BUILDING BRIGHTER FUTURES

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1 BUILDING BRIGHTER FUTURES SOUTH SOUND YMCA SCHOOL-AGED CHILD CARE WHAT YOU LL NEED WITH YOU TO REGISTER: Immunization records (must be transferred to provided CIS form, previous records nontransferable, one per child) Child(ren) s physician & dentist, name, address, and contact number Names, addresses, phone numbers of persons authorized to pick up you child(ren) from child care site Emergency contact information (other than parent/guardian) Preferred billing method for monthly bank draft DSHS families: authorization is required at time of registration 1. Call or go to to get our site provider number 2. Call DSHS for authorization 3. Contact the South Sound YMCA to confirm we ve received your authorization Visit for more information. BRIGGS COMMUNITY YMCA 1530 YELM HIGHWAY, OLYMPIA, WA HOURS OF OPERATION: MONDAY FRIDAY 5:00 AM 9:00 PM SATURDAY 8:00 AM 6:00 PM SUNDAY 12:00 NOON 5:00 PM OLYMPIA DOWNTOWN YMCA 510 FRANKLIN STREET SE, OLYMPIA, WA HOURS OF OPERATION: MONDAY FRIDAY 5:30 AM 7:30 PM SATURDAY 7:00 AM 12:00 NOON SUNDAY CLOSED

2 PARENT INFORMATION PAGE: PLEASE SAVE FOR YOUR REFERENCE Welcome to the South Sound YMCA Before and After School Care! Here at the South Sound YMCA, we believe children should have a place to go that provides them with opportunities to grow and thrive. Our staff provide a curriculum focused on academic enhancement and social growth. Children connect with others to build lasting relationships, develop a sense of belonging, and cultivate leadership skills. In our care, your child will receive: Encouragement to participate in organized physical activity A healthy snack A clean space set aside for homework and quiet activity Support from our qualified staff Monthly Rates Your monthly rates are based on the number of days school is in session and averaged over the 10 months of the school year. The only prorated months are December and June (Spring and Winter Break Camps are available by registration and for an additional fee). BEFORE AND AFTER SCHOOL CARE MONTHLY RATES Schedule Program Member Facility Member Details Full Time Care $460 $440 Any attendance ANNUAL REGISTRATION FEE: $50 PER CHILD Before Only $240 $230 Any attendance before regular school release time After Only $320 $310 Any attendance after regular school start time Part Time $350 $340 Up to three mornings and three afternoons per week Drop In Care Daily Rate THINGS YOU SHOULD KNOW: Full Day $40 In Service Day Morning Only $15 Any attendance before school Afternoon Only $25 Any attendance after school Schedule Change Requests/Cancellation of Care Parent/guardian must provide two weeks written notice for any decrease or cancellation of care. Please call or visit your local YMCA branch for more details. Notice may not be given at site and increases in care are subject to availability. Drop In Requests Requests for drop in attendance are required at least 24 hours in advance. The daily rate as provided on the parent reference page of this packet will be automatically drafted from your designated payment method on the 15th of the following month. Please contact your site director for more details on how to request drop in dates. Communication The primary means of communication regarding all child care accounting is . Please keep a current address on file so that we may provide you and your child(ren) with the best possible care. School District Schedule Deviations Y Care follows the same schedule the school district follows (two hour delays, snow days, etc.). You can sign up at to receive flash alerts notifying you of any schedule deviations. DSHS Authorization Our office must have a current DSHS authorization on file in order to apply your subsidy at the time of registration. The YMCA does not have any authority over 3rd party subsidies and cannot correct any discrepancies on your behalf. Foster families: please have your case worker call to confirm your child(ren) s coverage. Parent/Guardian Handbook The South Sound YMCA Parent/Guardian Handbook is available at Financial Assistance The South Sound YMCA is committed to helping people become the best they can be. We strive to keep the Y accessible to everyone regardless of their ability to pay. With the support and generosity of our donors through our Annual Campaign, we assist everyone who qualifies. Rev d 6/2/17 To register: 1. Fill out registration packet completely. Incomplete packets will not be accepted. 2. Return completed packet to one of our local branches. Faxed, mailed, or ed packets will not be accepted.

