” at any time after completing your profile. Be sure to click “Submit

Forms” when you are ready to submit.

Deadline: May 1, 2020

Re-Enrollment Form

2: Edit student forms for each returning student

DC Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5955 | dchealth.dc.gov version 02.28.19

Immunization Requirements for School Year 2019-2020

All students attending school in DC must present proof of appropriately spaced immunizations by the first day of school. Provide this sheet to your child’s licensed health professional to ensure proper immunization.

On the first day of school my student is: By the start of SY19-20, my student should have received:i

4 doses of Diphtheria/Tetanus/Pertussis (DTaP) 3 doses of Polio 1 dose of Varicella if no history of chickenpox ii 1 dose of Measles/Mumps/Rubella (MMR) 3 doses of Hepatitis B 2 doses of Hepatitis A 3 or 4 doses depending on the brand of Hib (Haemophilus Influenza Type B) 4 doses of PCV (Pneumococcal)

5 doses of Diphtheria/Tetanus/Pertussis (DTaP) 4 doses of Polio 2 doses of Varicella if no history of chickenpoxii 2 doses of Measles/Mumps/Rubella (MMR) 3 doses Hepatitis B 2 doses Hepatitis A 3 or 4 doses depending on the brand of Hib (Haemophilus Influenza Type B) 4 doses of PCV (Pneumococcal)

5 doses of Diphtheria/Tetanus/Pertussis (DTaP) 4 doses of Polio 2 doses of Varicella if no history of chickenpoxii 2 doses of Measles/Mumps/Rubella (MMR) 3 doses of Hepatitis B 2 doses of Hepatitis A

5 doses of Diphtheria/Tetanus/Pertussis (DTaP)/Td 1 dose of Tdap 4 doses of Polio 2 doses of Varicella if no history of chickenpoxii 2 doses of Measles/Mumps/Rubella (MMR) 3 doses of Hepatitis B 2 doses of Hepatitis Aiii 1 dose of Meningococcal (Men ACWY)iv 2 or 3 doses of Human Papillomavirus Vaccine (HPV)v

i The number of doses required varies by a child’s age and how long ago they were vaccinated. Please check with your child’s health suite personnel or health care provider for details.

ii All Varicella/chickenpox histories MUST be verified by a health care provider and documented with month and year of disease. iii If born on or after 01/01/05. iv Dose #1 at 11-12 years of age is required. A booster dose is recommended at 16 years of age. v Two doses if student receives first dose between ages 9 -14 (doses 6-12 months apart); 3 doses if student starts series on or after age 15.

1050 First St. NE, Washington, DC 20002 • Phone: (202) 727-6436 TTY: 711 • osse.dc.gov

Frequently Asked Questions - School Immunization Requirements

District law1 and regulations2 require schools in the District of Columbia to verify student compliance with the immunization requirements3 as part of enrollment and attendance. If a student is not compliant, the school is required to immediately notify the parent, guardian, or adult student in writing of the missing immunization(s). If the student does not come into compliance within a 20-school day period, the school is required to remove the student from attendance until the immunization certification is secured by the school.

1. Why are immunizations (vaccines) important? Many infectious diseases, such as measles, are highly contagious and dangerous for our youngest District residents. In order to prevent the spread of these infectious diseases, it is vital that all students are fully immunized before entering school. The Centers for Disease Control and Prevention (CDC) has resources with information on the importance of immunizations, including Six Things YOU Need to Know about Vaccines,4 Making the Vaccine Decision: Addressing Common Concerns,5 and Facts About HPV.6

2. Which immunizations are required for my child? Requirements are set by the District of Columbia Department of Health (DC Health) and are based on the child’s age.7 For a list of required immunizations, consult DC Health’s Immunization Requirements.8

3. How do I know which shots my child has already received? If you have questions about your child’s immunization history, contact your medical provider and request a copy of your child’s immunization history, or call the DC Health Immunization Program at (202) 576-7130.

