Submit this form by emailing it to the designated Army Child and Youth Services Program office, faxing it to the appropriate number, or mailing it to the specified address. Ensure all required fields are completed and the form is signed before submission. For email submissions, convert the completed form to a PDF and attach it to your email. If faxing, include a cover sheet with your contact information. For physical submissions, send the completed form to: Army Child and Youth Services Program, [Installation Address], [City, State, ZIP Code].

Ensure to submit the form at the start of each academic year. For 2024 and 2025, submit the form by August 1st to ensure timely processing.

The purpose of the Army Child and Youth Services Health Screening Tool is to gather essential health information about children and youth in order to provide appropriate care and services. This form supports the Army's Exceptional Family Member Program (EFMP) and Child and Youth Services Program by ensuring that detailed medical conditions and restrictions are documented. By completing this form, parents and caregivers help Army personnel understand and address the specific needs of each child. This ensures that the child receives the appropriate accommodations and health services necessary for their well-being and development.

• 1. Child's Name: The full name of the child.
• 2. Date of birth (YYYYMMDD): The child's date of birth in YYYYMMDD format.
• 3. Family member prefix: The appropriate family member designation for the child.
• 4. Type of placement requested: The type of program placement being requested for the child.
• 5. Sponsor name: Name of the sponsor, typically a parent or guardian.
• 6. Spouse name: Name of the spouse, if applicable.
• 7. Home phone: The home phone number of the family.
• 8. Duty phone: The duty phone number, usually for the sponsor.
• 9. Cell phone: The cell phone number for contact purposes.
• 10. Allergies: Indicate if the child has any allergies, and provide details if necessary.
• 11. Asthma reactive airway disease: Indicate if the child has asthma or reactive airway disease, and provide details if necessary.
• 12. Attention Deficit Disorder (ADD): Indicate if the child has ADD, and provide details if necessary.
• 13. Autism: Indicate if the child has autism, and provide details if necessary.
• 14. Behavioral/conduct concerns: Indicate if the child has any behavioral or conduct concerns, and provide details if necessary.
• 15. Blindness/visual problems: Indicate if the child has any blindness or visual problems, and provide details if necessary.
• 16. Diabetes: Indicate if the child has diabetes, and provide details if necessary.
• 17. Emotional problems: Indicate if the child has emotional problems requiring care, and provide details if necessary.
• 18. Epilepsy: Indicate if the child has epilepsy, and provide details if necessary.
• 19. Hearing problems: Indicate if the child has hearing problems, and provide details if necessary.
• 20. Heart problems: Indicate if the child has heart problems, and provide details if necessary.
• 21. Kidney problems: Indicate if the child has kidney problems, and provide details if necessary.
• 22. Speech/language delay: Indicate if the child has speech or language delay, and provide details if necessary.
• 23. Physical disability: Indicate if the child has a physical disability, and provide details if necessary.
• 24. Dietary restrictions: Indicate if the child has any dietary restrictions, and provide details if necessary.
• 25. Assistance with activities of daily living: Indicate if the child needs assistance with daily living activities.
• 26. Other conditions: Specify and explain any other conditions the child may have.
• 27. Medications: List any medications the child is taking and indicate which require administration during child care hours.
• 28. Early Intervention and Special Education: Indicate if the child has an IFSP, IEP, or 504 plan.
• 29. EFMP Enrollment: Indicate if the child is enrolled in the EFMP and specify the condition.
• 30. Authorization: Parent or guardian authorizes the release of medical information regarding the child.
• 31. Signature of Parent or Personal Representative of Child: Signature of the parent or representative of the child.
• 32. Date (YYYYMMDD): Date of form completion in YYYYMMDD format.

Failure to submit this form may result in the child not being able to participate in the Army Child and Youth Services Program. This can impact the child's access to necessary care and services.

• Ineligibility for Programs: The child may become ineligible for Army Child and Youth Services Programs without the completed form.
• Lack of Medical Information: The Army will not have the necessary medical information to provide appropriate care for the child.
• Delayed Services: Failure to submit the form may lead to delays in accessing services that the child needs.

• 1. Program Enrollment: When enrolling a child in the Army Child and Youth Services Program.
• 2. Exceptional Family Member Program: To provide information for the Exceptional Family Member Program.
• 3. Medical Assessments: For medical professionals to assess the child's health conditions.
• 4. Educational Services: To provide information for special education services.
• 5. Care Planning: For caregivers and educators to plan appropriate care for the child.