3 Last Name: First Name: MI: Member #: Exp. : Rev 10/28/2016 South Sound YMCA Program Membership Application The Y is a cause-driven organization that is for youth development, for healthy living and for social responsibility. Membership is open to all. Everyone is welcome to apply regardless of race, religion, age, gender, sexual orientation, national origin, economic level or disability. If you can t afford the full cost of programs, financial assistance is available to the extent possible. Please ask for a confidential scholarship application. Participants needing other accommodation should contact Y management. Primary Member Information (if program participant is under 18 years of age, list parent/guardian as primary) Name: First MI Last of Birth: / / Gender: Male Female Ethnic Origin Mailing Address: City State Zip Code Home Phone: ( ) Cell/Other Phone: ( ) Address: Emergency Contact: Relationship Phone #: ( ) Youth Member Information (if program participant is 18 years of age or older, a separate application is required) Name (First, MI, Last) of Birth Age Gender M/F Ethnic Origin Relationship / / / / / / / / Have you or anyone on this application ever been convicted of a sexual offense against a minor? Conditions of Membership: Member Conduct: Applicant agrees to abide by all policies and procedures of the YMCA and its branches and understands that failure to act in accordance with these rules may result in expulsion from the YMCA and revocation of the membership. Criminal History: The applicant acknowledges that the YMCA reserves the right to deny access or membership to any individual convicted of a sexual offense and/or is or has been a registered sex offender. Property Loss: The applicant understands that the YMCA is not responsible for personal property lost, damaged or stolen while using YMCA facilities or participating in YMCA programs. Photograph Permission: The applicant hereby gives permission for the YMCA to use, without limitation or obligation, photographs or other media that may include the member s image or voice to promote or interpret YMCA programs. Medical Treatment: The applicant gives permission for YMCA staff or volunteers to provide emergency medical treatment, and to transport to an emergency center for treatment. Also, the applicant consents to medical treatment deemed immediately necessary or advisable by a physician. The applicant understands any of the foregoing care will be at his/her own expense. Concussion Laws: The YMCA abides by all Washington State Concussion Laws, including removing a player with a head injury from the game, informing parents of the dangers of a head injury, and requiring written consent from a healthcare provider for the player to return to practice and/or games. The applicant understands concussions are serious and if he/she sees or experiences signs or symptoms of a concussion, he/she will seek medical attention and YMCA staff/volunteers will be notified. Refund Policy: Full refunds are only available for requests made in writing prior to the program registration deadline, or a minimum of 7 days prior to the start of the program for program without a deadline. See refund policy for details. I have read and understand the statements above. Signature (Parent/Guardian if under 18) Printed ************** TURN FORM OVER SIGNATURE ALSO REQUIRED ON OTHER SIDE ************** Member Services Staff Use Only Received by: : I.D. Checked Raptor Checked Waiver Field Populated

4 Rev 10/28/2016 South Sound YMCA Release & Waiver of Liability & Indemnity Agreement IN CONSIDERATION of being permitted to utilize the facilities, premises, services and programs of the YMCA (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities, premises or equipment, or participation in any off-site program affiliated with the YMCA, the undersigned, for himself or herself and such participating children and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the YMCA for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE YMCA FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO OBSERVATION OR USE OF PREMISES, FACILITIES OR EQUIPMENT, OR PARTICIPA- TION IN ANY OFF-SITE PROGRAM AFFILIATED WITH THE YMCA, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: THE UNDERSIGNED ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND CONVENANTS NOT TO SUE the YMCA and all branches thereof; its directors, officers, employees, and agents (hereinafter referred to as "releasees") from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the YMCA. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any, loss, liability, damage or cost they may, incur due to the presence of the undersigned or such children in, upon or about the YMCA premises or in any way observing or using any facilities, premises or equipment of the YMCA or participating in any program affiliated with the YMCA whether caused by the negligence of the releasees or otherwise. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence of releasees or otherwise while in, about or upon the premises of the YMCA and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the YMCA. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Washington and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. I HAVE READ AND UNDERSTAND THIS DOCUMENT AND RELEASE WHICH ADDITIONALLY APPLIES TO ALL FUTURE INTERACTIONS WITH THE YMCA. Signature (Parent/Guardian if under 18) Printed Child s Name Child s Name Child s Name Child s Name

5 SOUTH SOUND YMCA SCHOOL AGE CHILD CARE THE SOUTH SOUND YMCA & WASHINGTON STATE LICENSING REQUIRES ALL DOCUMENTS INCLUDED IN THE REGISTRATION PACKET BE COMPLETED PRIOR TO ACCEPTING A CHILD INTO ANY LICENSED PROGRAM. IN THE SPACES BELOW, WRITE N/A IF NOT APPLICABLE. Location & Enrollment Schedule Site Start Please choose ONE of the following schedules: Full Time Part Time Before Only After Only Child(ren) s Information *Up to 3 children per form, all provided information must be the same for each child 1 Drop In Only Legal First Name M Legal Last Name Preferred Name of Birth Age Gender 2 3 Legal First Name M Legal Last Name Preferred Name of Birth Age Gender Legal First Name M Legal Last Name Preferred Name of Birth Age Gender Address City State Zip Parent/Guardian Information Name (Primary Contact) Primary Phone # Secondary Phone # (required) Employer/Work Address Alt. Work Phone # * Authorized to Pick Up? Yes No Name (Secondary Contact) Primary Phone # Secondary Phone # (required) Employer/Work Address Alt. Work Phone # * Authorized to Pick Up? Yes No *Appropriate court documentation must be in place and a copy must be provided to deny parent/guardian access. Emergency Contact and Other Authorized Pick Up Persons (at least one must be provided, must be local, and at least 16 years of age) Emergency contact name other than parent/guardian Address Contact # Relationship to Child Name (authorized pick up only) Address Contact # Relationship to Child Name (authorized pick up only) Address Contact # Relationship to Child Child(ren) s Health Information (if the child[ren] does not have a medical or dental provider, a written plan for injury or accident is required) Physician/Clinic Name Contact # of last physical (must be within a year) Dentist/Clinic Name Contact # of last appointment (must be within a year) PLEASE EXPLAIN IF YOUR CHILD(REN) HAS A KNOWN HISTORY OF THE FOLLOWING: Bee Sting Seizures/ Child s Name Diabetes Respiratory Reaction Convulsions 1 Y N Y N Y N Y N 2 Y N Y N Y N Y N Allergies Current Medications 3 Y N Y N Y N Y N If you circled Y on any of the above and would like to speak to your Program Director, please ask the front desk for their name and contact information Any limitations on activities or any other information our staff should be aware of: Registered by: South Sound YMCA Use Only Rev d 6/2/17 Payment Method Saved Accounting: Complete Draft Scheduled Int & :

6 PARENT/GUARDIAN AGREEMENT REGISTRATION AND MEMBERSHIP I understand I must submit new enrollment paperwork each school year my child(ren) is/are in care and maintain a current Program or Facility Membership for the duration of the program. A non-refundable registration fee of $50.00 per child is collected at time of enrollment. I understand my child(ren) s monthly rate gives them access to Y Care. Credit will not be issued for missed days. I understand that the primary means of communication regarding all child care accounting is and agree to keep a current address on file. I understand for the safety of my child(ren), staff may not relate to my child(ren) outside of approved YMCA activities. YMCA staff are not permitted to have contact with participants they met through employment with the YMCA (babysitting, birthday parties, etc.). Any exceptions must be approved in advance by the Executive Director. I will adhere