Forms

Forms Required for Child

Form Due By Send To Notes
Forms Checklist (2017-18) June 16, 2017 Diann Vaughan
  • New families only
AUCP Registration Form (2017-18) June 16, 2017 Diann Vaughan
  • New and returning families (annually)
  • Both parents must sign & date the bottom of page 3
  • Fill in all spaces (or reflect N/A, where applicable)
Emergency Release Form June 16, 2017 Diann Vaughan
  • New families only
  • Must be notarized
Commonwealth of Virginia School Entrance Health Form June 16, 2017 Diann Vaughan
  • New and returning families
  • The most recent physical examination must be within the past 12 months for children over two-years old; within the past six months for children under two-years old
  • The bottom of page 1 must be signed and dated by parent
  • The bottom of both page 2 and page 4 must be signed and dated by physician
  • TB assessment on page 4 is required for all students over one year old and must be done after May 1, 2015
Proof of Child’s Identity Sept. 7, 2017 Diann Vaughan
  • New families only
  • Original documentation must be submitted in person for review by the Membership Chair, President or Director (the form and documentation may be presented at the New Family Orientation or Parent Welcome Night in September)
Authorization to Administer Medication
Food Allergy Action Plan
Medication Administration Record
Sept. 7, 2017 Diann Vaughan
  • Required for allergies and/or medication needs
  • Physician’s signature required on Authorization to Administer Medication form

Forms Required for EACH Co-oping Parent or Legal Guardian

Form Due By Send To Notes
Parent Reference Form June 16, 2017 Diann Vaughan
  • New families only
  • Two references must be completed for each co-oping parent
Sworn Statement or Affirmation June 16, 2017 Diann Vaughan
  • New and returning families (annually)
Criminal History Background Check June 16, 2017 Diann Vaughan
  • New families only
  • Enclose no money
Central Registry Form (Revised 2015) June 16, 2017 Diann Vaughan
  • New families only
  • Enclose no money
  • Parts II and III must be fully completed with full names (do not use initials)
  • Part IV must be notarized
  • Please print pages 2 and 3 on one sheet (front and back); No need to print page 1 (instruction sheet)
Tuberculosis Screening Certificate (Revised 2016) Sept. 7, 2017 Diann Vaughan
  • Required annually for each co-oping parent
  • New Families: Test must be done between August 14th and first day of school (if it is done earlier than this, it will have to be redone)
  • TB Screening Locations:
  • Arlington Co. Public Health Dept., 2100 Washington Blvd, 703-228-1300 (walk-in, Tues 3-6:30pm, Wed 9-12:30pm, Fri 7:30-11am)
  • Alexandria Health Dept., 4480 King Street, 703-746-4960 (walk-in Monday 8-11am and 2-6pm; appointment only Tues & Wed 8-11am and 1-3:30pm, Fri 8-11am
  • Fairfax Co. Health Dept., 7611 Little River Turnpike, Annandale, 703-534-8343 (walk-in, Mon & Wed 8am- 12:30pm/Tues 10am-2pm, or by appointment daily 8am-4:30pm)
  • Fairfax Co. Health Dept., 3750 Old Lee Highway, Fairfax City, 703-246-7100 (walk-in, Mon & Tues 8-12:30pm/Wed 10-2pm, or by appointment daily 8am-4:30pm)
  • Target Minute clinic and CVS pharmacy locations may do assessments as well for a fee; clinic hours vary

Additional Forms

Form Due By Send To Notes
AUCP Committee Selection Form (2017-18) June 16, 2017 Diann Vaughan
  • New families only
Media Release Form June 16, 2017 Diann Vaughan
  • New families only