4. How does my child’s school know whether my child has been immunized? When a child receives an immunization in the District of Columbia, the health provider adds it to the District of Columbia Immunization Information System (DOCIIS), a data system that monitors immunization information for residents and visitors to the District. Schools access DOCIIS to track compliance with immunization requirements. Schools may also keep paper records of your child’s immunization history in their school health file. Note: If your child received an immunization outside of the District of Columbia, it may not show up in DOCIIS.

1 DC Official Code § 38–501 et seq.: https://code.dccouncil.us/dc/council/code/titles/38/chapters/5/ 2 DCMR 5-E § 5300 et seq:. https://dcregs.dc.gov/common/dcmr/rulelist.aspx?ChapterNum=5-e53&chapterid=258 3 https://dchealth.dc.gov/service/school-health-services-program 4 https://www.cdc.gov/vaccines/vac-gen/vaxwithme.html 5 https://www.cdc.gov/vaccines/parents/why-vaccinate/vaccine-decision.html 6https://www.cdc.gov/vaccines/parents/diseases/hpv.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fparents%2Fdiseases%2Fteen%2Fhpv.html 7 DCMR 22-B §§ 130-152: https://dcregs.dc.gov/Common/DCMR/RuleList.aspx?ChapterNum=22-B1&ChapterId=576 8 https://dchealth.dc.gov/service/school-health-services-program

1050 First St. NE, Washington, DC 20002 • Phone: (202) 727-6436 TTY: 711 • osse.dc.gov

Continue to next page

5. How do I submit proof of immunization to my child’s school? If DOCIIS does not show that your child has received the necessary immunizations, your school will request proof of immunization. Submit proof of immunization via a written record, such as a completed Universal Health Certificate (recommended) or other official record from your health provider that includes the provider’s official stamp, seal, or signature.9 The school will make sure this document is entered in DOCIIS and added to your child’s school health file. An appointment card from a health provider does not meet the requirements for proof of immunization.

6. If my child does not have all of their immunizations, will they be able to attend school?

Students may only attend school for 20 school days without proof of immunization.10 If a school discovers that your child has not received the required immunizations, it will send home a written notice stating that you have 20 school days to present proof of immunization or your child will not be allowed to return to school until they have received the required immunizations and provided documentation to the school.

7. What will happen if my child does not get all of their required immunizations? Schools will identify non-compliant students and send home a written notice identifying the missing immunizations and stating that you have 20 school days to submit proof of the required immunizations. You should make an appointment with your child’s health provider as soon as possible after receiving the written notice. If proof of immunization is not submitted to the school within the 20 school days, your child will not be allowed to return to school until they have received the required immunizations and provided documentation to the school. Your child will receive an “unexcused absence” for each missed school day until the proof of immunization is submitted to the school. When the school receives the proof of immunization, your child will be allowed to return to school and the missed days will be reclassified as an “excused absence.”

8. What do I do if I believe my child has all their required immunizations, but the school tells me that my child is missing one or more? Contact your child’s health provider to confirm whether your child has received the required immunization(s). If the health provider confirms your child did receive the immunization(s), ask for written proof of the immunization(s) that you can give to the school. This written proof must include the health provider’s official stamp, seal, or signature. If the health provider informs you that your child has not received the required immunization(s), schedule an appointment as soon as possible for your child to receive it. At the appointment, have the health provider complete the Universal Health Certificate (recommended) or provide another form of written proof that includes the provider’s official stamp, seal, or signature.11 Present the documents to your child’s school to be added to their school health file.