to all Y policies stated within the Parent Handbook (a copy of the Handbook can be provided upon request and is available at PAYMENT INFORMATION All payments will be automatically drafted via my designated payment method according to the Payment Authorization Form I provided. Payments are due on the 1st (and 15th if applicable) of each month. A $20.00 late fee will be charged if paid after the due date unless an alternate arrangement has been made with the Accounts Receivable Specialist prior to the 1st of the month. Child Care services may be suspended beginning the 6th (and 21st) on delinquent accounts and reinstated once balance is paid in full. I am ultimately responsible for payment of child care fees. CHILD S ATTENDANCE AND ENROLLMENT SCHEDULE Two weeks written notice is required when cancelling or changing my child(ren) s schedule of care (may not be given at the Y Care site). The minimum duration a schedule change can be applied is one calendar month and up to three changes are permitted each school year. I understand if my child(ren) attends outside their registered schedule, the daily rate as provided on the parent reference page of this packet will be automatically drafted from my designated payment method on the 15th of the following month. Drop In: All requests for drop in attendance are required at least 24 hours in advance. The daily rate as provided on the parent reference page of this packet will be automatically drafted from my designated payment method on the 15th of the following month. Parents/Guardians are required to sign their child(ren) in and/or out each day. If a signature is missed, a Missing Signature Form must be filled out and signed. I understand my child(ren) must be picked up no later than 6:00 pm if attending the afternoon program. A late fee ($15.00 first occurrence, $45.00 each occurrence after) will be charged for arrival after 6:00 pm and will be automatically drafted from my designated payment method on the 15th of the following month. Waitlisted Sites: I understand children are contacted in the order they were registered for the waitlist. If a spot becomes available at my child(ren) s Y Care site, I will be notified by and given two business days to respond. If a response is not received within two business days, my child(ren) will be removed from the waitlist. SCHOOL DISTRICT BREAKS & IN SERVICE DAYS I am aware that the only prorated months of child care are December and June. I understand I will be drafted for the full month of April and that Spring and Winter Break Camps are available by registration and for an additional fee. Y Care will not be provided on national holidays or the day after Thanksgiving. I understand Y Care follows the same schedule the school district follows (two hour delays, snow days, etc.). I understand I can sign up at to be notified of any schedule deviations. Registration for an In Service Day is required. Based on my child(ren) s registered schedule, a daily rate may be applied and drafted from my designated payment method on the 15th of the following month. 3RD PARTY SUBSIDY POLICIES (DSHS, CHILD CARE AWARE, ETC.) I understand that any and all changes to my coverage will be communicated by DSHS or other 3rd party directly to me. I am ultimately responsible for the full cost of my child s care upon expiration or loss of coverage. I understand that the YMCA does not have any authority over 3rd party subsidies and cannot correct any discrepancies on my behalf. Any discrepancies in my child s coverage is my responsibility to remedy, as is adhering to any and all payment deadlines as listed above. I understand if my child does not attend Y Care in any calendar month for which they are enrolled, he/she will be removed from the roster for the remainder of the school year and will be charged a processing fee of (up to) $ Re-enrollment subject to availability. 3rd party billing with attendance invoices: I understand it is my responsibility to submit my child(ren) s signed attendance invoice(s) to the South Sound YMCA before the deadline. If a deadline is missed, I understand the financial obligation is my responsibility and will adhere to the payment deadlines as listed above. Medical Treatment: I give permission for YMCA staff or volunteers to provide emergency medical treatment to my child(ren), and to transport to an emergency center for treatment. I also consent to medical treatment deemed immediately necessary or advisable by a physician. I understand any of the foregoing care will be at my own expense. Collaboration: I authorize the YMCA to share any pertinent information concerning my child(ren) with professionals, such as social workers, teachers, counselors, etc. Additionally I authorize these professionals to share information with the YMCA. By signing below, I acknowledge I have read and understand the Parent/Guardian Agreement. Parent/Guardian Signature Printed Child(ren) s name(s):

