ARMY CHILD AND YOUTH SERVICES HEALTH SCREENING – TOOL #1
PRIVACY ACT STATEMENT
SNAP Case Number: ________________
10 U.S.C. 3013, Secretary of the Army; 29 U.S.C. 794, Nondiscrimination Under Federal Grants and
Programs, DoDD 1342.17 Family Policy; AR 608-75, Exceptional Family Member Program: AR 608-
FOR CER COMPLETION ONLY
10, Child Development Services; and E.O. 9397 (SSN).
□ Initial Registration
Information will be used to assist Army activities in their responsibilities in overall execution of the
Army’s Exceptional Family member Program (EFMP) and the Army Child and Youth Services
Date in from Patron:
Is child on waiting list? □ Yes □ No
Date care needed? ________________
The DoD “Blanket Routine Uses” that appear at the beginning of the Army’s compilation of systems of
Date out to APHN:
□ Re-registration/Child Already in Program
records apply to this system
Disclosure of requested information is voluntary; however; if information is not provided individual may
□ Change in Program
not be able to participate in Army Child and Youth Services Program.
Part A – General Information
Child/Youth School Grade
Date of Birth
Type of Placement Requested: (check all that apply)
□ Hourly Care
□ Full Day Care
□ Middle School/Teen Program
□ Summer Camp
□ Other: (specify)
□ Part Day Care
□ Before/After School Care
□ SKIES/Instructional Classes
Sponsor Duty Phone
Part B – Identification of Child/Youth Condition/Restrictions
Does you child have any of the following conditions/restrictions: (check no or yes and answer questions as appropriate)
7. Behavior/ conduct concerns (oppositional defiant disorder,
a. Life threatening reaction?
anxiety, depression, bipolar, other)?
b. Rescue Medication (Epi-pen, Benadryl, Inhaler)
8. Autism Spectrum Disorders (Autism, Aspergers, Rett
c. Does child/youth need rescue inhaler?
If your child/youth has an allergy, please list: ___________________________
9. Does your child have any of the following health concerns?
(circle all that apply)- Hearing impairment, vision impairment
other than corrective lenses, heart, kidney, physical disability
SEVERE skin condition
2. Special Diet
Please specify __________________________________________________
a. Is your child on a complex diet (i.e. gluten free, diabetic)
b. Does your child have a food intolerance/mild food
10. Does your child have a speech/language and/or hearing
allergy (i.e. rash from strawberries/milk intolerance)?
loss that affects their ability to communicate their basic
c. Does your child have a dietary religious restriction?
needs (hurt, bathroom, fear, thirst)?
3. Asthma/Reactive Airway Disease/Breathing Problems?
a. Does your child need a rescue med?
4. Does your child have diabetes?
5. Does your child have seizures?
11. Does your child have developmental delays other than
6. Attention Deficit Disorder (ADD/ADHD)
MILD speech language/MILD hearing loss?
a. Are there behavior/conduct concerns while on meds?
b. List ADD/ADHD medications: ____________________________________
12. Are there any other conditions or concerns that you would
Like staff to be aware of?
Part C – Medications
List any medications that are prescribed for your child/youth other than those listed above:
Will your child require medication administration during child care/youth supervision hours?
Part D – Early Intervention and Special Education
Does your child/youth receive special services/therapies? □ No □ Yes
Does your child/youth have an Individualized Education □ No □ Yes
Please specify: _____________________________________________
Plan (IEP), Individualized Family Service Plan (IFSP) or 504 Plan?
Part E – Exceptional Family Member Program (EFMP) Enrollment
Is your child enrolled in the EFMP? □ No □ Yes If yes, specify for what condition: _____________________________________
Printed Name and Signature of Parent/Personal Representative of Child/Youth
If you have answered NO to all the questions above you are now finished with this form.
Please sign and date indicating that the information above is accurate and complete to the best of your knowledge.
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 please notify CYS Services immediately.
If you answered YES to any of the questions above, complete Part F on the next page.
Form Updated 11 Mar 09