9 https://dchealth.dc.gov/service/school-health-services-program 10 DC Official Code § 38–505: https://code.dccouncil.us/dc/council/code/sections/38-505.html 11 https://dchealth.dc.gov/service/school-health-services-program

1050 First St. NE, Washington, DC 20002 • Phone: (202) 727-6436 TTY: 711 • osse.dc.gov

9. What if I do not want my child to be immunized?

Medical exemptions are available for children for whom immunizations are medically inadvisable. Medical exemptions must be signed by a private physician, their representative, or the public health authority. Religious exemptions may be obtained directly at the DC Health headquarters front desk (899 North Capitol St. NE). You may also opt out of the HPV vaccination for your child by submitting the DC Health Annual Human Papillomavirus (HPV) Vaccination Opt-Out Certificate to the school.12

10. What if the earliest appointment I could get for my child is after the start of the school year?

Health providers may be busy during the start of school. Plan ahead to ensure your child receives all required immunizations prior to the start of the school year. A list of pediatric immunization locations is available on the DC Health website.13

11. What if I do not have a primary care provider or if I do not have medical insurance?

If you do not have a primary care provider or doctor, call your insurance company to find one close to your home. If you do not have medical insurance, contact DC Health Link or contact the Citywide Call Center by dialing 3-1-1.14

12. What if I have documentation for immunizations that were received in another country? If your child received their immunizations in another country, direct questions about the documentation to your school nurse or your school’s immunization point of contact (IPOC). They will work with DC Health to determine whether the documentation is acceptable to prove immunization compliance.

13. What if I have questions about immunizations or the immunization attendance policy? For questions about immunizations and available resources, contact the DC Health Immunization Program at (202) 576-7130. For questions about the immunization attendance policy, contact your school or local education agency (LEA) central office. You may also contact OSSE at OSSE.SchoolHealth@dc.gov.15 This FAQ document will be updated over time. Last update date: Feb. 13, 2020.

12 https://dchealth.dc.gov/node/112212 13 https://dchealth.dc.gov/service/school-health-services-program 14 https://www.dchealthlink.com/ 15 https://osse.dc.gov/page/district-columbia-immunization-attendance-policy

Department of Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5925 | dchealth.dc.gov version 03.13.19 pg1

Universal Health Certificate

Use this form to report your child’s physical health to their school/child care facility which is required by DC Official Code §38-602. Have a licensed medical professional complete part 2 - 4.

Part 1: Child Personal Information | To be completed by parent/guardian.

Child Last Name: Child First Name: Date of Birth:

School or Child Care Facility Name: Gender: � Male � Female � Non-Binary

Home Address: Apt: City: State: ZIP:

Ethnicity: (check all that apply) � Hispanic/Latino � Non-Hispanic/Non-Latino � Other � Prefer not to answer

Race: (check all that apply) � American Indian/ Alaska Native

� Asian � Native Hawaiian/ Pacific Islander

� Black/African American

� White � Prefer not to answer

Parent First Name: Parent Last Name: Parent Phone:

Emergency Contact Name: Emergency Contact Phone:

Insurance Type: � Medicaid � Private � None Insurance Name/ID #:

Has the child seen a dentist/dental provider within the last year? � Yes � No

I give permission to the signing health examiner/facility to share the health information on this form with my child’s school, child care, camp, or appropriate DC Government agency. In addition, I hereby acknowledge and agree that the District, the school, its employees and agents shall be immune from civil liability for acts or omissions under DC Law 17-107, except for criminal acts, intentional wrongdoing, gross negligence, or willful misconduct. I understand that this form should be completed and returned to my child’s school every year.

Parent/Guardian Signature: _______________________________________________ Date: ____________________

Part 2: Child’s Health History, Exam, and Recommendations | To be completed by licensed health care provider. Date of Health Exam: BP:

____ /_____ � NML Weight: � LB Height: � IN BMI: BMI

Percentile: � ABNL � KG � CM

Vision

Screening: Left eye: 20/________ Right eye: 20/________ � Corrected

� Uncorrected � Wears glasses � Referred � Not tested

Hearing Screening: (check all that apply) � Pass � Fail � Not tested � Uses Device � Referred

Does the child have any of the following health concerns? (check all that apply and provide details below)

� Asthma

� Autism

� Behavioral

� Cancer

� Cerebral palsy

� Development

� Diabetes

� Failure to thrive

� Heart failure

� Kidney Failure

� Language/Speech

� Obesity

� Scoliosis

� Seizures

� Sickle Cell

� Significant food/medication/environmental allergies that may require emergency medical care. Details provided below.

