MARYLAND SCHOOLS RECORD OF PHYSICAL EXAMINATION
To Parents or Guardians:
In order for your child to enter a Maryland public school for the ﬁrst time, the following are required:
• A physical examination by an authorized health care provider must be completed within
nine months prior to entering the public school system or within six months after
entering the system. A physical examination form designated by the Maryland State Department
of Education and the Maryland Department of Health must be used to meet this requirement.
• Evidence of complete primary immunizations against certain childhood communicable
diseases is required for all students in preschool through the twelfth grade. A Maryland
Immunization Certiﬁcation form for newly enrolling students may be obtained from the local
Department of Health and Human Services or from school personnel. The form and the required
immunizations must be completed before a child may attend school. (Form MDH 896).
• Evidence of blood lead testing is required for all students who reside in a designated
at risk area or who are enrolled in Medicaid when ﬁrst entering Prekindergarten,
Kindergarten, and Grade 1, and for ALL children born on or after January 1, 2015.
The Maryland Department of Health and Mental Hygiene Blood Lead Testing Certiﬁcate (DHMH
4620) (or another written document signed by an authorized health care provider) shall be used
to meet this requirement.
Exemptions from immunizations are permitted if they are contrary to a student’s or family's religious
beliefs, and require parent/guardian signature on MDH Form 896. Students also may be exempted
from immunization requirements if an authorized health care provider certiﬁes that there is a medical
reason not to receive a vaccine. Exemptions from blood lead testing is permitted if it is contrary to
a family’s religious beliefs and practices. The Blood Lead Testing Certiﬁcate must be signed by an
authorized health care provider stating a questionnaire was done.
The health information on this form will be available only to those health and education personnel
who have a legitimate educational interest in your child.
In order to assist your child in gaining the most from their educational experience, please complete Part
I of this Physical Examination form. Part II must be completed by an authorized health care provider,
or attach a copy of your child’s physical examination to this form. If your child requires medication
and or a treatment to be administered in school, you must have the authorized health care provider
complete a medication and or treatment administration form for each medication and or treatment to
be administered. These forms can be obtained from your child’s school or online from the Montgomery
County Public Schools (MCPS) website at www.montgomeryschoolsmd.org: MCPS Form 525-12, Authorization
to Provide Medically Prescribed Treatment, Release and Indemniﬁcation Agreement, MCPS Form 525-13,
Authorization to Administer Prescribed Medication, Release and Indemniﬁcation Agreement, MCPS Form
525-14, Emergency Care for the Management of a Student with a Diagnosis of Anaphylaxis, Release and
Indemniﬁcation Agreement for Epinephrine Auto Injector. If you do not have access to an authorized
health care provider or if your child requires a special individualized health procedure, please contact
the principal and/or school nurse in your child’s school.
Please complete this Physical Examination form and
return it to your child’s school as quickly as possible.
Student Record Card 6
Maryland State Department of Education (MSDE)
Maryland Department of Health (MDH)
MONTGOMERY COUNTY PUBLIC SCHOOLS (MCPS)
MCPS Form SR-6
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