Physician will be required to complete this form with attached Official Proof of Immunizations for your child: Polio (3), DTaP (4), MMR (1), Hib (1), Hep B (3), Varicella (1).

If your child has a valid medical exemption from immunizations, please provide a letter from your child's physician stating such and if it is temporary (must include an end date) or permanent.

May require Physician instruction/signature if your child has a medical condition, allergy, or food allergy that may require VPP staff to administer any medication, keep medication on campus, or require special care a Physician signature and instruction is required.

**To complete the enrollment process, the Supplemental Allergy Packet (link above) must be completed for children with food allergies and/or a medical condition that may require medication administration at school.

Does not require Physician’s signature

This form will serve as your authorized list of people allowed to pick up your child from school in your absence.

The information provided here can be BRIEF. More detail can be provided on Form H.

Name, address and telephone number of the local licensing office (we have typed in to the form already):

Licensing Office Name: Bay Area Regional Office

Licensing Office Address: 1515 Clay Street, Suite 1102, MS: 29-04, Oakland CA 94612

Licensing Office Telephone #: (510) 622-2602

Physician will be required to complete this form

This form is for adults volunteering in the classroom: Copy of either (a) childhood or adult vaccine records, (b) blood test (titer) results showing immunity, or (c) repeat vaccine administration if childhood vaccine records cannot be found. Physician or RN will be required to complete the TB Test or TB risk assessment form.

- MMR (Measles, Mumps, Rubella)

- Pertussis (DTaP or Tdap or Pertussis)

- Flu shot within last 12 months or flu declination (Form J)

- TB Test or TB risk assessment (Form K) completed by MD/RN within last 60 days

- COVID-19 Acceptance/Declination Form (Form L) and a copy of your COVID vaccine record (if applicable)

- Valid government issued photo ID: Copy of driver's license, state ID, or passport

This form is for adults volunteering in the classroom: Only need to be completed by adults volunteering in the classroom who are declining to get the annual flu shot.

This form is for adults volunteering in the classroom: TB Test or TB risk assessment completed by MD/RN within last 60 days.

This form is for adults volunteering in the classroom: COVID-19 Acceptance/Declination Form to be submitted along with a copy of your COVID vaccine record (if applicable).

This form is part of the Supplementary Allergy Packet for families of a child with a medical condition or known allergy that may require VPP staff to administer/keep any medication on campus, require staff attention, or require special care by VPP staff. Please do not complete unless this applies to your child.

List of medications, emergency contacts, and physician’s instructions for medical emergencies.

This form is part of the Supplementary Allergy Packet for families of a child with a medical condition or known allergy that may require VPP staff to administer/keep any medication on campus, require staff attention, or require special care by VPP staff. Please do not complete unless this applies to your child.

This form is part of the Supplementary Allergy Packet for families of a child with a medical condition or known allergy that may require VPP staff to administer/keep any medication on campus, require staff attention, or require special care by VPP staff. Please do not complete unless this applies to your child.

This form is part of the Supplementary Allergy Packet for families of a child with a medical condition or known allergy that may require VPP staff to administer/keep any medication on campus, require staff attention, or require special care by VPP staff. Please do not complete unless this applies to your child.

Info will be posted in the kitchen for easy access for teachers/directors/classroom volunteers.