� Long-term medications, over-the-counter-drugs (OTC) or special care requirements. Details provided below.

� Significant health history, condition, communicable illness, or restrictions. Details provided below.

� Other:_________________________________________________________________

Provide details. If the child has Rx/treatment, please attach a complete Medication/Medical Treatment Plan form; and if the child was referred, please

note. _______________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

TB Assessment | Positive TST should be referred to Primary Care Physician for evaluation. For questions call T.B. Control at 202-698-4040. What is the child’s risk level for TB?

� High Æ complete skin test and/or Quantiferon test

� Low

Skin Test Date: Quantiferon Test Date:

Skin Test Results: � Negative � Positive, CXR Negative � Positive, CXR Positive � Positive, Treated

Quantiferon Results: � Negative � Positive � Positive, Treated

Additional notes on TB test:

Lead Exposure Risk Screening | All lead levels must be reported to DC Childhood Lead Poisoning Prevention. Call 202-654-6002 or Fax: 202-535-2607

ONLY FOR CHILDREN

UNDER AGE 6 YEARS

Every child must have 2 lead tests by age 2

1st Test Date: 1st Result: � Normal � Abnormal, Developmental Screening Date:

1st Serum/Finger

Stick Lead Level:

2nd Test Date: 2nd Result: � Normal � Abnormal, Developmental Screening Date:

2nd Serum/Finger

Stick Lead Level:

HGB/HCT Test Date: HGB/HCT Result:

Department of Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5925 | dchealth.dc.gov version 03.13.19 pg2

Part 3: Immunization Information | To be completed by licensed health care provider.

Immunizations Provide in the boxes below the dates of Immunization (MM/DD/YY)

Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5

DT (<7 yrs.)/ Td (>7 yrs.) 1 2 3 4 5

Tdap Booster 1

Haemophilus influenza Type b (Hib) 1 2 3 4

Hepatitis B (HepB) 1 2 3 4

Polio (IPV, OPV) 1 2 3 4

Measles, Mumps, Rubella (MMR) 1 2

Measles 1 2

Mumps 1 2

Rubella 1 2

Varicella 1 2 Child had Chicken Pox (month & year):

Pneumococcal Conjugate 1 2 3 4

Hepatitis A (HepA) (Born on or after 01/01/2005)

1 2

Meningococcal Vaccine 1 2

Human Papillomavirus (HPV) 1 2 3

Influenza (Recommended) 1 2 3 4 5 6 7

Rotavirus (Recommended) 1 2 3

� The child is behind on immunizations and there is a plan in place to get him/her back on schedule. Next appointment is: _________________

Medical Exemption (if applicable)

I certify that the above child has a valid medical contraindication(s) to being immunized at the time against:

� Diphtheria � Tetanus � Pertussis � Hib � HepB � Polio � Measles

� Mumps � Rubella � Varicella � Pneumococcal � HepA � Meningococcal � HPV

Alternative Proof of Immunity (if applicable)

I certify that the above child has laboratory evidence of immunity to the following and I’ve attached a copy of the titer results.

� Diphtheria � Tetanus � Pertussis � Hib � HepB � Polio � Measles

� Mumps � Rubella � Varicella � Pneumococcal � HepA � Meningococcal � HPV

Part 4: Licensed Health Practitioner’s Certifications| To be completed by licensed health care provider. This child has been appropriately examined and health history reviewed and recorded in accordance with the items specified on this form. At the time of the exam, this child is in satisfactory health to participate in all school, camp, or child care activities except as noted on page one.