7 Rev 8/24/17 CHILD CARE PAYMENT AUTHORIZATION FORM PARTICIPANT INFORMATION Child s Name: Parent/Guardian Name: PREFERRED PAYMENT SCHEDULE Once per month on the 1st or Twice per month on the 1st & 15th DSHS or other 3rd Party Authorized If 3rd Party Authorized: Provider Name: Case or Family # PAYMENT OPTION (select one) Option 1: Electronic Funds Transfer (Checking or Savings Account) Name on Account: (please print) Bank Name: Routing Number: Account Type: Checking Savings Account Number Last 4 digits only: Option 2: Recurring Debit or Credit Card Charge Name on Card: (please print) Type: Visa MC AMEX Discover Card Number Last 4 digits only: Exp. : Card Billing Address: Street City.. State Zip AUTHORIZATION I hereby authorize a monthly electronic funds transfer or debit/credit card charge on or after the date specified above. The YMCA may charge collection fees for any declined transactions and will make multiple attempts to collect funds for returned debit/credit card charges. I further understand and agree to the following: Transfers/charges will continue until I give written notice to change or terminate them. The frequency and occurrence of visits/usage has no bearing on fees. Scheduled program payments continue until registration ends. I will provide a minimum of two weeks written notice, prior to my next scheduled draft, to cancel this authorization. If I fail to provide adequate notice, I will draft one additional time before the cancelation takes effect and that payment is nonrefundable. I am responsible for notifying the YMCA of changes in my account number and expiration date. However, the YMCA may attempt to roll forward credit card expiration dates, where possible. I understand that rates are subject to change and as a result the amount transferred/charged my change. The YMCA will notify me in advance of increase in my fees by mail or . I am responsible for notifying the YMCA if my address or changes. It is my responsibility to bring any billing discrepancies to the YMCA s attention within 60 days after they are processed by my financial institution. After 60 days, I waive my right to dispute such discrepancies. If 3rd Party Subsidy applies, I understand that I am ultimately responsible for the full cost of care upon expiration, loss of coverage or when discrepancies exist. Signature of Account Holder: : SOUTH SOUND YMCA STAFF USE ONLY MEMBER SERVICES: Received By Billing Method Saved : Member #: Y & C ACCOUNTING STAFF: Program Payment Scheduled APSR checked Initials :

8 Certificate of Immunization Status (CIS) For Kindergarten-12 th Grade / Child Care Entry Office Use Only: Reviewed by: : Signed Cert. of Exemption on file? Yes No Please print. See back for instructions on how to fill out this form or get it printed from the Washington Immunization Information System. Child s Last Name: First Name: Middle Initial: Birthdate (): Sex: I give permission to my child s school to share immunization information with the Immunization Information System to help the school maintain my child s school record. Parent/Guardian Signature Required I certify that the information provided on this form is correct and verifiable. Parent/Guardian Signature Required Required for School and Child Care/Preschool Required Only for Child Care/Preschool DTaP, DT (Diphtheria, Tetanus, Pertussis) Tdap (Tetanus, Diphtheria, Pertussis) Required Vaccines for School or Child Care Entry Documentation of Disease Immunity Healthcare provider use only If the child named in this CIS has a history of Varicella (Chickenpox) or can show immunity by blood test (titer) it MUST be verified by a healthcare provider Td (Tetanus, Diphtheria) I certify that the child named on this CIS has: Hepatitis B 2-dose schedule used between ages a verified history of Varicella (Chickenpox). Hib ( Haemophilus influenzae type b) IPV / OPV (Polio) laboratory evidence of immunity (titer) to disease(s) marked below. Lab report(s) for titers MUST also be attached. MMR (Measles, Mumps, Rubella) PCV / PPSV (Pneumococcal) Varicella (Chickenpox) History of disease verified by IIS Recommended Vaccines (Not Required for School or Child Care Entry) Diphtheria Mumps Other: Hepatitis A Polio Hepatitis B Rubella Hib Measles Tetanus Varicella Flu (Influenza) Hepatitis A HPV (Human Papillomavirus) MCV, MPSV (Meningococcal) MenB (Meningococcal) Rotavirus Licensed healthcare provider signature (MD, DO, ND, PA, ARNP) Printed Name

