Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box. COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization Part I HEALTH INFORMATION FORM State law Ref. Code of Virginia 22. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION Form CRE-1 which may be obtained at any local health department school...
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Get the VA MCH 213 G 2010-2019

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Who needs a MCH 213 G form?

This form is used in the educational institutions of Virginia. Before entering the public kindergarten and elementary school, the child must be examined by doctors. This form provides the result of this examination.

What is the purpose of the MCH 213 G form?

The school entrance form contains information about the child and his health condition. This information is very important  in case of emergency situations, as it name the child’s allergies and chronic diseases.

What other documents must accompany the MCH 213 G form?

A copy of the signed immunization record should be attached to this form.

When is the MCH 213 G form due?

The Health form must be completed no longer than one year before the child starts the school.

What information should I provide in the MCH 213 G form?

The health statement has several parts for completion.

Part I is completed by the child’s parent or guardian. It contains the following information:

  • Name of school

  • Child’s name, date of birth, sex, language spoken,

  • Address

  • Name of mother or legal guardian

  • Name of father or legal guardian

  • Information about the child’s allergies, behavioral and other health problems, diabetes, head injury, hearing problems, spinal injury

  • Any other important health-related information

  • All the prescriptions the child takes regularly

  • Information about the child’s doctors

The parent or guardian must sign and date the form as well.

Part II is the Certification of Immunization. This part is completed and signed by the medical provider and contains a record of the child’s vaccinations (name of the vaccines and dates administered).

Part III is the Comprehensive Physical Examination Report. It’s completed by the qualified physician or physician assistant. This part contains several screens for completing including health assessments, developmental screen, hearing screen, and vision screen.

The last two parts are certified by the Health Care Professionals.

What do I do with the form after its completion?

The completed health care form is submitted to the school administration.   

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