� No � Yes

This child is cleared for competitive sports. Additional clearance(s) needed from:

___________________________________________________________________

� N/A � No � Yes � Yes, pending additional

clearance

I hereby certify that I examined this child and the information recorded here was determined as a result of the examination.

Licensed Health Care Provider Office Stamp Provider Name:

Provider Phone:

Provider Signature:

Date:

Access health insurance programs at https://dchealthlink.com. You may contact the Health Suite Personnel through the main office at your child’s school.

OFFICE USE ONLY | Universal Health Certificate received by School Official and Health Suite Personnel.

School Official Name: Signature: Date:

Health Suite Personnel Name: Signature: Date:

DC Pediatric Immunization Locations

Medicaid AcceptedYes

No

Prepared by the DC Primary Care Office

Ward 1

1. Children’s Health Center: Adams Morgan1630 Euclid St NWWashington, DC 20009(202) 476-5580

2. Children’s Health Center: Shaw2220 11th St NWWashington, DC 20001(202) 476-5500

3. Community of Hope:Marie Reed Health Center2250 Champlain St NWWashington, DC 20009(202) 540-9857

4. Howard University Faculty Practice Plan Department of Pediatrics2041 Georgia Ave NW, Rm 3300Washington, DC 20060(202) 865-3006

5. La Clinica Del Pueblo2831 15th St NWWashington, DC 20009(202) 462-4788

6. Mary’s Center: Adams Morgan2333 Ontario Rd NWWashington, DC 20009(844) 796-2797

7. MedStar Medical Group: Adams Morgan1805 Columbia Rd NW, Suite AWashington, DC 20009(202) 991-0127

8. Spanish Catholic Charities1618 Monroe St NWWashington, DC 20010(202) 798-5546

9. Unity Health Care: Columbia Road Health Center1660 Columbia Rd NW Washington, DC 20009(202) 328-3717

10. Unity Health Care: Upper Cardozo Health Center3020 14th St NW Washington, DC 20009(202) 745-4300

Ward 2

11. Children’s Pediatricians & Associates:Foggy Bottom2021 K St NW, Suite 800Washington, DC 20006(202) 833-3197

12. Kaiser Permenante: Northwest DC Medical Office Building*2301 M St NW, 4th FloorWashington, DC 20037(202) 419-6200

13. Medical Home Development2112 F St NW, Suite 504Washington, DC 20037(202) 684-2784

14. Office of Dr. M. Barnes-Marshall2440 M St NW, Suite 317Washington, DC 20037(202) 775-5990

15. Office of Dr. Joan Razi*3537 R St NWWashington, DC 20007(202) 333-1774

16. Q Street Medical Associates1759 Q St NWWashington, DC 20009(202) 667-5041

17. Washington Pediatric Associates1145 19Th St NW, Suite 708Washington, DC 20036(202) 955-5625

Ward 3

18. Chevy Chase Pediatrics5225 Connecticut Ave NW, Suite 103Washington, DC 20015(202) 363-0300

19. Family Medicine at MedStar Health Center at Spring Valley*4910 Massachusetts Ave NW, Suite 115Washington, DC 20016(202) 237-0015

20. MedStar Georgetown Pediatrics & Gyne-cology at Tenleytown4200 Wisconsin Ave NWWashington, DC 20016(202) 243-3400

21. Spring Valley Pediatric & Associates4900 Massachusetts Ave NWWashington, DC 20016(202) 966-5000

Ward 4

22. Andromeda Transcultural Health1400 Decatur St NWWashington, DC 20011(202) 291-4707

23. Children’s Medical Care Center: Corders5425 14th St NWWashington, DC 20011(202) 291-0147

24. Mary’s Center: Petworth3912 Georgia Ave NWWashington, DC 20011 (202) 483-8196

Ward 5

25. Children’s Health Center: Sheikh Zayed Campus111 Michigan Ave NWWashington, DC 20010Children’s Health Center: (202) 476-2123Adolescent Health Center: (202) 476-5464