9 Instructions for completing the Certificate of Immunization Status (CIS): printing it from the Immunization Information System (IIS) or filling it in by hand. To print with immunization information filled in: Ask if your healthcare provider s office enters immunizations into the WA Immunization Information System (Washington s statewide database). If they do, ask them to print the CIS from the IIS and your child s immunization information will fill in automatically. You can also print a CIS at home by signing up and logging into MyIR at If your provider doesn t use the IIS, or call the Department of Health to get a copy of your child s CIS: waiisrecords@doh.wa.gov or To fill out the form by hand: #1 Print your child s name, birthdate, sex, and sign your name where indicated on page one. #2 Vaccine information: Write the date of each vaccine dose received in the date columns (as ). If your child receives a combination vaccine (one shot that protects against several diseases), use the Reference Guide below to record each vaccine correctly. For example, record Pediarix under Diphtheria, Tetanus, Pertussis as DTaP, Hepatitis B as Hep B, and Polio as IPV. #3 History of Varicella Disease: If your child had chickenpox (varicella) disease and not the vaccine, a health care provider must verify chickenpox disease to meet school requirements. If your healthcare provider can verify that your child had chickenpox, ask your provider to check the box in the Documentation of Disease Immunity section and sign the form. If school staff access the IIS and see verification that your child had chickenpox, they will check the box under Varicella in the vaccines section. #4 Documentation of Disease Immunity: If your child can show positive immunity by blood test (titer) and has not had the vaccine, have your healthcare provider check the boxes for the appropriate disease in the Documentation of Disease Immunity box, and sign and date the form. You must provide lab reports with this CIS. Reference guide for vaccine abbreviations in alphabetical order Full Vaccine Full Vaccine Abbreviations Abbreviations Name Name DT Diphtheria, Tetanus Hep A Hepatitis A MCV / MCV4 DTaP DTP Flu (IIV) HBIG Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, Pertussis Influenza Hepatitis B Immune Globulin Reference guide for vaccine trade tames in alphabetical order For updated list, visit Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine Trade Name Vaccine ActHIB Hib Fluarix Flu Havrix Hep A Menveo Meningococcal Rotarix Rotavirus (RV1) Adacel Tdap Flucelvax Flu Hiberix Hib Pediarix For updated list, visit Full Vaccine Full Vaccine Abbreviations Abbreviations Abbreviations Full Vaccine Name Name Name Meningococcal Conjugate Vaccine Hep B Hepatitis B MenB Meningococcal B Hib HPV (2vHPV / 4vHPV / 9vHPV) IPV Haemophilus influenzae type b Human Papillomavirus Inactivated Poliovirus Vaccine MPSV / MPSV4 DTaP + Hep B + IPV RotaTeq Afluria Flu FluLaval Flu HibTITER Hib PedvaxHIB Hib Tenivac Td Bexsero MenB FluMist Flu Ipol IPV Pentacel DTaP + Hib + IPV Trumenba MenB Rotavirus (RV5) Boostrix Tdap Fluvirin Flu Infanrix DTaP Pneumovax PPSV Twinrix Hep A + Hep B Cervarix 2vHPV Fluzone Flu Kinrix DTaP + IPV Prevnar PCV Vaqta Hep A Daptacel DTaP Gardasil 4vHPV Menactra MCV or MCV4 ProQuad MMR + Varicella Varivax Varicella Engerix-B Hep B Gardasil 9 9vHPV Menomune MPSV4 Recombivax HB Hep B MMR MMRV Meningococcal Polysaccharide Vaccine Measles, Mumps, Rubella Measles, Mumps, Rubella with Varicella If you have a disability and need this document in another format, please call (TDD/TTY call 711). DOH December 2016 OPV PCV / PCV7 / PCV13 PPSV / PPV23 Oral Poliovirus Vaccine Pneumococcal Conjugate Vaccine Pneumococcal Polysaccharide Vaccine Rota (RV1 / RV5) Rotavirus Td Tetanus, Diphtheria Tdap VAR / VZV Tetanus, Diphtheria, acellular Pertussis Varicella