26. Community of Hope: Family Health & Birth Center801 17th St NEWashington, DC 20002(202) 398-5520

27. Mary’s Center: Fort Totten100 Gallatin St NEWashington, DC 20011(844) 796-2797

28. Office of Dr. M. Grissom2817 12th St NEWashington, DC 20017(202) 526-1030

29. Pediatric Professionals106 Irving St NW, Suite 306Washington, DC 20010(202) 291-2900

30. Providence Family Medicine1160 Varum St NE Suite 110 Medical BuildingWashington, DC 20017(202) 854-4090

31. Unity Health Care: Brentwood Health Center1251-B Saratoga Ave NEWashington, DC 20018(202) 832-8818

Ward 6

32. Bread for the City: Northwest Center1525 7th St NWWashington, DC 20001(202) 265-2400

33. Capitol Hill Community Health Clinic201 8Th St NE, Suite 3Washington, DC 20002(202) 546-7696

34. Children’s Pediatricians & Associates:Capitol Hill650 Pennsylvania Ave SE, Suite C-100 Washington, DC 20003(202) 833-4543

35. Family Practice Medical Services*1647 Benning Rd NE, Suite 302Washington, DC 20002(202) 398-2100

36. Kaiser Permanente:Capitol Hill Medical Center700 2nd St NEWashington, DC 20002(202) 346-3000

37. Providence’s Perry Family Health Center128 M St NW, Suite 50Washington, DC 20001(202) 854-3840

38. Unity Health Care: Southwest Health Center555 L St SEWashington, DC 20003(202) 548-4520

Ward 7

39. Children’s Pediatricians & Associates:Fort Davis3839 1/2 Alabama Ave SEWashington, DC 20020(202) 582-6800

40. Elaine Ellis Center of Health1628 Kenilworth Ave NEWashington, DC 20019(202) 803-2340

41. Nyame Nti Natural Health Solutions*3424 N St SEWashington, DC 20019(202) 491-5687

42. Unity Health Care:East of the River Health Center4414 Benning Rd NEWashington, DC 20019(202) 388-7891

43. Unity Health Care: Minnesota Avenue Health Center3924 Minnesota Ave NE Washington, DC 20019(202) 398-8683

44. Unity Health Care: Parkside Health Center765 Kenilworth Terrace NEWashington, DC 20019(202) 388-8160

Ward 8

45. Children’s Health Center: Anacostia2101 Martin Luther King Jr. Ave SE5th Floor Washington, DC 20020(202) 476-6900

46. Children’s Health Center: The ARC1801 Mississippi Ave SE Washington, DC 20020(202) 436-3060

47. Community of Hope: Conway Health & Resource Center4 Atlantic St SWWashington, DC 20032(202) 540-9857

48. Core Health & Wellness Center:Sheridan Station2516 Sheridan Rd SE, Suite AWashington, DC 20020(202) 610-6106

49. Core Health & Wellness Center:United Medical Center1328 Southern Ave SE, Suite 210Washington, DC 20032(202) 574-6618

50. Family and Medical Counseling Services, Inc.2041 Martin Luther King Jr. Ave SEWashington, DC 20020(202) 889-7900

51. Unity Health Care:Anacostia Health Center1500 Galen St SE Washington, DC 20020(202) 469-4699

52. Unity Health Care:Stanton Rd Health Center3240 Stanton Rd SE Washington, DC 20020(202) 889-3754

DC Health | 899 N. Capitol St., NE | Washington, DC 20002 | 202-442-5955 | dchealth.dc.gov

Oral Health Assessment Form For all students aged 3 years and older, use this form to report their oral health status to their school/child care facility.

Instructions • Complete Part 1 below. Take this form to the student's dental provider. The dental provider should complete Part 2.                                              • Return fully completed and signed form to the student's school/child care facility.

Part1:StudentInformation(Tobecompletedbyparent/guardian)

First Name _____________________________   Last Name _____________________________   Middle Initial ______ School or Child Care Facility Name_____________________________________Date of Birth (MMDDYYYY) Home Zip Code

Grade School Grade

Day‐care Pre‐K3 Pre‐K4 1 2 3 4 5 6 7 8 9 10 11 12

Adult Ed.

Part2:Student'sOralHealthStatus(Tobecompletedbythedentalprovider)

Q1   Does the patient have at least one tooth with apparent cavitation (untreated caries)? This does NOT   include stained pit or fissure that has no apparent breakdown of enamel structure or non‐cavitated demineralized lesions (i.e. white spots). 

Yes No

Q2   Does the patient have at least one treated carious tooth? This includes any tooth with amalgam, composite, temporary restorations, or crowns as a result of dental caries treatment.

Q3   Does the patient have at least one permanent molar tooth with a partially or fully retained sealant?

Q4   Does the patient have untreated caries or other oral health problems requiring care before his/her routine check‐up? (Early care need)

Q5   Does the patient have pain, abscess, or swelling? (Urgent care need)

Q6 How many of primary teeth in the patient's mouth are affected by caries that are either untreated or treated with fillings/crowns? Total Number

Q7 How many of permanent teeth in the patient's mouth are affected by caries that are either untreated, treated with fillings/crowns, or extracted due to caries? Total Number

Q8 What type of dental insurance does the patient have? Medicaid Private Insurance Other None

Dental Provider Name ______________________________                                 Dental Office Stamp                                         Dental Provider Signature ____________________________                                                                                        Dental Examination Date  ____________________________

This form replaces the previous version of the DC Oral Health Assessment Form used for entry into DC Schools, all Head Start programs, and child care centers. This form is approved by the DC Health and 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 Right and Privacy Act (FERPA) for the DC Schools and other providers.

DC Health | 899 North Capitol Street, NE., Washington, DC | 202.535.2180 | dchealth.dc.gov           January 2019    

D.C. Residency Verification Guide 2020-2021 School Year

Through May 27, 2020, all residency documents should be submitted by emailing the documents to

admissions@ingenuityprep.org. • How can I show my D.C. Residency?

1. Collect documentation of your address. The document(s) must have your current address and your name. The documents must belong to the same person (i.e., both belong to Mom or Dad, not one from each parent).

2. Only parents or legal guardians may submit D.C. residency. 3. The person whose name is on the documents must submit them to the school by email at

admissions@ingenuityprep.org. 4. When we have received and approved your documents you will receive an e-signature form to complete, stating

that you are the legal caregiver for your student and that you have not falsified any of the documents. • What documents can I use for residency verification?

Choose one from List A or two from List B in the chart below.

• I don’t have the right documents. What should I do? Email Mr. Chris at cmeehan@ingenuityprep.org as soon as possible for additional assistance. We are not able to extend the enrollment deadline for missing residency documents.

List A Provide one of these documents

List B Provide two of these documents

Pay stub from the last 45 days, showing your D.C. address AND D.C. taxes only (No other states can be shown on the pay stub)

D.C. car registration that has not expired

Financial assistance from D.C. Government such as TANF, Medicaid, or housing assistance from the last 12 months

Lease agreement AND receipt of rent payment with the receipt dated within the last two months

Supplemental Security Income showing current benefits, dated in the last 12 months

D.C. Driver’s License or government-issued ID

Tax information authorization form D-40 for 2019, certified by the Office of Tax and Revenue

One utility bill (gas, water, electric) with separate proof of payment dated in the last 2 months

Military Housing Orders or DEERS statement

Proof that the student is a ward of D.C.

Embassy letter dated on or after April 1, 2020

Online Tax Verification for families who have paid their 2019 taxes. Please ask Mr. Chris for more information to use this option.

Pre-Verified by DC Government, for students currently in Kindergarten or above. Families who qualify for this option will be notified.